| Benefits | Basic Managed Choice | Managed Choice | HCRA (Aetna Healthfund) |
|---|---|---|---|
| You Pay | You Pay | You Pay | |
| Preventative Services | $0 | $0 | $0 |
| Office Visits Primary Care Physician (PCP) Specialist |
$30 PCP copay (after deductible) $45 Specialist copay (after deductible) |
$30 PCP copay $40 Specialist copay |
Deductible and Coinsurance |
| Emergency | $100 copay (after deductible) |
$100 copay | Deductible and Coinsurance |
| Urgent Care Facility | $45 copay (after deductible) |
$40 copay | Deductible and Coinsurance |
| Deductible | $2,500 single $5,000 family |
$1,250 single $2,500 family |
$2,000 single $4,000 family |
| HCRA Fund | N/A | No | $1,000 single $2,000 family |
| Deductible after HCRA Fund | N/A | N/A | $1,000 single $2,000 family |
| Coinsurance | 35% | 35% | 30% |
| Annual Out-of-Pocket Maximum | $6,000 single $12,000 family |
$4,750 single $9,500 family |
$5,600 single $11,200 family |
Note: Prescription drug coverage is included in the medical plan. Prescription drug expenses are not subject to the medical plan deductible
| Benefits | Basic Managed Choice | Managed Choice | HCRA (Aetna Healthfund) |
|---|---|---|---|
| You Pay | You Pay | You Pay | |
| Office Visits and Preventative Care |
Deductible and Coinsurance | Deductible and Coinsurance | Deductible and Coinsurance |
| Emergency | $100 copay (after deductible) |
$100 copay | Deductible and Coinsurance |
| Deductible | $7,000 single $14,000 family |
$3,000 single $6,000 family |
$6,000 single $12,000 family |
| Coinsurance* | 50% | 50% | 50% |
| Annual Out-of-Pocket Maximum | $12,000 single $24,000 family |
$10,000 single $20,000 family |
$10,000 single $20,000 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.
| Type of Drug | Definition | Retail Pharmacy (Non-ShopRite) |
ShopRite Pharmacies or Spotswood Mail-Order |
|---|---|---|---|
| For a 30-day Supply | For a 90-day Supply | ||
| Generic | Drug with same active ingredients as brand name, with lower cost | $15 | $15 |
| Preferred Brand** | Drug marketed under a specific trademark or name by specific drug manufacturer and included on Aetna's drug list. | $40 | $40 |
| 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. | $60 | $60 |
| Specialty Brand | High-cost prescription medications used to treat complex, chronic conditions | $60 | Contact your local pharmacy for more information. |
* The cost of prescriptions under the Basic Managed Care Plan uses coinsurance. You pay 30% of the cost for Generic and Preferred Brand and
50% of the Non-Preferred Brand (not subject to the medical plan deductible).
** 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.
| Active PPO with PPOII and Extend(SM) Networks |
In-Network You Pay |
Out-of-Network You Pay |
|---|---|---|
| Annual Deductible - Individual* | $25 | $25 |
| Annual Deductible - Family* | $75 | $75 |
| Preventative Services | 100% | 100% |
| Basic Services | 85% | 80% |
| Major Services | 65% | 60% |
| Annual Benefit Maximum | $2,000 | $2,000 |
| Office Visit Copay | N/A | N/A |
| Orthodonic Services** | 50% | 50% |
| Orthodonic Deductible | None | None |
| Orthodonic Lifetime Maximum | $1,500 | $1,500 |
*The deductible applies to Basic and Major Services only.
**Orthodontia is covered only for children (appliance must be placed prior to age 20).
| Benefit | EyeMed Option 1 In-Network Member Cost |
EyeMed Option 1 Out-of-Network Member Cost |
EyeMed Option 2 In-Network Member Cost |
EyeMed Option 2 Out-of-Network Member Cost |
|---|---|---|---|---|
| Exam (one every 12 months) | $10 copay | Up to $35 | No copay | Up to $28 |
| Lenses (one every 12 months) | ||||
|
Single
Bifocal Trifocal |
$25 copay
$25 copay $25 copay |
Up to $25
Up to $40 Up to $60 |
No copay
No copay No copay |
Up to $25
Up to $39 Up to $63 |
| Contact Lenses (one order every 12 months) |
||||
| Conventional | No copay; $135 allowance + 15% off balance over $135 | Up to $95 | No copay; $180 allowance + 15% off balance over $180 | Up to $144 |
| Disposable | No copay; $135 allowance | Up to $95 | No copay; $180 allowance | Up to $144 |
| Medically Necessary | No copay; Paid in Full | Up to $200 | No copay; Paid in Full | Up to $200 |