| 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 $40 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, described later in this guide, 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 |
$6,000 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 | 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 $95 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 |