MEDICAL INSURANCE
Fast Track Urgent Care offers medical coverage through Aetna, you have three plan options to choose from. To find participating providers go to www.Aetna.com and click on “Find a Doctor”, then follow the prompts to complete the search within the “Network Name” network. The chart below provides a briefly overview of the medical plan offered. This chart is intended only to highlight the benefits available and should not be relied upon to fully determine your coverage. If the below illustration of benefits conflicts in any way with the Summary Plan Description (SPD), the SPD shall prevail. It is recommended that you review your exact description of services and supplies that are covered, those which are excluded or limited, and other terms and conditions of coverage.
BASE PLAN
BUY-UP PLAN #1
BUY-UP PLAN #2
IN-NETWORK
(Non-) Embedded
(Non-) Embedded
(Non-) Embedded
DEDUCTIBLE
(your first dollar cost for covered in-network claims)
Deductible (Individual / Family)
$ / $
$ / $
$ / $
COINSURANCE
(your responsibility on claims costs once you’ve met the deductible) Member%
Member%
Member%
OUT OF POCKET MAXIMUM
(once met all in-network covered services are covered by the plan)
Maximum Out-of-Pocket (Individual / Family)
$ / $
$ / $
$ / $
Maximum Includes
Deductible, Coinsurance, Prescription Costs & Copays
PREVENTIVE CARE Wellness, Immunizations, Mammography, Colonoscopy, etc.
Covered 100%, no cost to you
OFFICE VISITS
Referral Required
No
Office Visits (Illness/Injury)
$
$
$
Specialist Visits
$
$
$
HOSPITAL SERVICES Inpatient Hospital
__% after deductible
__% after deductible
__% after deductible
Outpatient Surgery
__% after deductible
__% after deductible
__% after deductible
Emergency Room
__% after deductible
__% after deductible
__% after deductible
Urgent Care
__% after deductible
__% after deductible
__% after deductible
DIAGNOSTIC TESTING Lab, X-Ray, Advanced Imaging (MRI, CAT, PET, etc.)
__% after deductible
__% after deductible
__% after deductible
PRESCRIPTIONS Retail (30 day supply) Tier 1 / 2 / 3 / 4
$ / $ / $
$ / $ / $
$ / $ / $
Medicare (Part D) Creditable
Yes / No
Yes / No
Yes / No
OUT-OF-NETWORK 1
Refer to plan summary for details Bi-Weekly Cost for Coverage
Employee Only
$
$
$
Employee + Spouse
$
$
$
Employee + Child(ren)
$
$
$
Employee + Family
$
$
$
1 Charges are subject to balance billing
3
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