Benefit Summary
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Plan NameAetna Choice® POS II
DescriptionAll Employees
CarrierAetna Inc
Policy Type Medical POS (2-Tier)
Effective Dates1/1/2023 to 1/1/2024
Benefit Attributes - All EmployeesPOS In-NetworkPOS Out-of-Network
Emergency Services
Emergency Room$75 copay (Waived if admitted)$75 copay, no deductible (Waived if admitted)
General Plan Information
Annual Deductible/Individual$0$1,500
Deductible Included in Out-of-Pocket LimitsN/AYes
Office Visit/Exam$35 copay70% after deductible
Outpatient Specialist Visit$35 copay70% after deductible
Annual Out-of-Pocket Limit/Individual$5,050$9,000
Annual Out-of-Pocket Limit/Family$10,100$18,000
Annual Deductible/Family$0$3,000
Coinsurance100%70%
Inpatient Hospital Services
Inpatient Hospitalization$250 copay ($625 copay max per Calendar Year)70% after deductible
Diagnostic X-Ray and Lab Tests100%70% after deductible
Outpatient Facility Charges100%70% after deductible
Mail Order
Generic$20 copayNot covered
Non-preferred SpecialtyN/AN/A
Brand (Non-Formulary/Non-preferred)$120 copayNot covered
Preferred GenericN/AN/A
Number of Days Supply for Mail Order31-90 daysN/A
Brand (Formulary/Preferred)$60 copayNot covered
Preferred SpecialtyN/AN/A
Maternity Care
Pregnancy and Maternity Care (Pre-Natal Care)100% for Prenatal: Delivery: $250 copay70% after deductible
Mental Health Benefits
Inpatient Care$250 copay ($625 copay max per Calendar Year)70% after deductible
Outpatient Care$35 copay for Office visit; Other outpatient services: 100%70% after deductible
Other Services and Supplies
Chiropractic Services$35 copay70% after deductible
Outpatient Rehabilitative Therapy Services
Occupational$35 copay (combined limit to 30 visits per Calendar Year)Not covered
Speech$35 copay (Visits combined with occupational In-network services)Not covered
Physical$35 copay (Limited 90 visits per Calendar Year)Not covered
Outpatient Services
Diagnostic X-Ray and Lab Tests100%70% after deductible
Adult Periodic Exams with Preventive Tests100%70% after deductible
Well-Child Care100%70% after deductible
Pediatric DentalNot coveredNot covered
Immunizations100%70% after deductible
Pediatric VisionNot coveredNot covered
Prescription Drug Benefits
Preferred GenericN/AN/A
Non-preferred Specialty$30 copayNot covered
Brand (Non-Formulary/Non-preferred)$60 copayNot covered
Generic$10 copayNot covered
Prescription Drug Deductible$50 specific deductibleN/A
Brand (Formulary/Preferred)$30 copayNot covered
InjectablesN/AN/A
Number of Days Supply30 daysN/A
Preferred Specialty$10 copayNot covered
Substance Abuse
Outpatient Services$35 copay for Office visit; Other outpatient services: 100%70% after deductible
Inpatient Hospitalization$250 copay ($625 copay max per Calendar Year)70% after deductible
Urgent Care
Urgent Care Facility$35 copay70% after deductible