2021 City of Hutchinson Benefit Guide FINAL - 11-20-20

7 Provider Network: Aetna Choice POS II $1,250 deductible Group #: 16569 Qualified High Deductible Health Plan (QHDHP) Group #: 16569 In-NetworkBenefits Out-of-Network Benefits In-NetworkBenefits Out-of-Network Benefits Mental Health Inpatient Deductible/80% Deductible/60% Deductible/100% Deductible/80% Outpatient $20 copay Deductible/60% Deductible/100% Deductible/80% Substance Abuse Inpatient Deductible/80% Deductible/60% Deductible/100% Deductible/80% Outpatient $20 copay Deductible/60% Deductible/100% Deductible/80% Other Services Chiropractic $20 copay Deductible/60% Deductible/100% Deductible/80% Retail Pharmacy (30 Day Supply) Generic (Tier 1) 25% copay NO out of network Prescription Coverage Deductible/100% NO out of network Prescription Coverage Preferred (Tier 2) 25% copay Deductible/100% Non-Preferred (Tier 3) 35% copay Deductible/100% Preferred Specialty (Tier 4) 25% copay to $300 max Deductible/100% MUST use specialty pharmacy after one fill at retail pharmacy – 1-866-629-6779 Mail Order Pharmacy (90 Day Supply) Generic (Tier 1) 25% copay NO out of network Prescription Coverage Deductible/100% NO out of network Prescription Coverage Preferred (Tier 2) 25% copay Deductible/100% Non-Preferred (Tier 3) 35% copay Deductible/100% Preferred Specialty (Tier 4) Mail Order not available Mail Order not available Medical, Prescription, Surency Vision and TeladocMonthly Employee Contributions Taken Pre-Tax $1,250 Deductible $3,000 Deductible HDHP Employee $49.56 $0.00 Employee & Spouse $213.06 $96.06 Employee & Child(ren) $205.34 $92.56 Employee & Spouse & Child(ren) (Family) $478.20 $313.56 THE ABOVE MONTHLY EMPLOYEE RATES ARE FOR MEDICAL, PRESCRIPTION, SURENCY VISION AND TELADOC BUNDLED TOGETHER. BENEFIT SUMMARIES FOR VISION AND TELADOC FOLLOW.