AETNA – C1 (In-Network Only)

  • Deductible: $1,500 person / $3,000 family for In-Network
  • Out of Pocket Limit: $5,000 per person / 10,000 Family
  • Primary care Visit – $20 Copayment / Specialist visit – $40 copayment

Other practitioner Drug Coverage:

  • Generic – $15 copayment / Brand – $30 copayment / Specialty – $60 copayment
  • Emergency room services: $200 copayment / Urgent Care: $50 copayment
  • Hospital stay / Mental health services / Pregnancy / Other special health needs: 30% coinsurance
  • COVID Testing 10: 100%

Employee deduction per week:

Employee $37.10
Employee/ Child(ren) $64.90
Employee/Spouse $78.00
Family $113.25

AETNA – C2 (In-Network / Out of Network)

  • Deductible: $1,500 person / $3,000 family for In-Network
    $3,000 person / $6,000 family for Out of Network
  • Out of Pocket Limit: $5,000 per person / $10,000 Family
    $15,000 per person / $30,000 Family
  • Primary care Visit – $20 Copayment / Specialist visit – $40 copayment
  • Other practitioner visit – 20% coinsurance In-Network 30% Out of Network

Prescription Drug Coverage:

  • Generic – $15 copayment / Brand – $30 copayment / Specialty: $50 copayment
  • Hospital room services: $200 copayment / Urgent Care: $50 copayment
  • Hospital stay / Mental health services / Pregnancy / Other special health needs: 20% coinsurance In-Network 30% Out of Network
  • COVID Testing: 100%

Employee deduction per week:

Employee $44.25
Employee/ Child(ren) $75.52
Employee/Spouse $93.23
Family $136.15

Aetna Enrollment/Change Request