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2017 Medical Benefits <br /> PPO 500 Health Fund 1000 Health Fund 1500 <br />MEDICAL BENEFITS Aetna Aetna Aetna <br /> Choice POS II Choice POS II Choice POS II <br /> Current Current Current <br />Deductible Embedded Deductible Embedded Deductible Embedded Deductible <br /> In-Network $500 Ind./ $1,500 Fam. $1,000 Ind./ $3,000 Fam. $1,500 Ind./ $4,500 Fam. <br /> Non-Network $1,000 Ind./ $3,000 Fam. $2,000 Ind./ $6,000 Fam. $3,000 Ind./ $9,000 Fam. <br />Out Of Pocket Max Includes Ded. / Coins. / Copays Includes Ded. / Coins. / RX Includes Ded. / Coins. / RX <br />Copays Copays <br /> In-Network $3,500 Ind./ $10,500 Fam. $3,000 Ind./ $9,000 Fam. $4,200 Ind./ $12,600 Fam. <br /> Non-Network $7,000 Ind./ $21,000 Fam. $6,000 Ind./ $18,000 Fam. $9,000 Ind./ $27,000 Fam. <br />Max OOP (Medical & Rx) <br />Coinsurance <br /> In-Network 20% 20% 20% <br /> Non-Network 50% 50% 50% <br />Lifetime Max Unlimited Unlimited Unlimited <br />Emergency Room <br /> In-Network $150 Copay Ded./ 20% Ded./ 20% <br /> Non-Network $150 Copay Ded./ 20% Ded./ 20% <br />Ambulance <br /> In-Network Ded./ 20% Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />Urgent Care <br /> In-Network $40 Copay Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />Physician Office Visit <br /> In-Network $25 Copay Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />Specialist Office Visit <br /> In-Network $40 Copay Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />Spinal Manipulation Therapy Maximum 20 Visits/Year <br /> In-Network $40 Copay Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />Preventive Care <br /> In-Network $0 - No Cost Sharing Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />Routine Hearing Exam <br /> In-Network $0 - No Cost Sharing Ded./ 20% Ded./ 20% <br /> Non-Network Ded./ 50% Ded./ 50% Ded./ 50% <br />3 <br /> <br />