Aetna Select 1
Aetna Select 2
Aetna Choice POS II 600
Aetna Choice POS II HRA
Network
Aetna Select Open Access
Aetna Select Open Access
Aetna Choice POS II (Open Access)
Aetna Choice POS II (Open Access)
Plan Provisions
UM Providers
In-Network
UM Providers
In-Network
UM Providers
In -Network
Out-of-Network
UM Providers
In-Network
Out-of-Network
Health Reimbursement Account (HRA) Per Member
$600 paid up front by UM per member
(up to $1,800 per family) reduces your annual deductible
Calendar Year Deductible
Individual
N/A
$250
$600
$1,200
$1,500
$3,000
Family
N/A
$750
$1,800
$3,600
$4,500
$9,000
Well 'Canes Preventive Care Services
 
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
Physician Expenses
Primary Care Physician
$15 copay
$20 copay
$20 copay
$25 copay
$15 copay
$20 copay
Deductible then 20% coinsurance
Deductible then $15 copay
Deductible then $20 copay
Deductible then 30% coinsurance
Specialist
$25 copay
$40 copay
$35 copay
$50 copay
$25 copay
$40 copay
Deductible then 40% coinsurance
Deductible then $25 copay
Deductible then $40 copay
Deductible then 30% coinsurance
Maternity (Office Services)
$25 copay for first visit, then all office services covered at 100%
$40 for first visit, then all office services covered at 100%
$35 copay for first visit, then all office services covered at 100%
$50 copay for first visit, then all office services covered at 100%
$25 copay for first visit, then all office services covered at 100%
$40copay for first visit, then all office services covered at 100%
Deductible, then 40% coinsurance
Deductible then $25 copay for the first visit, then all office services covered at 100%
Deductible, then $40 copay for first visit, then all office visits covered at 100%
Deductible, then 30% coinsurance
Allergy Injections
(per visit)
$5 copay
$5 copay
$5 copay
$5 copay
$5 copay
$5 copay
Deductible, then 40% coinsurance
Deductible, then $5 copay
Deductible, then $5 copay
Deductible, then 30% coinsurance
Hospital Expenses
Inpatient
$150 copay per day to a maximum of $750 per admission
$250 copay per day to a maximum of $1,250 per admission
Deductible then $200 copay per day to a maximum of $1,000 per admission
Deductible then $300 copay per day to a maximum of $1,500 per admission
Deductible then $150 copay per day to a maximum of $750 per admission
Deductible then $250 copay per day to a maximum of $1,250 per admission
Deductible then 40% coinsurance
Deductible then $100 copay per day to a maximum of $500 per admission
Deductible then $200 copay per day to a maximum of $1,000 per admission
Deductible
then 30% coinsurance
Emergency Room
$100 copay
$100 copay
Deductible then $150 copay
Deductible then $150 copay
Deductible then $100 copay
Deductible then $100 copay
Deductible then $100
Deductible then $100 copay
Deductible then $100 copay
Deductible then $100 copay
Urgent Care
$50 copay
$50 copay
Deductible then $75 copay
Deductible then $75 copay
Deductible then $40 copay
Deductible then $40 copay
Deductible then 40% coinsurance
Deductible then $35 copay
Deductible then $35 copay
Deductible then 30% coinsurance
Minute Clinics
N/A
$20 copay
N/A
$25 copay
N/A
$20 copay
Deductible then 40% coinsurance
N/A
Deductible then $20 copay
Deductible then 30% coinsurance
Ambulance
$0 copay
$0 copay
Deductible then $0 copay
Deductible then $0 copay
Deductible then 20% coinsurance
Deductible then 20% coinsurance
Deductible then 20% coinsurance
Deductible then 20% coinsurance
Deductible then 20% coinsurance
Deductible then 20% coinsurance
Outpatient Services
Surgery
$100 copay
$150 copay
Deductible then $100 copay
Deductible then $250 copay
Deductible then $50 copay
Deductible then $150 copay
Deductible then 40% coinsurance
Deductible then $50 copay
Deductible then $150 copay
Deductible then 30% coinsurance
High-end Imaging (MRI, PET, CT, MRA and SPECT)
$150 copay
$250 copay
Deductible then $150 copay
Deductible then $350 copay
Deductible then 10% coinsurance
Deductible then 20% coinsurance
Deductible then 40% coinsurance
Deductible then $100 copay
Deductible then $250 copay
Deductible then 30% coinsurance
Low-end Imaging (all other non-invasive services)
$0 copay
$30 copay
$0 copay
Deductible then $50 copay
$0 copay
Deductible then 20% coinsurance
Deductible then 40% coinsurance
Deductible then $0 copay
Deductible then $40 copay
Deductible then 30% coinsurance
Lab Work (Quest)
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
$0 copay
Deductible then 40% coinsurance
Deductible then $0 copay
Deductible then $0 copay
Deductible then 30% coinsurance
Outpatient Therapy (Physical, Speech and Occupational
Per Visit
$15 copay
$20 copay
$20 copay
$25 copay
$15 copay
$20 copay
Deductible then 40% coinsurance
Deductible then $15 copay
Deductible then $20 copay
Deductible then 30% coinsurance
Outpatient Chemotherapy and Radiation
Facility
$0 copay
$20 copay
Deductible then $0 copay
Deductible then $20 copay
Deductible then $0 copay
Deductible then 20% coinsurance
Deductible then 40% coinsurance
Deductible then $0 copay
Deductible then 20% coinsurance
Deductible then 30% coinsurance
Physician
$0 copay
$0 copay
Deductible then $0 copay
Deductible then $0 copay
Deductible then $0 copay
Deductible then 20% coinsurance
Deductible then 40% coinsurance
Deductible then $0 copay
Deductible then 20% coinsurance
Deductible then 30% coinsurance
Medical Out-of-Pocket Maximum
Individual
$3,000
$4,000
$4,100
$8,200
$3,500
$7,000
Family
$9,000
$12,000
$12,300
$24,600
$10,500
$21,000
Prescription Drugs
Not included in
Out-of-Pocket Maximum
Not included in
Out-of-Pocket Maximum
Not included in
Out-of-Pocket Maximum
Included in
Out-of-Pocket Maximum
Level One
$10 copay
$10 copay
$10 copay
$10 copay
$10 copay
$10 copay
not covered
$10 copay
$10 copay
not covered
Level Two
$35 Copay
$35 copay
$35 copay
$35 copay
$35 copay
$35 copay
not covered
$35 copay
$35 copay
not covered
Level Three
$55 Copay
$55 copay
$55 copay
$55 copay
$55 copay
$55 copay
not covered
$55 copay
$55 copay
not covered
Level Four
$100 Copay
$100 copay
$100 copay
$100 copay
$100 copay
$100 copay
not covered
$100 copay
$100 copay
not covered
90 Days at UM Pharmacies and Retail
3x retail copay
3x retail copay
3x retail copay
3x retail copay
3x retail copay
3x retail copay
not covered
3x retail copay
3x retail copay
not covered
Mail Order
N/A
2.5x retail copay
N/A
2.5x retail copay
N/A
2.5x retail copay
not covered
N/A
2.5x retail copay
not covered
Wal-Mart Generics
$5 copay
$5 copay
$5 copay
$5 copay