Office of Human Resources - Benefits Design & Management

Medical Plans Comparison | MAIN OPEN ENROLLMENT PAGE | MEDICAL MAIN


EPO
Aetna | AmeriBen |Cigna
United Healthcare
PPO*
Aetna | AmeriBen
United Healthcare
HSA OPTION with HealthFund HSA*
Aetna Choice POS II
IN-NETWORK
IN-NETWORK
OUT-OF-NETWORK
IN-NETWORK
OUT-OF-NETWORK
HealthFund HSA
PLAN YEAR DEDUCTIBLE

Participants will receive Aetna HSA Visa debit card to pay for qualified out-of-pocket expenses for medical and prescription costs only.

NOTE:
There may be fees and restrictions when using debit card.

ASU CONTRIBUTION
Single: $42 per month
Family: $83 per month

EMPLOYEE MAXIMUM
ANNUAL CONTRIBUTION
Single: $3000
Family: $5950

HSA funds will roll over from year-to-year. Once funds reach $2000, they can be invested similar to funds in an IRA. Investment options (JPMorgan Chase Mutual Fund).

IMPORTANT:
If elected, your Health FSA will be limited to dental and vision expenses.

Individual None $500 $1000 $1200 $2400
Family None $1000 $2000 $2400 $4800
COINSURANCE MAXIMUM (includes deductible)
Individual n/a n/a n/a $2000 $5000
Family n/a n/a n/a $4000 $10,000
OUT-OF-POCKET MAXIMUM (excludes deductible)
Individual None $1000 $4000 n/a n/a
Family None $2000 $8000 n/a n/a
LIFETIME MAXIMUM
Family None $2,000,000 $2,000,000 n/a n/a
EMPLOYEE COST FOR CARE
EPO
PPO

HSA
IN-NETWORK
IN-NETWORK
OUT-OF-NETWORK
IN- NETWORK
OUT-OF- NETWORK
OFFICE VISITS (PREVENTATIVE)
PCP $15 $15, subject
to deductible 		50%, subject
to deductible 		$0 50% of total cost, up to the coinsurance maximum; then you pay 0% for the remaining part of the year
OB/GYN $10 $10,subject
to deductible
NON-PREVENTATIVE SERVICES
PCP $15 $15, subject
to deductible 		50%, subject
to deductible

You pay 100% of
the contracted rate, up to the deductible;

After deductible is met, you pay 10%, up to the coinsurance maximum

Then you pay 0% for the remaining part of
the year

You pay 100% of
the total cost, up
to the deductible;

After deductible is met,
you pay 50%, up
to the coinsurance maximum

Then you pay 0%
for the remaining part of the year

Specialist $30 $30, subject
to deductible 		50%, subject
to deductible
OB/GYN $10 $10, subject
to deductible 		50%, subject
to deductible
EPO
PPO
HSA
IN-NETWORK
IN-NETWORK
OUT-OF-NETWORK
IN- NETWORK
OUT-OF- NETWORK
PRESCRIPTION DRUGS | NEW PROVIDER: MedImpact
Generic $10 $10 NO COVERAGE

You pay 100% of the contracted rate, up to the deductible

Then you pay
$10 (Generic)
$20 (Formulary)
$40 (Non-formulary)

NO COVERAGE
Formulary $20 $20
Non-formulary $40 $40

NOTES
Prescription drugs coverage is available at most pharmacies and is generally limited to medications that do not have an equally effective over-the-counter substitute. 
Mail Order/specialty drugs will remain with Walgreens Health Initiatives.
Formulary list has been modified and is subject to change throughout the plan year.
Members must pay the copayment and the difference in cost between the name brand drug and the generic equivalent (if available).
EPO
PPO
HSA
IN-NETWORK
IN-NETWORK
OUT-OF-NETWORK
IN- NETWORK
OUT-OF-NETWORK
OUTPATIENT SERVICES
Freestanding ambulatory facility or hospital outpatient surgical center
(Non-diagnostic Services Only) 		$50 $50, subject to deductible 50%, subject to deductible See non-preventative services above.
EMERGENCY
Ambulance $0 $0, subject
to deductible 		Amount above the in-network rate, subject to deductible

You pay 100% of
the contracted rate, up to the deductible;

After deductible is met, you pay 10%, up to the coinsurance maximum

Then you pay 0% for the remaining part of the year

You pay 100% of
the total cost, up
to the deductible.

After deductible is met, you pay 10%, up to the coinsurance maximum.

Then you pay 0%
for the remaining part of the year.

ER (no admission) $125 $125, subject
to deductible 		$125, subject
to deductible
Urgent Care $40 $40,subject
to deductible 		50%, subject
to deductible
HOSPITAL ADMISSIONS
Hospital Admission $150 $150, subject
to deductible 		50%, subject
to deductible

You pay 100% of
the contracted rate, up to the deductible;

After deductible is met, you pay 10%, up to the coinsurance maximum

Then you pay 0% for the remaining part of the year

You pay 100% of
the total cost, up
to the deductible;

After deductible is met,
you pay 50%, up
to the coinsurance maximum

Then you pay 0%
for the remaining part of the year

Maternity $250 per baby
+ $150 hospital admission

$250 per baby, subject
to deductible
+ $150 hospital admission, subject
to deductible

50%, subject
to deductible
NOTE: $250 per baby fee will be waived if patient completes the "Healthy Pregnancy" program

( Must be enrolled by the 12th week of pregnancy or immediately upon hire, whichever is later.)
INTERNATIONAL COVERAGE
Emergency and Urgent Only Emergency and Urgent Only at In-Network Benefit Level; Other services covered at Out-of-Network Benefit Level Emergency and Urgent Only
Pharmacy services are not covered under any plans.
EPO
PPO
HSA
IN-NETWORK IN-NETWORK OUT-OF-NETWORK IN- NETWORK OUT-OF-NETWORK
MAMMOGRAPHY (Preventative)
  $0 $0, subject
to deductible		 50%, subject
to deductible 		See preventative office visits above. See preventative office visits above.
DURABLE MEDICAL EQUIPMENT

You pay 100% of
the contracted rate, up to the deductible;

After deductible is met, you pay 10%, up to the coinsurance maximum

Then you pay 0% for the remaining part of the year

You pay 100% of
the total cost, up
to the deductible;

After deductible is met,you pay 50%, up to the coinsurance maximum

Then you pay 0%
for the remaining part of the year

  $0 $0, subject
to deductible		 50%, subject
to deductible
CHIROPRACTIC (Limited to 20 visits per plan year)
  $15 $15, subject
to deductible		 50%, subject
to deductible
RADIOLOGY
  $0 $0, subject
to deductible		 50%, subject
to deductible
HOME HEALTH SERVICES
Hours per plan year
(OCT-SEPT) 		168 168 168
BARIATRIC SURGERY
  20% 20% 50%
Will not apply toward deductible or out-of-pocket.
Hospital admission waived.
BEHAVORIAL HEALTH
Inpatient $150 $150, subject
to deductible		 50%, subject
to deductible
Outpatient $15 $15, subject
to deductible		 50%, subject
to deductible
* IMPORTANT: All PPO and HSA out-of-network benefits are subject to reasonable and customary charges as defined by the insurance industry.