ÌÒñ«ÉçÇø

(January 1, 2024 through December 31, 2024)

The Choice plan, offers both in- and out-of-network coverage. This plan introduces a deductible and coinsurance for both in- and out-of-network services. In-network providers must be within the Aetna Managed Choice Network, which is a national network (in-network providers are available nation-wide).

• Coverage for Acupuncture – the coverage is limited to 10 visits per calendar year. In-network, $30 copayment per visit; out-of-network, member pays 30% coinsurance after the deductible has been satisfied.
• Coverage for Hearing Aids (for medical plans sitused in New York) – the coverage is limited to 1 hearing aid per ear every 3 years; in-network, member pays 15% coinsurance after deductible has been satisfied; out-of-network, member pays 40% coinsurance after deductible has been satisfied.

In-Network Benefits

• Co-payments of $30 to see a Primary Care Physician and $50 to see a Specialist. No referrals are needed.
• In-network mental health and substance abuse outpatient visits are covered at the primary office visit copayment ($30). Previously, these services were covered at the specialist office visit copayment ($50).
• Preventive care exams (PDF) are covered at 100%.
• All services beyond a regular office visit , including lab work performed at an in-network independent lab, are subject first to a $850 calendar year deductible for individual coverage, $1,700 calendar year deductible for employee + 1 and family coverage, then 15% member co-insurance. This includes lab work and x-ray s performed at an outpatient hospital facility, outpatient surgery, and inpatient hospitalization.
• $100 Emergency Room co-payment, which is waived if you (or a covered dependent ) are admitted to the hospital.
• The calendar year (in-network) Out-of-Pocket Maximum is $2,000 for an individual and $4,000 for employee + 1 and family coverage.
• In-network prescription co-payments of: $20 for generic medications, $45 for preferred brand medications, and $70 for non-preferred brand medications, after the calendar year deductible for non-generic prescriptions ($125 per person, $375 for +1 and family) has been satisfied. $0 co-payments for generic preventive medications on this list (PDF).
• Please review the Aetna Advance Control Plan Drug Guide brochure.

Out-of-Network Benefits

• The calendar year deductible is $2,500 for individual coverage and $5,000 for employee + 1 and family coverage.
• After the (calendar year) deductible is met, all services are subject to 40% employee co-insurance, until the Out-of-Pocket Maximum is reached.
• The annual (calendar year) Out-of-Pocket Maximum, which is based on 300% of Medicare rates, is $6,000 for individual coverage and $12,000 for employee + 1 and family coverage. For out-of-network providers, you may, in fact, pay more than the Out-of-Pocket Maximum if your provider charges rates that are above the 300% of Medicare guidelines.
• In most cases, for out-of-network services, employees pay in advance for services and submit a claim form to Aetna Healthcare. All claim forms are located on the Human Resources web page under "Forms."