TwinMed 2015 OE Guide - OOS V2

December 3, 2014  |  By  | 


MEDICAL PLAN OPTIONS Plan option EPO Core Plan * Buy-Up Plan ** Provider Selection: In-NetworkIn-NetworkOut-of-Network Annual Deductible (per calendar year [Individual/Family] ) What you pay before the plan will pay. $4,000/ $8,000$1,500/ $3,000$4,000/ $8,000 Out-of-Pocket Maximum (per calendar year [Individual/Family] ) The maximum you will have to pay for the plan year. $6,000/ $12,000 $5,000/ $10,000$10,000/ $20,000 Ofce Visits, Urgent Care & Emergency Care Preventive Care No charge; ded. waivedNo charge40% after deductible Physician Visits $35 per visit; ded. waived $20 per visit; ded. waived 40% after deductible Specialist Visits $50 per visit; ded. waived $30 per visit; ded. waived 40% after deductible Urgent Care $50 per visit; ded. waived $30 per visit; ded. waived 40% after deductible Emergency Room (Non-Emergency Use Not Covered) $300 copay; plus 20%; ded. waived $200 copay; plus 20%; ded. waived X-Ray & Lab Diagnostic X-ray & Lab 0%; ded. waived0%; ded. waived40% after deductible Advanced Imaging $200 copay; ded. waived$200 copay; ded. waived40% after deductible Hospitalization Inpatient Hospital 20% after deductible20% after deductible40% after deductible Outpatient Surgery 20% after deductible20% after deductible40% after deductible Ambulance (Non-Emergency Use Not Covered) 20%; ded. waived20%; ded. waived20%; ded. waived Prescripon Drugs Generic Drugs Preferred Brand Name Non-Preferred Drugs Home Delivery (90-day supply) Specialty CareRx $10 copay $35 copay $60 copay $20/$70/$120 (For parcipang Pharmacies Only) 50% for formulary and non-formulary drugs $10 copay $25 copay $50 copay $20/$50/$100 (For participating Pharmacies Only) 50% for formulary and non- formulary drugs 40% of submied cost aer the applicable preferred copay. Not Applicable Not Applicable Twin Med provides you with Two medical plan opons through Aetna. The rst is a *Core plan that is In-Network only. The second opon is the Buy-Up plan which provides addional benets for an addional premium. Aetna Medical Plan Opons Employee monetary responsibilies (your share of the cost) for the medical plans are outlined in the table below. *Please note that certain States require to have an Out-of-Network Benet. Please reference your Benet plan summaries to see which States require the Out-of-Network Benet. You are responsible for all charges incurred by non-network providers. **Charges incurred by non-network providers in the plan are paid according to a Fee Schedule. You are responsible for charges above the Fee Schedule and the provider may balance bill you for those charges. 2

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