| Benefits | Basic Managed Choice (Only available under the Broad Network) |
HCRA
(Aetna Healthfund) |
|---|---|---|
| You Pay | You Pay | |
| Preventative Services | $0 | $0 |
| Office Visits Primary Care Physician (PCP) Specialist |
$30 PCP copay (after deductible) $45 Specialist copay (after deductible) |
30% after deductible |
| Emergency | $100 copay (after deductible) |
30% after deductible |
| Urgent Care Facility | $45 copay (after deductible) |
30% after deductible |
| Deductible | $2,500 single $5,000 family |
$2,000 single $4,000 family |
| HCRA Fund | N/A | $800 single $1,600 family |
| Deductible after HCRA Fund | N/A | $1,200 single $2,400 family |
| Coinsurance | 35% | 30% |
| Annual Out-of-Pocket Maximum | $6,000 single $12,000 family |
$5,600 single $11,200 family |
Note: Prescription drug coverage is included in the medical plan. Prescription drug expenses are not subject to the medical plan deductible
| Benefits | Basic Managed Choice (Only available under the Broad Network) |
HCRA (Aetna Healthfund) |
|---|---|---|
| You Pay | You Pay | |
| Office Visits and Preventative Care |
Deductible and Coinsurance | Deductible and Coinsurance |
| Emergency | $100 copay (after deductible) |
Deductible and Coinsurance |
| Deductible | $7,000 single $14,000 family |
$6,000 single $12,000 family |
| Coinsurance* | 50% | 50% |
| Annual Out-of-Pocket Maximum | $12,000 single $24,000 family |
$10,200 single $20,400 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. |
** 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 | In-Network Member Cost | Out-of-Network Member Cost |
|---|---|---|
| Exam (one every 12 months) | No copay | Up to $28 |
| Frames (one every 24 months) | No copay; $180 allowance + 20% off balance over $180 | $90 |
| Lenses (one every 12 months) | ||
|
Single
Bifocal Trifocal |
No copay
No copay No copay |
Up to $25
Up to $39 Up to $63 |
| Contact Lenses (one order every 12 months) |
||
| Conventional | No copay; $180 allowance + 15% off balance over $180 | Up to $144 |
| Disposable | No copay; $180 allowance | Up to $144 |
| Medically Necessary | No copay; Paid in Full | Up to $200 |