Plan Details
Plan Name	Aetna OAMC POS 2000
Effective Dates	Jan 01, 2024 to Jan 01, 2025
Benefits	In-Network	Out-of-Network
Annual Deductible/Individual	$2,000	$4,000
Annual Deductible/Family	$4,000	$8,000
Coinsurance	30% 70%	50% 50%
Office Visit/Exam	$30	50%
Outpatient Specialist Visit	$50	50%
Annual Out-of-Pocket Limit/Individual	$5,000	$10,000
Annual Out-of-Pocket Limit/Family	$10,000	$20,000
Preventive Care	100%	50% 50% after deductible
Inpatient Hospitalization	30% 70% after deductible	50% 50% after deductible
Surgical Services Outpatient Facility Charge	70% after deductible	50% after deductible
Emergency Room	$250 70% after $250 copay (copay waived if admitted)	$250 70% after $250 copay (copay waived if admitted)
Urgent Care Facility	$50 $50	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)	$55	Not covered
Prescription Drugs - Specialty	30% 70% after deductible	Not covered
Chiropractic Services	$50 copay, limited to 20 visits per year	50% after deductible, limited to 20 visits per year
Acupuncture	$30 / 20 visits/year	50% after deductible, limited to 20 visits per year