Applications & Forms..... Group Medical Dental Life Insurance Vision
Aetna
Company
Name of
Plan
Effective
Network
In-Network Deductible
In-Network
Out/pocket max
In-Network
Office visits
Participating Drugs
Gen / Brand / Ded
Aetna
MC HSA Comp. HDHP $2300
4-08
PPO
2300 indiv /
4600 family
1700 indiv /
3400 family
$0 copay /
20% coinsurance after deductible
$20 / $40 / AD $ded
Aetna
MC HSA Comp. HDHP $3000
4-08
PPO
3000 indiv / 6000 family
1000 indiv/
2000 family
$0 copay /
0% coinsurance
$20 / $40 / AD $ded
Aetna
MC HRA HDHP $5000 80/50
4-08
PPO
5000 indiv /
10000 fam
2000 indiv /
4000 family
$0 copay /
20% coinsurance
$20 / $40 / AD $ded
Aetna
MC HRA HDHP $3000 80/50
4-08
PPO
3000 indiv / 6000 fam
1500 indiv /
3000 family
$0 copay /
20% coinsurance
$20 / $40 / AD$ded
Aetna
MC HRA HDHP $3300 80/50
4-08
PPO
3300 indiv /
6600 family
1700 indiv /
3400 family
$0 copay /
20% coinsurance
$20 / $40 / AD $ded
Aetna
EPO 80 (Open Access)
4-07
PPO
0 / 0
2000 indiv /
2 member max
$20 copay /
20% coinsurance
$15 / $35 / AD $ded
Aetna
EPO Limited (Open Access)
4-08
PPO
1000 indiv
4500 indiv
$0 copay /
50% coinsurance
$20 / $40 / AD $ded
Aetna
MC 2500 100/50
12-07
PPO
2500 indiv /
7500 fam
0 / 0
$25 copay /
0% coinsurance
$15 / $35 / 0 $ded
Aetna
MC $2000 80/50/50
4-07
PPO
2000 indiv /
2 mem max
5000 indiv /
2 member max
$25 copay /
20% coins Prof /
50% coins Facility
$15 / $35 / 0 $ded
Aetna
MC $1000 70/50/50
4-08
PPO
1000 indiv /
2 mem max
5000 indiv /
2 member max
$25 copay /
30% coinsurance
$15 / $35 / 0 $ded
Aetna
MC $1000 80/50/50
4-07
PPO
1000 indiv /
2 mem max
5000 indiv /
2 member max
$20 copay /
20% coins Prof /
50% coins Facility
$15 / $35 / 0 $ded
Company
Name of
Plan
Effective
Network
In-Network Deductible
In-Network
Out/pocket max
In-Network
Office visits
Participating Drugs
Gen / Brand / Ded
Aetna
MC $500 50/50
12-07
PPO
500 indiv /
2 mem max
5000 indiv /
2 member max
$35 copay /
0% coinsurance
$15 / na / 0 $ded
Aetna
MC $500 80/60
4-07
PPO
500 indiv /
2 mem max
4000 indiv /
2 member max
$35 copay /
0% coinsurance
$15 / $35 / 0 $ded
Aetna
MC $500 90/70
4-07
PPO
500 indiv /
2 mem max
4000 indiv /
2 member max
$15 copay /
10% coinsurance
$15 / $35 / 0 $ded
Aetna
MC $250 80/60
4-07
PPO
250 indiv /
2 mem max
3500 indiv /
2 member max
$20 copay /
20% coinsurance
$15 / $35 / 0 $ded
Aetna
MC $250 90/70
4-07
PPO
250 indiv /
2 mem max
3000 indiv /
2 member max
$15 copay /
10% coinsurance
$10 / $25 / 0 $ded
Aetna
MC Basic
4-07
PPO
1500 indiv /
2 mem max
3000 indiv /
2 member max
3 visits / $20 copay /
20% coinsurance
$15 / 50% copay / 0 $ded
Aetna
Indemnity
4-08
PPO
5000 indiv /
2 mem max
3500 indiv /
2 member max
0 visits / $0 copay /
