Medical and Pharmacy Coverage
Teen Challenge offers the following Medical plans through
Aetna and offers “in and out-of-network” benefits.
Insurance Carrier:
Aetna Medical Insurance
Medical Plan:
Copay Plan - $5k / 80%
HDHP w/HSA - $5k / 100%
In-Network: Office Visit Copay - Primary Care
$45
Deductible; then 100% Coinsurance
Office Visit Copay - Specialist Care
$80
Deductible; then 100% Coinsurance
Urgent Care Copay
$75
Deductible; then 100% Coinsurance
Emergency Room Care
$425 Copay; then 100% Coinsurance
Deductible; then 100% Coinsurance
Preventative Visit Copay
$0
$0
Diagnostic Testing (X-Ray / Blood Work)
Deductible; then 80% Coinsurance
Deductible; then 100% Coinsurance
Advanced Imaging
Deductible; then 80% Coinsurance
Deductible; then 100% Coinsurance
Coinsurance
80%
100%
Employee Deductible
$5,000
$5,000
Family Deductible
$10,000
$10,000
Employee Out-of-Pocket Max
$7,500 (includes deductible)
$5,500 (includes deductible)
Family Out-of-Pocket Max
$15,000 (includes deductible)
$11,000 (includes deductible)
Inpatient Hospital
Deductible; then 80% Coinsurance
Deductible; then 100% Coinsurance
Outpatient Hospital or Facility
Deductible; then 80% Coinsurance
Deductible; then 100% Coinsurance
Out-of-Network: Coinsurance
60%
70%
Employee Deductible
$10,000
$10,000
Family Deductible
$20,000
$20,000
Employee Out-of-Pocket Max
$21,450
$13,500
Family Out-of-Pocket Max
$42,900
$27,000
Prescription Drugs: ( 30 Day Supply) Rx Deductible
$150 Individual / $300 Family
Combined with Medical
Tier 1 - Generic
$15
Deductible; then $10
Tier 2 - Preferred
$45
Deductible; then $35
Tier 3 - Non-Preferred
$85
Deductible; then $60
Tier 4 - Specialty
$125
Deductible; then 100% Coinsurance
Employee Bi-Weekly Deduction Employee Only
$57.08
$52.40
Employee + Spouse
$342.50
$314.38
Employee + Child(ren)
$313.97
$288.18
Family
$627.93
$576.37
6
TEEN CHALLENGE 2023 BENEFITS GUIDE
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