|
Aetna Open Choice POS II |
Open Access Aetna Select |
MMSI Health Tradition PPO |
In-Network Benefits |
Out-of-Network Benefits |
In-Network Benefits |
Out-of-Network Benefits |
Choice of Physician |
Choice of in-network physician(s) or out-of-network physician(s) |
Choice of in-network physician(s) only, no pre-selection of a primary care physician necessary |
Choice of in-network physician(s)
or out-of-network physician(s) |
Deductible per
Plan Year |
$1,750 Individual $3,500 Family |
$3,500 Individual
$7,000 Family |
None |
$500 Individual
$1,000 Family |
$2,000 Individual
$4,000 Family |
Annual Out-of-Pocket Maximum |
$4,000 Individual
$8,000 Family |
$6,000 Individual
$12,000 Family |
$1,500 Individual
$3,000 Family |
$3,000 Individual
$6,000 Family |
$4,000 Individual
$8,000 Family |
Basic Care |
Primary Physician Office Visits (Family & Gen. Practice, Int. Medicine, & Pediatrician) |
90% after deductible |
70% after deductible |
$15 co-pay
per visit |
$15 co-pay per visit |
70% after deductible |
Specialist Physician Office Visit |
90% after deductible |
70% after deductible |
$40 co-pay
per visit |
$40 co-pay per visit |
70% after deductible |
Outpatient X-ray & Laboratory |
90% after deductible |
70% after deductible |
No co-pay |
90% after deductible |
70% after deductible |
Physical, Occupational, Speech Therapy (max 60 visits per plan year) |
90% after deductible |
70% after deductible |
$15 co-pay
per visit |
90% after deductible |
70% after deductible |
Hearing & Vision |
Hearing Examinations |
$10 co-pay per visit |
No benefit |
$10 co-pay
per visit |
$10 co-pay per visit |
No benefit |
Vision Examinations |
$10 co-pay per visit |
No benefit |
$10 co-pay
per visit |
$10 co-pay per visit |
No benefit |
Vision Materials (frames, lenses, contacts, etc.) |
Discounts available through Vision One program at Sears, JC Penney & Target |
Discounts available through Vision One program at Sears,
JC Penney &
Target |
Discounts available through (VSP) Vision Service Plan |
Wellness |
Routine Physicals, Exams, Pap Smears, Mammograms, Immunizations |
100% no deductible |
70% after deductible |
No co-pay
|
No co-pay |
70% after deductible |
Well Baby Care |
100% no deductible |
70% after deductible |
No co-pay |
No co-pay |
70% after deductible |
Chiropractor (maximum 20 visits per plan year) |
90% after deductible |
70% after deductible |
$15 co-pay
per visit |
90% after deductible |
70% after deductible |
Maternity Care |
Office Visits |
90% after deductible |
70% after deductible |
$15 co-pay
first visit only |
$15 co-pay first visit only |
70% after deductible |
Delivery |
90% after deductible |
70% after deductible |
$300 co-pay |
90% after deductible |
70% after deductible |
Inpatient Hospital Care & Outpatient Surgery |
Inpatient Hospital |
90% after deductible |
70% after deductible |
$300 co-pay
per admission |
90% after deductible |
70% after deductible |
Outpatient Surgery |
90% after deductible |
70% after deductible |
$150 co-pay |
90% after deductible |
70% after deductible |
Emergency Care & Urgent Care |
Emergency Room (waived if admitted) |
$100 co-pay, plus 10% co-insurance after deductible |
$100 co-pay, plus 10% co-insurance after in-network deductible |
$150 co-pay |
$150 co-pay, plus 10% co-insurance after deductible |
$150 co-pay, plus 10% co-insurance after in-network deductible |
Urgent Care Facility |
$50 co-pay, plus 10% co-insurance after deductible |
$50 co-pay, plus 10% co-insurance after in-network deductible |
$50 co-pay
per visit |
$50 co-pay, plus 10% co-insurance after deductible |
$50 co-pay, plus 10% co-insurance after in-network deductible |
Ambulance |
Ground |
90% after deductible |
70% after deductible |
No co-pay |
90% after deductible |
90% after deductible |
Air |
90% after deductible |
70% after deductible |
No co-pay |
90% after deductible |
90% after deductible |
Extended Care |
Home Health Care (maximum 40 visits per plan year) |
90% after deductible |
70% after deductible |
$15 co-pay
per visit |
90% after deductible |
70% after deductible |
Skilled Nursing (maximum 60 days) |
90% after deductible |
70% after deductible |
$150 co-pay
per admission |
90% after deductible |
70% after deductible |
Hospice Care |
90% after deductible |
70% after deductible |
No co-pay |
90% after deductible |
70% after deductible |
Prescriptions |
| If you choose a brand name drug over an available generic drug, you will pay the generic co-pay plus the difference in cost between the generic drug and the brand name drug. If your doctor indicates that you must take the brand name drug, then you will pay only the applicable brand drug co-pay. |
Generic |
$10 co-pay |
50% co-insurance |
$10 co-pay |
$10 co-pay |
50% co-insurance |
Brand Name |
20% co-insurance
($30 min-$50 max) |
50% co-insurance |
20% co-insurance
($30 min-$50 max) |
20% co-insurance
($30 min-$50 max) |
50% co-insurance |
Non-Formulary |
40% co-insurance
($50 min-$100 max) |
50% co-insurance |
40% co-insurance
($50 min-$100 max) |
40% co-insurance
($50 min-$100 max) |
50% co-insurance |
Mail Order Generic |
$20 (90-day supply) |
No benefit |
$20
(90-day supply) |
$20 (90-day supply) |
No benefit |
Mail Order Brand Name |
$60 (90-day supply) |
No benefit |
$60
(90-day supply) |
$60 (90-day supply) |
No benefit |
Mail Order Non-Formulary |
$110 (90-day supply) |
No benefit |
$110
(90-day supply) |
$110 (90-day supply) |
No benefit |
EMPLOYEE ASSISTANCE PROGRAM |
|
This program provides ancillary work-life benefits at no cost to employees and family members for a wide array of non-medical issues, such as stress management, marriage and family issues, et. The EAP also includes referral services for child and elder care, adoption assistance, legal assistance and other services.
You receive five (5) free visits per issue, per 12 month period.
Call 800-554-6931 or visit their website at www.cignabehavioral.com |
Mental Health |
CIGNA Behavioral Health Outpatient Psychological Consultations |
$15 co-pay for first 30 visits, $30 per visit thereafter |
$15 co-pay for first 30 visits, $30 per visit thereafter |
$15 co-pay for first 30 visits, $30 per visit thereafter |
Non-CIGNA Behavioral Health Outpatient Psychological Consultations |
In-network 90% after deductible, out-of-network 70% after deductible |
No benefit |
90% after out-of-network deductible |
CIGNA Behavioral Health Inpatient Care |
No benefit |
$300 co-pay
per admission;
covered at 80% |
No benefit |
Non-CIGNA Behavioral Health Inpatient Care |
$150 co-pay per admission, covered at 80% |
No benefit |
$150 co-pay per admission, covered at 80% |
Maximum Lifetime Benefit |
Lifetime Maximum |
$2,000,000 maximum per person combined all plans. |
$2,000,000 maximum per person combined all plans. |