Medical and Pharmacy Coverage
Teen Challenge offers the following plans through Aetna. Please reference the Summary Plan Description for more details.
Insurance Carrier: Medical Plan Number:
Aetna Medical Insurance
Copay plan - $5k / 80%
HDHP w/HSA - $5k / 100%
In-Network: Office Visit Copay - Primary Care Office Visit Copay - Specialist Care
$45 Copay $80 Copay $75 Copay
Deductible; then 100% Coinsurance Deductible; then 100% Coinsurance Deductible; then 100% Coinsurance
Urgent Care Copay Emergency Room Care Preventative Visit Copay
$425 Copay; then 80% Coinsurance Deductible; then 100% Coinsurance
$0
$0
Diagnostic Testing & Blood Work
Deductible; then 80% Coinsurance Deductible; then 100% Coinsurance Deductible; then 80% Coinsurance Deductible; then 100% Coinsurance
Advanced Imaging
Coinsurance
80%
100%
Employee Deductible Family Deductible
$5,000 $10,000
$5,000 $10,000
Employee Out-of-Pocket Max Family Out-of-Pocket Max
$7,500 (includes deductible) $15,000 (includes deductible)
$5,500 (includes deductible) $11,000 (includes deductible)
Inpatient Hospital
Deductible; then 80% Coinsurance Deductible; then 100% Coinsurance Deductible; then 80% Coinsurance Deductible; then 100% Coinsurance
Outpatient Hospital or Facility
Out-of-Network: Coinsurance
70%
70%
Employee Deductible Family Deductible
$10,000 $20,000 $20,000 $40,000
$10,000 $20,000 $20,000 $40,000
Employee Out-of-Pocket Max Family Out-of-Pocket Max
Prescription Drugs: ( 30 Day Supply) Rx Deductible
$0
Combined with Medical Deductible; then $10 Copay Deductible; then $30 Copay Deductible; then $60 Copay Deductible; then $250 Copay
Tier 1 - Generic Tier 2 - Preferred
$15 Copay $35 Copay $65 Copay $250 Copay
Tier 3 - Non-Preferred
Tier 4 - Specialty
Employee Bi-Weekly Deduction Employee Only
$54.28
$50.44
Employee + Spouse Employee + Child(ren)
$325.64 $298.51 $597.03
$302.61 $277.39 $554.78
Family
7 Teen Challenge 2022 Enrollment Guide
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