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Plan Highlights

Aetna Plan A

Aetna Plan B

Annual Calendar Year DeductibleIn-Network (A)Out-of-Network (A)In-Network (B)Out-of-Network (B)

Maximum Calendar Year
Medical/Mental Health (A)Medical Only (A)Medical/Mental Health (B)Medical Only (B)

Lifetime MaximumUnlimited (A)Unlimited (A)Unlimited (B)Unlimited (B)

Professional ServicesIn-Network (A)Out-of-Network (A)In-Network (B)Out-of-Network (B)
Primary Care Physician (PCP)$15 Copay40%$25 Copy + 20%50%
Specialist$15 Copay 40%$25 Copy + 20%50%
Preventive Care ExamNo Charge (3)N/ANo Charge (3)N/A
Well-baby care (first 5 years)No Charge (3)N/ANo Charge (3)N/A
Diagnostic X-ray and LabNo Charge40%20%50%
Complex Diagnostics (MRI/CT Scan)No Charge40%20%50%
Therapy (3)(Physical, Occupational, Speech)No Charge40%20%50%

Professional Hospital ServicesIn-Network (A)Out-of-Network (A)In-Network (B)Out-of-Network (B)
Inpatient (3)No Charge40%20%50%
Outpatient Surgery (3)$100 CopayN/A$100 Copay + 20%N/A
Emergency Room$100 Copay
(Copay waived if admitted)
$100 Copay
(Copay waived if admitted)
$100 Copay + 20%
(Copay waived if admitted)
$100 Copay + 20%
(Copay waived if admitted)
Urgent Care$35$35 + 40%$35 + 20%$35 + 50%

Maternity Care*In-Network (A)Out-of-Network (A)In-Network (B)Out-of-Network (B)
Physician Services (prenatal or postnatal)$15 Copay40%$25 Copay50%
Hospital Services5%40%20%50%

  • *Effective January 1, 2024, the annual deductible will be waived for all covered family members of a dual-covered member enrolled in the PPO Plan A or PPO Plan B
  • (1) Member pays coinsurance applicable to Usual, Customary and Reasonable (UCR) rate
  • (2) Refer to the Your Rights and Protections Against Surprise Medical Bills notice
  • (3) Plan deductible waived
  • (4) Requires pre-authorization

The above information is a summary only. Please refer to your Evidence of Coverage or Plan Booklet for complete details of Plan benefits, limitations and exclusions.

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