Core Plan
A traditional PPO plan with copays for everyday care - paired with an FSA. Network: Aetna · Administrator: Aetna · Plan type: PPO with Copays
Core Plan
Plan Details
HSA Eligible
No
FSA Eligible
Yes
Medical Premiums - Core Plan
| Coverage Tier | Salaried (Semi-Monthly) | Hourly (Weekly) |
|---|---|---|
| Employee Only | Engaged Tier 1 $20-59.99k$30.00 $60-99.99k$40.00 $100k+$50.00 Engaged Tier 2 $20-59.99k$50.00 $60-99.99k$60.00 $100k+$70.00 Non-Engaged $20-59.99k$292.05 $60-99.99k$310.20 $100k+$328.35 | Engaged Tier 1 $20-59.99k$13.85 $60-99.99k$18.46 $100k+$23.08 Engaged Tier 2 $20-59.99k$23.08 $60-99.99k$27.69 $100k+$32.31 Non-Engaged $20-59.99k$134.79 $60-99.99k$143.17 $100k+$151.55 |
| Employee + Spouse | Engaged Tier 1 $20-59.99k$60.00 $60-99.99k$80.00 $100k+$100.00 Engaged Tier 2 $20-59.99k$80.00 $60-99.99k$100.00 $100k+$120.00 Non-Engaged $20-59.99k$346.50 $60-99.99k$382.80 $100k+$419.10 | Engaged Tier 1 $20-59.99k$27.69 $60-99.99k$36.92 $100k+$46.15 Engaged Tier 2 $20-59.99k$36.92 $60-99.99k$46.15 $100k+$55.38 Non-Engaged $20-59.99k$159.92 $60-99.99k$176.68 $100k+$193.43 |
| Employee + Children / Family | Engaged Tier 1 $20-59.99k$90.00 $60-99.99k$120.00 $100k+$150.00 Engaged Tier 2 $20-59.99k$110.00 $60-99.99k$140.00 $100k+$170.00 Non-Engaged $20-59.99k$400.95 $60-99.99k$455.40 $100k+$509.85 | Engaged Tier 1 $20-59.99k$41.54 $60-99.99k$55.38 $100k+$69.23 Engaged Tier 2 $20-59.99k$50.77 $60-99.99k$64.62 $100k+$78.46 Non-Engaged $20-59.99k$185.05 $60-99.99k$210.18 $100k+$235.32 |
Employee Only
Salaried (Semi-Monthly)
Engaged Tier 1
$20-59.99k$30.00
$60-99.99k$40.00
$100k+$50.00
Engaged Tier 2
$20-59.99k$50.00
$60-99.99k$60.00
$100k+$70.00
Non-Engaged
$20-59.99k$292.05
$60-99.99k$310.20
$100k+$328.35
Hourly (Weekly)
Engaged Tier 1
$20-59.99k$13.85
$60-99.99k$18.46
$100k+$23.08
Engaged Tier 2
$20-59.99k$23.08
$60-99.99k$27.69
$100k+$32.31
Non-Engaged
$20-59.99k$134.79
$60-99.99k$143.17
$100k+$151.55
Employee + Spouse
Salaried (Semi-Monthly)
Engaged Tier 1
$20-59.99k$60.00
$60-99.99k$80.00
$100k+$100.00
Engaged Tier 2
$20-59.99k$80.00
$60-99.99k$100.00
$100k+$120.00
Non-Engaged
$20-59.99k$346.50
$60-99.99k$382.80
$100k+$419.10
Hourly (Weekly)
Engaged Tier 1
$20-59.99k$27.69
$60-99.99k$36.92
$100k+$46.15
Engaged Tier 2
$20-59.99k$36.92
$60-99.99k$46.15
$100k+$55.38
Non-Engaged
$20-59.99k$159.92
$60-99.99k$176.68
$100k+$193.43
Employee + Children / Family
Salaried (Semi-Monthly)
Engaged Tier 1
$20-59.99k$90.00
$60-99.99k$120.00
$100k+$150.00
Engaged Tier 2
$20-59.99k$110.00
$60-99.99k$140.00
$100k+$170.00
Non-Engaged
$20-59.99k$400.95
$60-99.99k$455.40
$100k+$509.85
Hourly (Weekly)
Engaged Tier 1
$20-59.99k$41.54
$60-99.99k$55.38
$100k+$69.23
Engaged Tier 2
$20-59.99k$50.77
$60-99.99k$64.62
$100k+$78.46
Non-Engaged
$20-59.99k$185.05
$60-99.99k$210.18
$100k+$235.32
Deductible - Out of Pocket & Coinsurance
| Feature | In-Network | Out-of-Network |
|---|---|---|
| Deductible (Individual) | $1,500 | $3,000 |
| Deductible (Family ) | $3,000 | $6,000 |
| Out-of-Pocket Max (Individual) | $5,000 | $15,000 |
| Out-of-Pocket Max (Family ) | $10,000 | $30,000 |
| Coinsurance (Plan Pays) | 80% | 50% |
Deductible (Individual)
In-Network$1,500
Out-of-Network$3,000
Deductible (Family )
In-Network$3,000
Out-of-Network$6,000
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-Network80%
Out-of-Network50%
Covered Services
| Service | In-Network | Out-of-Network |
|---|---|---|
| Preventive Care | No Charge | 50% after deductible |
| Primary Care Visit | $35 copay | 50% after deductible |
| Specialist Visit | $50 copay | 50% after deductible |
| Diagnostic Care | 20% 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$35 copay
Out-of-Network50% after deductible
Specialist Visit
In-Network$50 copay
Out-of-Network50% after deductible
Diagnostic Care
In-Network20% 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: 20% after deductible in-network; 50% after deductible out-of-network
- Outpatient services: 20% after deductible in-network; 50% after deductible out-of-network
- Out-of-network pharmacy: Not covered