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2021 Medical Plan Benefits <br />BENEFITS AetnaPPO 500*HF 1000HF 1500 <br />$500 Individual / $1,000 Individual / $1,500 Individual / <br />Deductible Network$1,500 Family$3,000 Family$4,500 Family <br />Non-NetworkN/A N/AN/A <br />$500 Individual/$500 Individual/ <br />Health Fund Allowance N/A$1,000 Family$1,000 Family <br />Out-of-Pocket Maximum Includes DeductibleIncludes DeductibleIncludes Deductible <br />$3,500 Individual / $3,000 Individual / $4,200 Individual / <br />Network$10,500 Family$9,000 Family$12,600 Family <br />Non-NetworkN/AN/A N/A <br />Co-insurance Network80%80%80% <br />Non-NetworkN/AN/A N/A <br />Lifetime Maximum Unlimited Unlimited Unlimited <br />You PayYou PayYou Pay <br />Office Visit Network$25 PCP / $40 Spec Deductible/ 20%Deductible/ 20% <br />Non-NetworkN/AN/A N/A <br />Wellness Visit Network$0 Copay $0 Copay$0 Copay <br />Non-NetworkN/AN/A N/A <br />In-Patient & Out-Patient <br />Hosp. NetworkDeductible/ 20%Deductible/ 20%Deductible/ 20% <br />Non-NetworkN/AN/A N/A <br />Urgent Care Network$40 Copay Deductible/ 20%Deductible/ 20% <br />Non-NetworkN/AN/A N/A <br />$150 Copay/ $150 Copay/ $150 Copay/ <br />Emergency Room NetworkDeductible/ 20%Deductible/ 20%Deductible/ 20% <br />$150 Copay/ $150 Copay/ $150 Copay/ <br />Non-NetworkDeductible/ 20%Deductible/ 20%Deductible/ 20% <br />Generic/Brand/$10/$30/$60$10/$30/$60$10/$30/$60 <br />Prescriptions Non-Formulary20% Spec <$100 20% Spec <$100 20% Spec <$100 <br />Mail Order (90 day) <br />Mandatory <br />Maintenance$20/$60/$120$20/$60/$120$20/$60/$120 <br />Network Website www.aetna.comChoice POS II Choice POS II Choice POS II <br />© 2018 HUB International Limited. <br />33 <br /> <br />