Buy Up Plan
A traditional PPO plan with copays for everyday care - paired with an FSA. Network: Aetna · Administrator: Aetna
Buy Up Plan
Plan Details
HSA Eligible
No
FSA Eligible
Yes
Medical Premiums - Buy Up Plan
| Coverage Tier | Salaried (Semi-Monthly) | Hourly (Weekly) |
|---|---|---|
| Employee Only | Engaged Tier 1 $20-59.99k$45.00 $60-99.99k$55.00 $100k+$65.00 Engaged Tier 2 $20-59.99k$65.00 $60-99.99k$75.00 $100k+$85.00 Non-Engaged $20-59.99k$308.55 $60-99.99k$326.70 $100k+$344.85 | Engaged Tier 1 $20-59.99k$20.77 $60-99.99k$25.38 $100k+$30.00 Engaged Tier 2 $20-59.99k$30.00 $60-99.99k$34.62 $100k+$39.23 Non-Engaged $20-59.99k$142.41 $60-99.99k$150.78 $100k+$159.16 |
| Employee + Spouse | Engaged Tier 1 $20-59.99k$90.00 $60-99.99k$110.00 $100k+$130.00 Engaged Tier 2 $20-59.99k$110.00 $60-99.99k$130.00 $100k+$150.00 Non-Engaged $20-59.99k$379.50 $60-99.99k$415.80 $100k+$452.10 | Engaged Tier 1 $20-59.99k$41.54 $60-99.99k$50.77 $100k+$60.00 Engaged Tier 2 $20-59.99k$50.77 $60-99.99k$60.00 $100k+$69.23 Non-Engaged $20-59.99k$175.15 $60-99.99k$191.91 $100k+$208.66 |
| Employee + Children / Family | Engaged Tier 1 $20-59.99k$150.00 $60-99.99k$180.00 $100k+$210.00 Engaged Tier 2 $20-59.99k$170.00 $60-99.99k$200.00 $100k+$230.00 Non-Engaged $20-59.99k$450.45 $60-99.99k$504.90 $100k+$559.35 | Engaged Tier 1 $20-59.99k$69.23 $60-99.99k$83.08 $100k+$96.92 Engaged Tier 2 $20-59.99k$78.46 $60-99.99k$92.31 $100k+$106.15 Non-Engaged $20-59.99k$207.90 $60-99.99k$233.03 $100k+$258.16 |
Employee Only
Salaried (Semi-Monthly)
Engaged Tier 1
$20-59.99k$45.00
$60-99.99k$55.00
$100k+$65.00
Engaged Tier 2
$20-59.99k$65.00
$60-99.99k$75.00
$100k+$85.00
Non-Engaged
$20-59.99k$308.55
$60-99.99k$326.70
$100k+$344.85
Hourly (Weekly)
Engaged Tier 1
$20-59.99k$20.77
$60-99.99k$25.38
$100k+$30.00
Engaged Tier 2
$20-59.99k$30.00
$60-99.99k$34.62
$100k+$39.23
Non-Engaged
$20-59.99k$142.41
$60-99.99k$150.78
$100k+$159.16
Employee + Spouse
Salaried (Semi-Monthly)
Engaged Tier 1
$20-59.99k$90.00
$60-99.99k$110.00
$100k+$130.00
Engaged Tier 2
$20-59.99k$110.00
$60-99.99k$130.00
$100k+$150.00
Non-Engaged
$20-59.99k$379.50
$60-99.99k$415.80
$100k+$452.10
Hourly (Weekly)
Engaged Tier 1
$20-59.99k$41.54
$60-99.99k$50.77
$100k+$60.00
Engaged Tier 2
$20-59.99k$50.77
$60-99.99k$60.00
$100k+$69.23
Non-Engaged
$20-59.99k$175.15
$60-99.99k$191.91
$100k+$208.66
Employee + Children / Family
Salaried (Semi-Monthly)
Engaged Tier 1
$20-59.99k$150.00
$60-99.99k$180.00
$100k+$210.00
Engaged Tier 2
$20-59.99k$170.00
$60-99.99k$200.00
$100k+$230.00
Non-Engaged
$20-59.99k$450.45
$60-99.99k$504.90
$100k+$559.35
Hourly (Weekly)
Engaged Tier 1
$20-59.99k$69.23
$60-99.99k$83.08
$100k+$96.92
Engaged Tier 2
$20-59.99k$78.46
$60-99.99k$92.31
$100k+$106.15
Non-Engaged
$20-59.99k$207.90
$60-99.99k$233.03
$100k+$258.16
Deductible - Out of Pocket & Coinsurance
| Feature | In-Network | Out-of-Network |
|---|---|---|
| Deductible (Individual) | $500 | $1,000 |
| Deductible (Family ) | $1,000 | $2,000 |
| Out-of-Pocket Max (Individual) | $5,000 | $15,000 |
| Out-of-Pocket Max (Family ) | $10,000 | $30,000 |
| Coinsurance (Plan Pays) | 10% | 50% |
Deductible (Individual)
In-Network$500
Out-of-Network$1,000
Deductible (Family )
In-Network$1,000
Out-of-Network$2,000
Out-of-Pocket Max (Individual)
In-Network$5,000
Out-of-Network$15,000
Out-of-Pocket Max (Family )
In-Network$10,000
Out-of-Network$30,000
Coinsurance (Plan Pays)
In-Network10%
Out-of-Network50%
Covered Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Preventive Care | No Charge | 50% after deductible |
| Primary Care Visit | $25 copay | 50% after deductible |
| Specialist Visit | $45 copay | 50% after deductible |
| Diagnostic Care | 10% after deductible | 50% after deductible |
| Urgent Care | $50 copay | 50% after deductible |
| Emergency Room | $500 copay | $500 copay |
Preventive Care
In-NetworkNo Charge
Out-of-Network50% after deductible
Primary Care Visit
In-Network$25 copay
Out-of-Network50% after deductible
Specialist Visit
In-Network$45 copay
Out-of-Network50% after deductible
Diagnostic Care
In-Network10% after deductible
Out-of-Network50% after deductible
Urgent Care
In-Network$50 copay
Out-of-Network50% after deductible
Emergency Room
In-Network$500 copay
Out-of-Network$500 copay
Pharmacy Benefits
| Tier | In-Network |
|---|---|
| Retail (30-day)- Generic | $10 copay |
| Retail (30-day)- Preferred Brand | $30 copay |
| Retail (30-day)- Non-Preferred Brand | $60 copay |
| Mail Order (90-day) - Tier 1 | $20 copay |
| Mail Order (90-day) - Tier 2 | $60 copay |
| Mail Order (90-day) - Tier 3 | $120 copay |
Retail (30-day)- Generic
In-Network$10 copay
Retail (30-day)- Preferred Brand
In-Network$30 copay
Retail (30-day)- Non-Preferred Brand
In-Network$60 copay
Mail Order (90-day) - Tier 1
In-Network$20 copay
Mail Order (90-day) - Tier 2
In-Network$60 copay
Mail Order (90-day) - Tier 3
In-Network$120 copay
Plan Notes
- Inpatient services: 10% after deductible in-network; 50% after deductible out-of-network
- Outpatient services: 10% after deductible in-network; 50% after deductible out-of-network
- Out-of-network pharmacy: Not covered