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Medical Plan Summary

Medical Plan Summary

Deductible, Coinsurance, and Out-of-Pocket Maximums

Medical Mutual Open Aetna Network5000 PPO3000 PPO
Deductible (Single/Family)
– Network$5,000/$10,000$3,000/$6,000
– Non-Network$10,000/$20,000$6,000/$12,000
– Network70%80%
– Non-Network50%60%
Out-of-Pocket (Includes Deductible)
– Network$7,900/$15,800$5,500/$11,000
– Non-Network$20,000/$40,000$15,000/$30,000


Medical Mutual Open Aetna Network5000 PPO3000 PPO
Physician Office Visit
– Primary Care Physician$40$30
– Specialty Care Physician$75$70
Emergency Medical Care
– Urgent Care$75$70
– Emergency Care$350$300
Hospital Care
– Inpatient CoverageDeductible/CoinsuranceDeductible/Coinsurance
– Outpatient SurgeryDeductible/CoinsuranceDeductible/Coinsurance
Prescription Drugs
– Retail$10/$50/$90$10/$50/$90
– Mail Order$25/$125/$225$25/$125/$225
– Specialty Rx30% to $25030% to $250

Per Pay Rates (Semi-Monthly)

Medical Mutual Open Aetna Network5000 PPO3000 PPO
– Employee Only$62.16$95.70
– Employee + Spouse$382.58$589.03
– Employee + Child(ren)$209.63$322.76
– Family$382.58$589.03

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