DECIDE

Take some time and review the many new choices, programs and resources available to help keep you and your family healthy. 

In-Network Medical Services

Benefits Basic Managed Choice
(You Pay)
Preventative Services $0
Office Visits
Primary Care Physician (PCP) Specialist 		$30 PCP copay (after deductible)
$45 Specialist copay (after deductible)
Emergency $100 copay (after deductible)
Urgent Care Facility $45 copay (after deductible)
Deductible $2,500 single
$5,000 family
HCRA Fund N/A
Deductible after HCRA Fund N/A
Coinsurance 35%
Annual Out-of-Pocket Maximum $6,000 single
$12,000 family

Note: Prescription drug coverage is included in the medical plan. Prescription drug expenses are not subject to the medical plan deductible

Out-of-Network Medical Services

Benefits Basic Managed Choice
(You Pay)
Office Visits and Preventative Care
 Deductible and Coinsurance
Emergency $100 copay (after deductible)
Deductible $7,000 single
$14,000 family
Coinsurance* 50%
Annual Out-of-Pocket Maximum $12,000 single
$24,000 family

* The plan pays out-of-network benefits based on Medicare reimbursement levels (up to 110% of Medicare for professional services and 140% for facility charges). In addition to your coinsurance, you are responsible for amounts that exceed these levels.

Prescription Drugs: HCRA Plan*

Type of Drug Definition
Generic Drug with same active ingredients as brand name, with lower cost
Preferred Brand* Drug marketed under a specific trademark or name by specific drug manufacturer and included on Aetna's drug list.
Non Preferred Brand*
(No generic available) 		Drug marketed under a specific trademark or name by specific drug manufacturer and NOT included on Aetna's drug list.
Specialty Brand High-cost prescription medications used to treat complex, chronic conditions

* If you or your physician requests a brand-name medication when a generic is available, you will pay the applicable copay plus the difference between the cost of the generic and brand-name drug.