Plan Features
Aetna HSA $4000
Aetna HSA $2500
Aetna OAP
Medical
IN NETWORK Deductibles (Indiv / Family)
$4,000 / $8,000
$2,500 / $5,000
$1,500 / $3,000
$0
100%
$0
Preventive Care
Ded. then $40 Ded. then $60
Ded. & 20% Coins. Ded. & 20% Coins. Ded. & 20% Coins. Ded. & 20% Coins. Ded. & 20% Coins. Ded. & 20% Coins. Ded. & 20% Coins. Ded. & 20% Coins.
$30 $50
Primary Care Visit
Specialist Visit
Ded. Ded. Ded. Ded.
100% 100%
Diagnostic Exam
X-Rays
Ded. & 10% Coins. Ded. & 10% Coins.
Outpatient Procedure
Inpatient Visit
Ded. then $100 Ded. then $75
$150
Emergency Room
$75
Urgent Care
Ded. then $10.00 / $40.00 / $70.00
Ded. then $10.00 / $40.00 / $70.00
Pharmacy / RX (30 Day Supply) Pharmacy / RX (90 Day Supply)
$10.00 / $40.00 / $70.00
2.5x
2.5x
2.5x
$6,250 / $12,500
$5,000 / $10,000
$3,000 / $6,000
Out-of-Pocket Max (Indiv / Family)
OUT OF NETWORK Deductibles (Indiv / Family)
Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered Not Covered
$5,000 / $10,000 Ded. & 50% Coins. Ded. & 50% Coins. Ded. & 50% Coins. Ded. & 50% Coins. Ded. & 50% Coins. Ded. & 50% Coins. Ded. & 50% Coins. Ded. & 20% Coins. Ded. & 50% Coins.
$3,000 / $6,000
Not Covered
Preventive Care
Ded. & 50% Coins. Ded. & 50% Coins.
Primary Care Visit
Specialist Visit
Not Covered Not Covered
Diagnostic Exam
X-Rays
Ded. & 50% Coins. Ded. & 50% Coins.
Outpatient Procedure
Inpatient Visit
$150
Emergency Room
Ded. & 50% Coins.
Urgent Care
Not Covered
$10,000 / $20,000
$6,000 / $12,000
Out-of-Pocket Max (Indiv / Family)
Weekly $41.62 $197.47 $152.98 $259.48
Bi-Weekly
Weekly $64.28 $249.49 $197.73 $396.66
Bi-Weekly
Weekly $90.86 $300.68 $242.26 $465.54
Bi-Weekly
EMPLOYEE COST
$83.23 $394.95 $305.95 $518.95
$128.56 $498.97 $395.45 $793.33
$181.72 $601.35 $484.53 $931.08
Employee
Employee + Spouse
Employee + Child(ren)
Employee + Family
Let’s keep moving, New York. Let’s keep moving.
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