| Benefits | Basic Managed Care Plan | Managed Care Plan | HCRA Plan |
|---|---|---|---|
| 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 $45 Specialist copay |
30% after deductible |
| Emergency | $100 copay (after deductible) |
$100 copay | 30% after deductible |
| Urgent Care Facility | $45 copay (after deductible) |
$40 copay | 30% after deductible |
| 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 |
$4,600 single $9,200 family (after HCRA fund) |
Note: Prescription drug coverage is included in the medical plan. Prescription drug expenses are not subject to the medical plan deductible
| Benefits | Basic Managed Care Plan | Managed Care Plan | HCRA Plan |
|---|---|---|---|
| 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 |
$2,000 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.
| Benefit | In-Network You Pay |
Out-of-Network You Pay |
|---|---|---|
| Deductible (Individual/Family)* | $25/$75 (waived for preventive services) | $25/$75 (waived for preventive services) |
| Annual Benefit Maximum | $2,000 per person | $2,000 per person |
| Orthodontia Lifetime Maximum | $1,500 per person | $1,000 per person |
| Type A — (cleanings, oral exams and other maintenance type procedures) | 0% of PDP Fee** | 0% of R&C Fee*** |
| Type B — (fillings and other standard dental procedures) | After deductible, 15% of PDP Fee** | After deductible, 20% of R&C Fee*** |
| Type C — (bridges, dentures and other complex procedures) | After deductible, 35% of PDP Fee** | After deductible, 40% of R&C Fee*** |
| Type D — Orthodontia | 50% of PDP Fee** | 50% of R&C Fee*** |
* Applies only to type B & C services combined.
** PDP Fee refers to the fees that participating PDP dentists have agreed to accept as payment in full, subject to any copayments, deductibles, cost
sharing, and benefit maximums.
*** R&C Fee refers to the Reasonable and Customary (R&C) charge, which is based on the lowest of (1) the dentist’s actual charge, (2) the dentist’s
usual charge for the same or similar services, or (3) the charge of most dentists in the same geographic area for the same or similar services as
determined by MetLife.
| 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 |
| Frames (one every 24 months) | No copay; $120 allowance + 20% off balance over $120 | Up to $48 | No copay; $180 allowance + 20% off balance over $180 | $90 |
| Lenses (one every 12 months) | Single Vision: $25 copay Bifocal: $25 copay Trifocal: $25 copay |
Single Vision: Up to $25 Bifocal: Up to $40 Trifocal: Up to $60 |
No copay | Single Vision: Up to $25 Bifocal: Up to $39 Trifocal: Up to $63 |
| Contact Lenses (one order every 12 months) | Conventional: No copay; $135 allowance + 15% balance over $135 Disposable: No copay; $135 allowance Medically Necessary: No copay; Paid in Full |
Conventional: Up to $135 Disposable: Up to $95 Medically Necessary: Up to $200 |
Conventional: No copay; $180 allowance + 15% balance over $180 Disposable: No copay; $180 allowance Medically Necessary: No copay; Paid in Full |
Conventional: Up to $144 Disposable: Up to $144 Medically Necessary: Up to $200 |