Medical Plan Options
HDHP Plan
EPO Plan
PPO Buy-Up Plan
In Network Coverage
Network
Aetna Choice POS II
Aetna Choice POS II
Aetna Choice POS II
Deductible (Plan Year)
$3,000 / $6,000
$1,500 / $3,000
$1,000 / $2,000
Coinsurance
You Pay 10%
You Pay 20%
You Pay 10%
Out of Pocket Maximum $5,000 / $10,000
$4,500 / $9,000
$5,000 / $10,000
Employer HSA Contribution
$250
None
None
Preventive
100% Covered
100% Covered
100% Covered
Primary / Specialist Visit
10% After Deductible
$30 / $60
$25 / $50
Urgent Care
10% After Deductible
$25 Copay
$25 Copay
$10 Copay, After Deductible
Teladoc Medical
$10 Copay
$10 Copay
Teladoc Mental Health
10% After Deductible
$60 Copay
$50 Copay
Inpatient & Outpatient Hospital
10% After Deductible
20% After Deductible
10% After Deductible
Emergency Room
10% After Deductible
$400 Copay
$400 Copay
Rx Deductible
Included in Medical
$100 / $200
$100 / $200
Rx Copays (Retail – 30 days)
$10/$50/$80
$10/$50/$80
$10/$50/$80
Rx Copays (Mail Order – 90 days)
2.5X Retail
2X Retail
2X Retail
Out of Network Coverage
Deductible
$5,000 / $10,000
$3,000 / $6,000
No out of network coverage
Coinsurance
30%
30%
Out of Pocket Maximum $10,000 / $20,000
$5,000 / $10,000
The best way to verify whether your doctor, lab or hospital participates in the Aetna Choice POS II Network is to call the provider and ask. You can also search online at www.aetna.com/docfind/custom/mymeritain or call customer service at (800) 925.2272 .
9
** For illustrative purposes only. Please refer to your plan documents for all plan details
Made with FlippingBook. PDF to flipbook with ease