MEDICAL INSURANCE
Wesgarde offers 2 medical plan options through Meritain Health. To find participating providers go to www.aetna.com click on “Find a Doctor”. When selecting a network, be sure to select Aetna Choice POS II Network.
The chart below provides a brief overview of the medical plan options available to you. 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.
Copay Plan (Silver)
HD HSA Plan (Gold)
IN-NETWORK: Plan Year / Contract Year Basis
Calendar Year
Calendar Year
Deductible (Individual / Family)
$3,000 / $6,000
$2,000 / $4,000
Maximum Out-of-Pocket (Individual/Family)
$6,000 / $12,000
$4,000 / $8,000
Out-of Pocket Max Includes
Deductible, Coinsurance, & Copays
Deductible & Coinsurance
Lifetime Major Medical Maximum
Unlimited
Unlimited
Coinsurance
100%
100%
Routine Preventive Services
Wellness Immunizations / Flu Shots Mammography/Colonoscopy CO-PAYS PCP Required / Open Access
Covered 100%
Covered 100%
Open Access
Open Access
Office Visits for Illness/Injury
$30 Copay
No Charge After Deductible
Specialist Visits
$40 Copay
No Charge After Deductible
Physical/Occupational/Speech Therapy
$40 Copay
No Charge After Deductible
Chiropractic Care (20 visits per calendar year for)
$30 Copay
No Charge After Deductible
Inpatient Hospital
Deductible & Coinsurance
No Charge After Deductible
Outpatient Surgery
Deductible & Coinsurance
No Charge After Deductible
Emergency Room (subject to a 30% penalty non accident/non-life threatening)
$300 Copay
No Charge After Deductible
Urgent Care
$75 Copay
No Charge After Deductible
OUTPATIENT DIAGNOSTIC SERVICES Lab Services (Freestanding Lab)
Covered 100% after Deductible
No Charge After Deductible
X-Ray Services (Freestanding X-Ray)
$50 Copay
No Charge After Deductible
Complex Diagnostic
$300 Copay
No Charge After Deductible
PRESCRIPTIONS Retail (30 day supply)
$10/ $50/ $75
10% After the Deductible
Specialty
50% up to $250 max Copay
10% After the Deductible
Mail Order (90 day supply)
2.5 X’s retail
10% After the Deductible
OUT-OF-NETWORK: Deductible (Individual / Family)
$6,000/$12,000
$3,000/$6,000
Maximum Out-of-Pocket (Individual/Family)
$12,000/$24,000
$6,000/$12,000
Coinsurance
70%/30%
70%/30%
Copay Plan (Silver)
HD HSA Plan (Gold)
Employee Cost Per Pay Period
Standard Rate $ 51.29 $156.59 $120.96 $190.09
Tobacco User Rate
Standard Rate $ 66.69 $203.59 $156.95 $232.00
Tobacco User Rate
Employee Only
$ 66.29 $171.59 $135.96 $205.09
$ 81.69 $218.59 $171.95 $247.00
Employee + Spouse Employee + Child(ren)
Family
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