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Medical Plan Summary
Medical Plan Summary
Deductible, Coinsurance, and Out-of-Pocket Maximums
| Medical Mutual Open Aetna Network | 5000 PPO | 3000 PPO |
|---|---|---|
| Deductible (Single/Family) | ||
| – Network | $5,000/$10,000 | $3,000/$6,000 |
| – Non-Network | $10,000/$20,000 | $6,000/$12,000 |
| Coinsurance | ||
| – Network | 70% | 80% |
| – Non-Network | 50% | 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 |
Services
| Medical Mutual Open Aetna Network | 5000 PPO | 3000 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 Coverage | Deductible/Coinsurance | Deductible/Coinsurance |
| – Outpatient Surgery | Deductible/Coinsurance | Deductible/Coinsurance |
| Prescription Drugs | ||
| – Retail | $10/$50/$90 | $10/$50/$90 |
| – Mail Order | $25/$125/$225 | $25/$125/$225 |
| – Specialty Rx | 30% to $250 | 30% to $250 |
Per Pay Rates (Semi-Monthly)
| Medical Mutual Open Aetna Network | 5000 PPO | 3000 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 |
