Plan Details
Plan Name	Aetna OAMC POS HDHP 5500 (HSA)
Effective Dates	Jan 01, 2024 to Jan 01, 2025
Benefits	In-Network	Out-of-Network
Annual Deductible/Individual	$5,500	$11,000
Annual Deductible/Family	$11,000	$22,000
Coinsurance	10%	30%
Office Visit/Exam	10% 10% after deductible	30% 30% after deductible
Outpatient Specialist Visit	10% 10% after deductible	30% 30% after deductible
Annual Out-of-Pocket Limit/Individual	$6,550	$13,100
Annual Out-of-Pocket Limit/Family	$13,100	$26,200
Preventive Care	0%	30% after deductible
Inpatient Hospitalization	10% 10% after deductible	30% 30% after deductible
Surgical Services Outpatient Facility Charge	10% after deductible	30% after deductible
Emergency Room	10% 10% after deductible, copay waived if admitted	10% 10% after deductible, copay waived if admitted
Urgent Care Facility	10% 10% after deductible	30% 30% 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	10% after deductible, limited to 20 visits per year	30% after deductible, limited to 20 visits per year
Acupuncture	10% after deductible / 20 visits/year	30% after deductible / 20 visits/year