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  OutofNetwork 
OutofNetwork 

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  
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 
Highend 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 
Lowend Imaging (all other noninvasive 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 OutofPocket 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 OutofPocket Maximum 
Not included in OutofPocket Maximum 
Not included in OutofPocket Maximum 
Included in OutofPocket 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 
WalMart Generics  $5 copay 
$5 copay 
$5 copay 
$5 copay 