Aetna Select 1 |
Aetna Select 2 |
Aetna Choice POS II 600 |
Aetna Choice POS II HRA |
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| Network | Aetna Select Open Access |
Aetna Select Open Access |
Aetna Choice POS II (Open Access) |
Aetna Choice POS II (Open Access) |
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| Plan Provisions | Out-of-Network |
Out-of-Network |
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| Health Reimbursement Account (HRA) Per Member | $600 paid up front by UM per member (up to $1,800 per family) reduces your annual deductible |
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| Calendar Year Deductible | ||||||||||
| Individual | N/A |
$250 |
$600 |
$1,200 |
$1,500 |
$3,000 |
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| Family | N/A |
$750 |
$1,800 |
$3,600 |
$4,500 |
$9,000 |
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| Well 'Canes Preventive Care Services | ||||||||||
| Physician Expenses | ||||||||||
| Primary Care Physician | $15 copay |
$20 copay |
$20 copay |
$25 copay |
$15 copay |
$20 copay |
Deductible then 20% coinsurance |
Deductible then $15 copay |
Deductible then $20 copay |
Deductible then 30% coinsurance |
| Specialist | $25 copay |
$40 copay |
$35 copay |
$50 copay |
$25 copay |
$40 copay |
Deductible then 40% coinsurance |
Deductible then $25 copay |
Deductible then $40 copay |
Deductible then 30% coinsurance |
| Maternity (Office Services) | $25 copay for first visit, then all office services covered at 100% |
$40 for first visit, then all office services covered at 100% |
$35 copay for first visit, then all office services covered at 100% |
$50 copay for first visit, then all office services covered at 100% |
$25 copay for first visit, then all office services covered at 100% |
$40copay for first visit, then all office services covered at 100% |
Deductible, then 40% coinsurance |
Deductible then $25 copay for the first visit, then all office services covered at 100% |
Deductible, then $40 copay for first visit, then all office visits covered at 100% |
Deductible, then 30% coinsurance |
| Allergy Injections (per visit) |
$5 copay |
$5 copay |
$5 copay |
$5 copay |
$5 copay |
$5 copay |
Deductible, then 40% coinsurance |
Deductible, then $5 copay |
Deductible, then $5 copay |
Deductible, then 30% coinsurance |
| Hospital Expenses | ||||||||||
| Inpatient | $150 copay per day to a maximum of $750 per admission |
$250 copay per day to a maximum of $1,250 per admission |
Deductible then $200 copay per day to a maximum of $1,000 per admission |
Deductible then $300 copay per day to a maximum of $1,500 per admission |
Deductible then $150 copay per day to a maximum of $750 per admission |
Deductible then $250 copay per day to a maximum of $1,250 per admission |
Deductible then 40% coinsurance |
Deductible then $100 copay per day to a maximum of $500 per admission |
Deductible then $200 copay per day to a maximum of $1,000 per admission |
Deductible then 30% coinsurance |
| Emergency Room | $100 copay |
$100 copay |
Deductible then $150 copay |
Deductible then $150 copay |
Deductible then $100 copay |
Deductible then $100 copay |
Deductible then $100 |
Deductible then $100 copay |
Deductible then $100 copay |
Deductible then $100 copay |
| Urgent Care | $50 copay |
$50 copay |
Deductible then $75 copay |
Deductible then $75 copay |
Deductible then $40 copay |
Deductible then $40 copay |
Deductible then 40% coinsurance |
Deductible then $35 copay |
Deductible then $35 copay |
Deductible then 30% coinsurance |
| Minute Clinics | N/A |
$20 copay |
N/A |
$25 copay |
N/A |
$20 copay |
Deductible then 40% coinsurance |
N/A |
Deductible then $20 copay |
Deductible then 30% coinsurance |
| Ambulance | $0 copay |
$0 copay |
Deductible then $0 copay |
Deductible then $0 copay |
