AETNA CHOICE POS II

All covered services are subject to medical necessity as determined by the plan. Please note that all out-of-network services are subject to Reasonable and Customary (R&C) limitations.

AETNA CHOICE POS II PLAN

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Carrier: Aetna
Plan Type: POS
Network Name: Aetna Choice POS II Network
Out of Network Coverage: Yes

Premiums

Plan	EMPLOYEE ONLY	EMPLOYEE + SPOUSE	EMPLOYEE + CHILD(REN)	EMPLOYEE + FAMILY
PremiumsBiweekly Contributions	$46.05	$92.12	$82.45	$147.84
PremiumsWeekly Contributions	$23.02	$46.06	$41.23	$73.92

Premiums

Biweekly Contributions

EMPLOYEE ONLY: $46.05
EMPLOYEE + SPOUSE: $92.12
EMPLOYEE + CHILD(REN): $82.45
EMPLOYEE + FAMILY: $147.84

Premiums

Weekly Contributions

EMPLOYEE ONLY: $23.02
EMPLOYEE + SPOUSE: $46.06
EMPLOYEE + CHILD(REN): $41.23
EMPLOYEE + FAMILY: $73.92

Medical Services

Service	IN-NETWORK	OUT-OF-NETWORK
Calendar year deductible - individual	$750	$1,500
Calendar year deductible - family	$2,000	$4,000
Coinsurance (employee pays)	20%*	40%*
Calendar year out-of-pocket maximum - individual	$4,000	No out-of-pocket maximum
Calendar year out-of-pocket maximum - family	$8,000	No out-of-pocket maximum
Preventive care	You pay 0%	40%*
Primary care	$25 copay	40%*
Specialist services	$50 copay	40%*
Diagnostic care	20%*	40%*
Mental health - inpatient	Not covered	Not covered
Mental health - outpatient	Not covered	Not covered
Urgent care	$65 copay	40%*
Emergency room	20%*	20%*

Calendar year deductible - individual

IN-NETWORK: $750
OUT-OF-NETWORK: $1,500

Calendar year deductible - family

IN-NETWORK: $2,000
OUT-OF-NETWORK: $4,000

Coinsurance (employee pays)

IN-NETWORK: 20%*
OUT-OF-NETWORK: 40%*

Calendar year out-of-pocket maximum - individual

IN-NETWORK: $4,000
OUT-OF-NETWORK: No out-of-pocket maximum

Calendar year out-of-pocket maximum - family

IN-NETWORK: $8,000
OUT-OF-NETWORK: No out-of-pocket maximum

Preventive care

IN-NETWORK: You pay 0%
OUT-OF-NETWORK: 40%*

Primary care

IN-NETWORK: $25 copay
OUT-OF-NETWORK: 40%*

Specialist services

IN-NETWORK: $50 copay
OUT-OF-NETWORK: 40%*

Diagnostic care

IN-NETWORK: 20%*
OUT-OF-NETWORK: 40%*

Mental health - inpatient

IN-NETWORK: Not covered
OUT-OF-NETWORK: Not covered

Mental health - outpatient

IN-NETWORK: Not covered
OUT-OF-NETWORK: Not covered

Urgent care

IN-NETWORK: $65 copay
OUT-OF-NETWORK: 40%*

Emergency room

IN-NETWORK: 20%*
OUT-OF-NETWORK: 20%*

*After deductible

RETAIL RX (30-DAY SUPPLY)

Tier	IN-NETWORK	OUT-OF-NETWORK
Generic	$10 copay	Not covered
Preferred	$30 copay	Not covered
Non-preferred	$80 copay	Not covered
Specialty drugs	20%	Not covered

Generic

IN-NETWORK: $10 copay
OUT-OF-NETWORK: Not covered

Preferred

IN-NETWORK: $30 copay
OUT-OF-NETWORK: Not covered

Non-preferred

IN-NETWORK: $80 copay
OUT-OF-NETWORK: Not covered

Specialty drugs

IN-NETWORK: 20%
OUT-OF-NETWORK: Not covered

MAIL ORDER RX (90-DAY SUPPLY)

Tier	IN-NETWORK	OUT-OF-NETWORK
Generic	$20 copay	Not covered
Preferred	$60 copay	Not covered
Non-preferred	$160 copay	Not covered
Specialty drugs	20%	Not covered

Generic

IN-NETWORK: $20 copay
OUT-OF-NETWORK: Not covered

Preferred

IN-NETWORK: $60 copay
OUT-OF-NETWORK: Not covered

Non-preferred

IN-NETWORK: $160 copay
OUT-OF-NETWORK: Not covered

Specialty drugs

IN-NETWORK: 20%
OUT-OF-NETWORK: Not covered

Plan Notes

All covered services are subject to medical necessity as determined by the plan. Please note that all out-of-network services are subject to Reasonable and Customary (R&C) limitations.
Out-of-network providers come at a much higher cost — 40% coinsurance after the deductible — meaning you are responsible for a significant portion of the bill (except for emergency care), so staying in network ensures you receive quality care at the best value.
Inpatient and outpatient mental health services are not covered under this plan.