Non-Arizona Medical

Plan Features Aetna Choice Plus HDHP PPO Aetna Open Access Select $500 EPO Aetna Choice Plus $100 PPO Aetna Open Access Select $0 EPO Kaiser Traditional HMO
(CA only)
In-Network In-Network Only In-Network  In-Network Only In-Network Only
Calendar Year Deductible
Individual/Family		 $2,000/$4,000 $500/$1,000 $100/$200 None None
Calendar Year Out-of-Pocket Maximum
Individual/Family		 $3,000/$6,000 $1,500/$4,500 $2,500/$5,000 $1,500/$4,500 $1,500/$3,000
HSA Employer Contribution Individual/Family $1,000/$2,000* N/A N/A N/A N/A
Primary/Specialist Office Visit 20%** $20 copay/
$40 copay		 $20 copay/
$40 copay		 $20 copay/
$40 copay		 $15 copay
Preventive Services No charge No charge No charge No charge No charge
Emergency Room 20%** $100 copay (waived if admitted) $100 copay + 20% 
(copay waived if admitted)		 $100 copay (waived if admitted) $100 copay (waived if admitted)
Inpatient Hospitalization 20%** $500 copay 20%** $500 copay $250 copay
Prescription Drugs
Retail
30-Day Supply
Generic
Preferred
Non-Preferred		 $10 copay**
$30 copay**
$50 copay**		 $10 copay
$30 copay
$50 copay		 $10 copay
$30 copay
$50 copay		 $10 copay
$30 copay
$50 copay		 $10 copay
$30 copay
Up to $150 copay
Mail Order 
90-Day Supply
Generic
Preferred
Non-Preferred		 $20 copay**
$60 copay**
$100 copay**		 $20 copay
$60 copay
$100 copay		 $20 copay
$60 copay
$100 copay		 $20 copay
$60 copay
$100 copay		 $20 copay
$60 copay
Not covered

*Prorated for new hires.
**After deductible.

Free In-Network Preventive Care

Annual checkups help you stay healthy. Take care of yourself and your family by using your FREE in-network preventive care benefits each year! Preventive care visits allow you to take action early and keep treatable health issues from becoming chronic conditions.
The total amount that you pay for your benefits coverage depends on the plans you choose, how many dependents you cover, and for medical coverage, how much you earn. Your healthcare costs are deducted from your pay on a pre-tax basis—before federal, state, and social security taxes are calculated—so you pay less in taxes.

Bi-Weekly Payroll Deductions

  Aetna Choice Plus HDHP PPO Aetna Open Access Select $500 EPO Aetna Choice Plus $100 PPO Aetna Open Access Select $0 EPO Kaiser Traditional HMO 
Employee Only $0.00 $31.00 $67.60 $69.90 $80.54
Employee + Spouse $0.00 $102.24 $148.66 $153.68 $177.19
Employee + Children $0.00 $88.35 $128.45 $132.79 $161.08
Employee + Family $0.00 $141.54 $205.78 $212.75 $241.62

New York Weekly Payroll Deductions

 

Aetna Choice POS II – HDHP

Aetna Open Access Select – $500

 Aetna Choice POS II – $100 Aetna Open Access Select –  $0 
Employee Only $0.00 $15.50 $33.80 $34.95
Employee + Spouse $0.00 $51.12 $74.33 $76.84
Employee + Children $0.00 $44.17 $64.22 $66.40
Employee + Family $0.00 $70.77 $102.89 $106.38

The Aetna Choice Plus HDHP PPO offers a variety of benefits, but it’s important to understand how the plan works to see if it’s the right choice for you.

Free Preventive Care Pay for Medical Care Share the Cost Plan Pays 100%
In-network preventive care is always covered at 100%. You pay 100% of your medical care until you meet the deductible. You and Lucid share the cost for care. Lucid pays the cost of your monthly premium, while your costs include the deductible, coinsurance, and copays. If you reach the out-of-pocket max, the plan pays 100%.
Aetna Choice POS II – HDHP
Benefit Level In-Network Out-of-Network
Network Name Aetna Choice POS II
(Open Access)		 N/A
Calendar Year Deductible
Individual
Individual in a family
Family		 $2,000
$2,000
$4,000		 $4,000
$4,000
$8,000
Calendar Year Out-of-Pocket Maximum
Individual
Individual in a family
Family		 $3,000
$3,000
$6,000		 $6,000
$6,000
$12,000
Primary Office Visit 20%* 40%*
Emergency Room 20%*
Hospitalization 20%* 40%*
Rx Generic/Preferred/Non-Preferred
30-Day Retail		 $10/$30/$50 Not Covered
Rx Generic/Preferred/Non-Preferred
90-Day Mail Order		 $20/$60/$100 Not Covered

*After deductible.