Deductible then 20% coinsurance |
Deductible then 20% coinsurance |
Deductible then 20% coinsurance |
Deductible then 20% coinsurance |
Deductible then 20% coinsurance |
Deductible then 20% coinsurance |
| Outpatient Services | ||||||||||
| Surgery | $100 copay |
$150 copay |
Deductible then $100 copay |
Deductible then $250 copay |
Deductible then $50 copay |
Deductible then $150 copay |
Deductible then 40% coinsurance |
Deductible then $50 copay |
Deductible then $150 copay |
Deductible then 30% coinsurance |
| High-end Imaging (MRI, PET, CT, MRA and SPECT) | $150 copay |
$250 copay |
Deductible then $150 copay |
Deductible then $350 copay |
Deductible then 10% coinsurance |
Deductible then 20% coinsurance |
Deductible then 40% coinsurance |
Deductible then $100 copay |
Deductible then $250 copay |
Deductible then 30% coinsurance |
| Low-end Imaging (all other non-invasive services) | $0 copay |
$30 copay |
$0 copay |
Deductible then $50 copay |
$0 copay |
Deductible then 20% coinsurance |
Deductible then 40% coinsurance |
Deductible then $0 copay |
Deductible then $40 copay |
Deductible then 30% coinsurance |
| Lab Work (Quest) | $0 copay |
$0 copay |
$0 copay |
$0 copay |
$0 copay |
$0 copay |
Deductible then 40% coinsurance |
Deductible then $0 copay |
Deductible then $0 copay |
Deductible then 30% coinsurance |
Outpatient Therapy (Physical, Speech and Occupational
|
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| Per Visit | $15 copay |
$20 copay |
$20 copay |
$25 copay |
$15 copay |
$20 copay |
Deductible then 40% coinsurance |
Deductible then $15 copay |
Deductible then $20 copay |
Deductible then 30% coinsurance |
| Outpatient Chemotherapy and Radiation | ||||||||||
| Facility | $0 copay |
$20 copay |
Deductible then $0 copay |
Deductible then $20 copay |
Deductible then $0 copay |
Deductible then 20% coinsurance |
Deductible then 40% coinsurance |
Deductible then $0 copay |
Deductible then 20% coinsurance |
Deductible then 30% coinsurance |
| Physician | $0 copay |
$0 copay |
Deductible then $0 copay |
Deductible then $0 copay |
Deductible then $0 copay |
Deductible then 20% coinsurance |
Deductible then 40% coinsurance |
Deductible then $0 copay |
Deductible then 20% coinsurance |
Deductible then 30% coinsurance |
| Medical Out-of-Pocket Maximum | ||||||||||
| Individual | $3,000 |
$4,000 |
$4,100 |
$8,200 |
$3,500 |
$7,000 |
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| Family | $9,000 |
$12,000 |
$12,300 |
$24,600 |
$10,500 |
$21,000 |
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| Prescription Drugs | Not included in Out-of-Pocket Maximum |
Not included in Out-of-Pocket Maximum |
Not included in Out-of-Pocket Maximum |
Included in Out-of-Pocket Maximum |
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| Level One | $10 copay |
$10 copay |
$10 copay |
$10 copay |
$10 copay |
$10 copay |
not covered |
$10 copay |
$10 copay |
not covered |
| Level Two | $35 Copay |
$35 copay |
$35 copay |
$35 copay |
$35 copay |
$35 copay |
not covered |
$35 copay |
$35 copay |
not covered |
| Level Three | $55 Copay |
$55 copay |
$55 copay |
$55 copay |
$55 copay |
$55 copay |
not covered |
$55 copay |
$55 copay |
not covered |
| Level Four | $100 Copay |
$100 copay |
$100 copay |
$100 copay |
$100 copay |
$100 copay |
not covered |
$100 copay |
$100 copay |
not covered |
| 90 Days at UM Pharmacies and Retail | 3x retail copay |
3x retail copay |
3x retail copay |
3x retail copay |
3x retail copay |
3x retail copay |
not covered |
3x retail copay |
3x retail copay |
not covered |
| Mail Order | N/A |
2.5x retail copay |
N/A |
2.5x retail copay |
N/A |
2.5x retail copay |
not covered |
N/A |
2.5x retail copay |
not covered |
| Wal-Mart Generics | $5 copay |
$5 copay |
$5 copay |
$5 copay |
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