Medical Benefits
We offer a choice between two medical plans with Aetna – the Point of Service (POS) and the Health Reimbursement Arrangement (HRA).
| Aetna | POS | HRA | ||
|---|---|---|---|---|
| Plan Benefits | In-Network | Out-of-Network | In-Network | Out-of-Network |
| Deductible | Before Fund Deductible : $500 Company paid HRA Fund: $500 / $800 (Helps offset your deductible) |
|||
| Single/Family | $1,500 / $3,000 | $3,000 / $6,000 | $2,500 / $5,500 | $6,500 / $13,500 |
| Coinsurance Paid by Carrier |
90% | 70% | 70% | 50% |
| Out-of-pocket Maximum (incl. ded.) Single/Family | $3,500 / $7,000 | $5,000 / $10,000 | $6,350 / $12,700 | $12,500 / $25,000 |
| Lifetime Maximum | Unlimited | Unlimited | ||
| Physicians Office Visit |
$25 Copay | Ded. + Coins. | Ded. + Coins. | Ded. + Coins. |
| Specialty Care Office Visit | $50 Copay | Ded. + Coins. | Ded. + Coins. | Ded. + Coins. |
| Preventive Care Office Visit | No Charge | Ded. + Coins. | No Charge | Ded. + 30% Coins. |
| Hospital Inpatient |
$500 Copay | 30% Coins. after $500 Copay, after Deductible | Ded. + Coins. | Ded. + Coins. |
| Outpatient Surgery | Ded. + Coins. | Ded. + Coins. | Ded. + Coins. | Ded. + Coins. |
| Emergency Room |
$100 Copay | Ded. + 30% Coins. | ||
| Retail Prescription Drugs Generic/ Brand/ Non-Formulary | $10 / $30 / $50 | 30% Coins. after Copay | $10 / $30 / $50 | 30% Coins. after Copay |
| Mail Order Rx (90 day supply) |
2x Retail | Not Covered | 2x Retail | Not Covered |
| Out-of-Network UCR Level | N/A | 80th Percentile | N/A | 80th Percentile |
| Dependent Definition | To Age 26 (end of the month) | |||
Specialty drugs are used to treat rare or complex chronic conditions such as cancer, rheumatoid arthritis, hemophilia and HIV. The PrudentRx Co-Pay Program assists members by helping them enroll in manufacturer Co-Pay Assistance Programs for specialty drugs. By enrolling in the PrudentRx Co-Pay Program, your out-of-pocket cost for prescriptions covered under the PrudentRx Co-Pay Program will be $0. Otherwise, medications in the specialty tier will be subject to a 30% co-insurance if you choose not to enroll. This applies to all drugs on the specialty drug list dispensed by CVS Specialty, regardless if copay card is available. Certain exceptions apply such as specialty drugs which are not dispensed by CVS Specialty pharmacy. In this case, the drug will be at a regular copay, not at the $0 copay or 30% specialty copay. Examples of these are HIV medications or limited distribution drugs dispensed at other specialty pharmacies.
How to Enroll:
If you currently take one or more medications included in the PrudentRx Program Drug List, you will be automatically enrolled in the PrudentRx Co-Pay Program. You may choose to opt out of the program; however, you will pay more for your specialty medications if you opt out.
If you currently take specialty medications that are included in the PrudentRx Program Drug List you will receive a welcome letter and phone call from PrudentRx that provides specific information about the program as it pertains to your medication. If you or a covered family member are not currently taking, but will start a new medication covered under the PrudentRx Co-Pay Program, you can reach out to PrudentRx (1-800-578-4403) or they will proactively contact you. You must use CVS Specialty on the first fill of a new specialty medication prescription and going forward.