The Aetna Open Access Select $500 plan provides comprehensive coverage through a network of selected providers. Here are the plan’s key features:

  • You can visit any in-network doctor or specialist without needing a referral or choosing a primary care physician (PCP).
  • The plan includes a $500 annual deductible, meaning you are responsible for the first $500 of covered medical expenses each year before the plan starts to share costs.
  • The plan provides benefits for in-network providers only, except for emergencies. You must use the EPO’s provider network for non-emergency services.
  • After meeting the deductible, you’ll pay a portion of your expenses through coinsurance or copays.
  • Lower out-of-pocket costs when you use in-network providers.
Aetna Open Access Select – $500 
Benefit Level In-Network Only
Network Name Aetna Select (Open Access)
Calendar Year Deductible
Individual
Individual in a family
Family		 $500
$500
$1,000
Calendar Year Out-of-Pocket Maximum
Individual
Individual in a family
Family		 $1,500
$1,500
$4,500
Primary/Specialist Office Visit $20 copay/$40 copay
Emergency Room $100 copay (copay waived if admitted)
Hospitalization $500 copay*
Rx Generic/Preferred/Non-Preferred
30-Day Retail		 $10/$30/$50
Rx Generic/Preferred/Non-Preferred
90-Day Mail Order		 $20/$60/$100

*After deductible.

The Aetna Choice POS II – $100 plan offers flexibility and cost savings. Here are the plan’s key features:

  • You can see any doctor or specialist, with the best savings coming from in-network providers.
  • This plan includes a $100 annual deductible, meaning you are responsible for the first $100 of covered medical expenses each year before the plan starts to share costs.
  • After meeting the deductible, you’ll pay a portion of the costs through coinsurance and copayments.
  • Lower out-of-pocket costs when you use in-network providers.
Aetna Choice POS II – $100
Benefit Level In-Network Out-of-Network
Network Name Aetna Choice POS II
(Open Access)		 N/A
Calendar Year Deductible
Individual
Individual in a family
Family		 $100
$100
$200		 $500
$500
$1,000
Calendar Year Out-of-Pocket Maximum
Individual
Individual in a family
Family		 $2,500
$2,500
$5,000		 $5,000
$5,000
$10,000
Primary/Specialist Office Visit $20 copay/$40 copay 40%*
Emergency Room $100 copay + 20% (copay waived if admitted)
Hospitalization 20%* 40%*
Rx Generic/Preferred/Non-Preferred
30-Day Retail		 $10/$30/$50 Not Covered
Rx Generic/Preferred/Non-Preferred
90-Day Mail Order		 $20/$60/$100 Not Covered

*After deductible.

The Aetna Open Access Select – $0 plan provides comprehensive coverage through a network of selected providers. Here are the plan’s key features:

  • You can visit any in-network doctor or specialist without needing a referral or choosing a primary care physician (PCP).
  • The plan covers in-network services only, except for emergencies. You must stay within the EPO network to receive benefits for non-emergency services.
  • The plan has no annual deductible, meaning it starts covering eligible services right away.
  • After meeting the deductible, you’ll pay a portion of your expenses through coinsurance or copays.
  • Lower out-of-pocket costs when you use in-network providers. Out-of-network services are not covered except for emergency services.
Aetna Open Access Select – $0
Benefit Level In-Network Only
Network Name Aetna Select (Open Access)
Calendar Year Deductible
Individual
Individual in a family
Family		 None
Calendar Year Out-of-Pocket Maximum
Individual
Individual in a family
Family		 $1,500
$1,500
$4,500
Primary/Specialist Office Visit $20 copay/$40 copay
Emergency Room $100 copay (copay waived if admitted)
Hospitalization $500 copay
Rx Generic/Preferred/Non-Preferred
30-Day Retail		 $10/$30/$50
Rx Generic/Preferred/Non-Preferred
90-Day Mail Order		 $20/$60/$100

The Kaiser Traditional plan provides comprehensive coverage through Kaiser Permanente’s network of providers and facilities. Here are the plan’s key features:

  • You’ll select a primary care physician (PCP) to coordinate your care, including referrals to in-network specialists when needed.
  • The plan covers in-network services only, except for emergencies. You must stay within the Kaiser network to receive benefits for non-emergency services.
  • There is no annual deductible.
  • You’ll pay fixed copayments for most services.
Kaiser Traditional
Benefit Level In-Network Only
Network Name Kaiser
Calendar Year Deductible
Individual
Individual in a family
Family		 None
Calendar Year Out-of-Pocket Maximum
Individual
Individual in a family
Family		 $1,500
$1,500
$3,000
Primary/Specialist Office Visit $15 copay
Emergency Room $100 copay (copay waived if admitted)
Hospitalization $250 copay
Rx Generic/Preferred/Non-Preferred
30-Day Retail		 $10/$30/10% up to $150 maximum
Rx Generic/Preferred/Non-Preferred
90-Day Mail Order		 $20/$60/Not Covered

Resources

Documents