OH Gold PPO /50 Metallic Level: Gold. $500 copay per admission after deductible. T1A-$3 copay plus 30% T1-$10 copay plus 30%
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1 OH Gold PPO /50 Metallic Level: Gold OH Gold PPO /50 Metallic Level: Gold Member benefits* Network Care Out-of-network care Network Care Out-of-network care Calendar year $1,000/$2,000 $3,000/$6,000 $1,000/$2,000 $3,000/$6,000 Calendar year out-of-pocket limit $4,000/$8,000 $12,000/$24,000 $3,500/$7,000 $10,500/$21,000 Deductible & out-of-pocket limit accumulation1 Embedded Embedded $25 copay; $50 copay; $25 copay; $500 copay per admission after $250 copay after $350 copay; $75 copay; 50% after $20 copay; 50% after $50 copay; 50% after $20 copay; 50% after 50% after 50% after 50% after 20% after 50% after 50% after 20% after 50% after 50% after 20% after 50% after 50% after 20% after 50% after 50% after 20% after 50% after $200 copay; 50% after $75 copay; 50% after 50% after 20% after 50% after 50% after 20% after 50% after Pharmacy** Network Out of network Network Out of network Pharmacy None None None None Preferred brand drugs $50 copay $50 copay plus 30% $50 copay $50 copay plus 30% Nonpreferred drugs $90 copay $90 copay plus 30% $90 copay $90 copay plus 30% Specialty drugs 24
2 OH Silver PPO /50 OH Silver PPO /50 Member benefits* Network Care Out-of-network care Network Care Out-of-network care Calendar year $2,000/$4,000 $6,000/$12,000 $4,000/$8,000 $12,000/$24,000 Calendar year out-of-pocket limit $6,000/$12,000 $18,000/$36,000 $6,600/$13,200 $19,800/$39,600 Deductible & out-of-pocket limit accumulation1 Embedded Embedded $40 copay; $60 copay; $40 copay; $40 copay; $60 copay; 50% after $40 copay; 50% after $60 copay; 50% after $40 copay; 50% after $40 copay; 50% after $60 copay; 50% after 50% after 50% after 50% after 50% after 20% after 50% after 20% after 50% after 20% after 50% after 20% after 50% after 20% after 50% after 20% after 50% after 20% after $350 copay; $75 copay; 50% after $75 copay; 50% after 20% after 50% after 20% after 50% after 20% after 50% after 20% after 50% after Pharmacy** Network Out of network Network Out of network Pharmacy None None None None Preferred brand drugs $50 copay $50 copay plus 30% $50 copay $50 copay plus 30% Nonpreferred drugs $90 copay $90 copay plus 30% $90 copay $90 copay plus 30% Specialty drugs 25
3 OH Silver PPO /50 HSA TIF OH Bronze PPO /50 HSA EMB Metallic Level: Bronze Member benefits* Network Care Out-of-network care Network Care Out-of-network care Calendar year $2,600/$5,200 $7,800/$15,600 $5,000/$10,000 $15,000/$30,000 Calendar year out-of-pocket limit $5,200/$10,400 $15,600/$31,200 $6,450/$12,900 $19,350/$38,700 Deductible & out-of-pocket limit accumulation1 True integrated family (TIF) Embedded 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after Pharmacy** Network Out of network Network Out of network Pharmacy Preferred brand drugs Nonpreferred drugs Specialty drugs after after after after $50 copay after $50 copay plus 30% after $90 copay after $90 copay plus 30% after after after after after after after after after $50 copay after $50 copay plus 30% after $90 copay after $90 copay plus 30% after after after after after 26
4 OH Bronze PPO /50 HSA EMB Metallic Level: Bronze Member benefits* Network Care Out-of-network care Calendar year $6,200/$12,400 $18,600/$37,200 Calendar year out-of-pocket limit $6,450/$12,900 $19,350/$38,700 Deductible & out-of-pocket limit accumulation1 Embedded 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after 50% after Pharmacy** Network Out of network Pharmacy Preferred brand drugs Nonpreferred drugs Specialty drugs after after after after $50 copay after $50 copay plus 30% after $90 copay after $90 copay plus 30% after after after 50% after 27
5 Indemnity plan OH Silver Indemnity % Member benefits Calendar year $2,000/$4,000 Calendar year out-of-pocket limit $6,000/$12,000 Deductible & out-of-pocket limit accumulation1 Rehabilitation services (PT/OT/ST) Chiropractic Embedded 20% after 20% after Not covered 20% after 20% after 20% after 20% after 20% after 20% after 20% after 20% after 20% after Pharmacy* Network Out of network Pharmacy None None Preferred generic drugs** Preferred brand drugs $50 copay $50 copay Nonpreferred drugs*** $90 copay $90 copay Specialty drugs Refer to page 30 for footnotes. 29
6 Footnotes All services are subject to the unless noted otherwise. Some benefits are subject to age and frequency schedules, limitations or visit maximums. Members or providers may be required to precertify or obtain approval for certain services. 1 Embedded No one family member may contribute more than the individual /out-of-pocket limit amount to the family /out-of-pocket limit. Once the family /out-of-pocket limit is met, all family members will be considered as having met their /out-of-pocket limit for the remainder of the calendar year. * If the physician prescribes or the member requests a covered brand-name prescription drug when a generic prescription drug equivalent is available, the member will pay the difference in cost between the brand-name prescription drug and the generic prescription drug equivalent plus the applicable cost sharing. The cost difference between the generic and brand does not count toward the out of pocket limit. Not all drugs are covered. It is important to look at the Preferred Drug List (Aetna Value Plus Formulary) to understand which drugs are covered. **T1A=Value drugs; T1=Preferred generic drugs. ***Includes nonpreferred generic and brand drugs. P=Preferred specialty drugs; NP=Nonpreferred specialty drugs. Note: For a summary list of limitations and exclusions, refer to Ohio 2 50 Plan Guide. You can also visit our Producer World website at for specific Summary of Benefits and Coverage documents. Or for more information, please contact your licensed agent or Aetna sales representative. 30
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