20% coinsurance
$10 / $25 / 150 $ded
Aetna
HMO HRA $1500 $25/$50
4-08
HMO
1500 indiv / 3000 family
3500 indiv /
7000 family
$40 copay /
0% coinsurance
$20 / $40 / 0 $ded
Aetna
HMO HRA $750 $15/$30
4-08
HMO
750 indiv / 1500 family
2000 indiv /
4000 family
$25 copay /
na
$20 / $40 / 0 $ded
Aetna
HMO Deductible 1000
4-08
HMO
1000 indiv /
2000 family
3500 indiv /
7000 family
$40 copay /
30% coinsurance
$20 / $40 / 0 $ded
Aetna
HMO $30/$40
4-07
HMO
0 / 0
3000 indiv /
6000 family
$30 copay / na
$15 / $35 / 0 $ded
Aetna
HMO $20/$40
4-07
HMO
0 / 0
2500 indiv /
5000 family
$20 copay / na
$15 / $35 / 0 $ded
Company
Name of
Plan
Effective
Network
In-Network Deductible
In-Network
Out/pocket max
In-Network
Office visits
Participating Drugs
Gen / Brand / Ded
Aetna
HMO $10/$30
4-07
HMO
0 / 0
2000 indiv /
4000 family
$10 copay / na
$15 / $35 / 0 $ded
Aetna
HMO $10/$20
4-07
HMO
0 / 0
1500 indiv /
3000 family
$10 copay / na
$10 / $25 / 0 $ded
Aetna
Value Network* HMO $30/$40
4-07
HMO
0 / 0
3000 indiv /
6000 family
$30 copay / na
$15 / $35 / 150 $ded
Aetna
Value Network* HMO $10/$20
4-07
HMO
0 / 0
1500 indiv /
3000 family
$10 copay / na
$10 / $25 / 0 $ded
Aetna
Vitalidad Mexico con Aetna HMO $5
1-08
HMO
0 / 0
1500 indiv /
3000 family
$5 copay / na
$5 / $5 / 0 $ded
Aetna
Vitalidad Mexico con Aetna HMO $10
1-08
HMO
0 / 0
2000 indiv /
4000 family
$10 copay / na
$10 / $10 / 0 $ded
Applications & Forms..... Group Medical Dental Life Insurance Vision
Company
Name of
Plan
Effective
Network
In-Network Deductible
In-Network
Out/pocket max
In-Network
Office visits
Participating Drugs
Gen / Brand / Ded
Blue Cross
2-08
PPO
3000 / 6000
3000 / 6000
0 visits / $0 copay /
0% coinsurance
$0 / $/ AD $ded
Blue Cross
2-08
PPO
1500 / 3000
1500 / 3000
0 visits / $0 copay /
0% coinsurance
$/ $/ AD $ded
Blue Cross
2-08
PPO
3000 / 6000
3000 / 6000
0 visits / $0 copay /
0% coinsurance
$0 / $/ AD $ded
Blue Cross
7-08
PPO
2500 per person - 2 person max
5000 per person - 2 person max
0 visits / $25 copay /
25% coinsurance
$15 / $25 / 250 $ded
Blue Cross
7-08
PPO
3500 per person - 2 person max
5000 per person - 2 person max
0 visits / $35 copay /
35% coinsurance
$15 / $35 / 250 $ded
Blue Cross
7-08
PPO
5000 per person - 2 person max
7500 per person - 2 person max
0 visits / $40 copay /
40% coinsurance
$15 / $35 / 250 $ded
Blue Cross
2-08
PPO
5000 / 10000
5000 / 10000
2 visits / $20 copay /
0% coinsurance
$10 / $25 / 0 $ded
Blue Cross
2-08
PPO
1250 / 2500
3250 / 6500
0 visits / $0 copay /
100% coinsurance
$10 / $25 / 0 $ded
Company
Name of
Plan
Effective
Network
In-Network Deductible
In-Network
Out/pocket max
In-Network
Office visits
Participating Drugs
Gen / Brand / