03-23-19 Special Meeting of the La Porte City Council - Budget Retreat

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IIII iiitIIII IIII IIII iiir IIIV iiir l s A. Deductible Network Non -Network ww� .mm— $500 Individual / $1,500 Family mmm $1,000 Individual / $3,000 Family wmm $1,500 Individual / $4,500 Family N/A N/A N/A Health Fund Allowance N/A $500Individual/ $1,000 Family $500Individual/ $1,000 Family Out -of -Pocket Maximum Network Non -Network Includes Deductible Includes Deductible Includes Deductible $3,500 Individual / $10,500 Family $3,000 Individual / $9,000 Family $4,200 Individual / $12,600 Family N/A N/A N/A Co-insurance Network 80% 80% 80% Non -Network N/A N/A N/A Lifetime Maximum Unlimited Unlimited Unlimited Office Visit Network Non -Network $25 PCP / $40 Spec Deductible/ 20% Deductible/ 20% N/A N/A N/A Wellness Visit Network Non -Network $0 Copay $0 Copay $0 Copay N/A N/A N/A In -Patient & Out -Patient Hosp. Network Non -Network Deductible/ 20% Deductible/ 20% Deductible/ 20% N/A N/A N/A Urgent Care Network Non -Network $40 Copay Deductible/ 20% Deductible/ 20% N/A N/A N/A Emergency Room Network Non -Network $150 Copay/ Deductible/ 20% $150 Copay/ Deductible/ 20% $150 Copay/ Deductible/ 20% $150 Copay/ Deductible/ 20% $150 Copay/ Deductible/ 20% $150 Copay/ Deductible/ 20% Generic/Brand/ Prescriptions Non -Formulary $10/$30/$60 20% Spec <$100 $10/$30/$60 20% Spec <$100 $10/$30/$60 20% Spec <$100 Mail Order (90 day) — Mandatory Maintenance $20/$60/$120 $20/$60/$120 $20/$60/$120 Network Website www.aetna.com Open Access Select Open Access Select Open Access Select 21 I )�018IItJI�liilriiolioii�lI "1111ed