Medical and Pharmacy Coverage
Hi Tech Utility offers the following Medical plans through Aetna and offers “in and out-of-network” benefits. Please review as each plan has different benefits which are highlighted. Insurance Carrier: Aetna Medical Insurance Medical Plan:
$2,500 / 80% Copay Plan $5,000 / 100% Copay Plan $6,750 / 100% IRx Plan
In-Network: Office Visit Copay - Primary Care
$35
$35
$25
Office Visit Copay - Specialist Care
$70
$70
Deductible; then 100% Coinsurance
Urgent Care Copay
$75
$75
$50
Emergency Room Care
Deductible; then 80% Coinsurance
Deductible; then 100% Coinsurance
Deductible; then 100% Coinsurance
Preventative Visit Copay
$0
$0
$0
Diagnostic Testing (X-Ray / Blood Work)
Deductible; then 80% Coinsurance
Deductible; then 100% Coinsurance
Deductible; then 100% Coinsurance
Advanced Imaging
Deductible; then 80% Coinsurance
Deductible; then 100% Coinsurance
$500 Copay; (applies to deductible)
Coinsurance
80%
100%
100%
Employee Deductible
$2,500
$5,000
$6,750
Family Deductible
$5,000
$10,000
$13,500
Employee Out-of-Pocket Max
$6,000 (includes deductible)
$7,150 (includes deductible)
$8,150 (includes deductible)
Family Out-of-Pocket Max
$12,000 (includes deductible)
$14,300 (includes deductible)
$16,300 (includes deductible)
Inpatient Hospital
Deductible; then 80% Coinsurance
Deductible; then 100% Coinsurance $1,000 Copay; (applies to deductible)
Outpatient Hospital or Facility
Deductible; then 80% Coinsurance
Deductible; then 100% Coinsurance $1,000 Copay; (applies to deductible)
Out-of-Network: Coinsurance
50%
50%
N/A
Employee Deductible
$5,000
$10,000
N/A
Family Deductible
$15,000
$30,000
N/A
Employee Out-of-Pocket Max
$15,000
$25,000
N/A
Family Out-of-Pocket Max
$45,000
$75,000
N/A
Prescription Drugs: ( 30 Day Supply) Tier 1a / 1b - Generic
$3 / $10
$3 / $10
$2 / $15
Tier 2 - Preferred
$50
$50
$85 (after deductible)
Tier 3 - Non-Preferred
$80
$80
$125 (after deductible)
Tier 4 - Specialty - Preferred
20% to a $250 max
20% to a $250 max
$275 (after deductible)
Tier 4 - Specialty - Non-Preferred
40% to a $500 max
40% to a $500 max
$575 (after deductible)
Employee Weekly Deduction Employee Only
$54.03
$45.97
$24.61
Employee + Spouse
$172.23
$157.53
$115.49
Employee + Child(ren)
$158.32
$144.81
$104.38
Family
$267.00
$247.61
$187.54
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HI TECH UTILITY 2024 BENEFITS GUIDE
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