Plan Details
Plan Name	Aetna OAMC POS 500
Effective Dates	Jan 01, 2024 to Jan 01, 2025
Benefits	In-Network	Out-of-Network
Annual Deductible/Individual	$500	$5,000
Annual Deductible/Family	$1,000	$10,000
Coinsurance	20%	50%
Office Visit/Exam	$30	50% 50% after deductible
Outpatient Specialist Visit	$40	50% 50% after deductible
Annual Out-of-Pocket Limit/Individual	$4,000	$10,000
Annual Out-of-Pocket Limit/Family	$8,000	$20,000
Preventive Care	100%	50% after deductible
Inpatient Hospitalization	$750 $750 per day for the first 3 days per confinement, thereafter Covered 100%; after deductible	50% after deductible
Surgical Services Outpatient Facility Charge	$750	50% after deductible
Emergency Room	$250 $250 copay after deductible (copay waived if admitted)	$250 $250 copay after deductible (copay waived if admitted)
Urgent Care Facility	$50 $50 office visit copay	50% 50% after deductible
Prescription Drug Deductible	0	$0 0
Prescription Drugs - Generic	$10	Not covered
Prescription Drugs - Brand (Formulary/Preferred)	$30	Not covered
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	$50	Not covered
Prescription Drugs - Specialty	-	-
Chiropractic Services	$40 copay, limited to 20 visits per year	50%; after deductible, limited to 20 visits per year
Acupuncture	$30 / 20 visits/year	50% after deductible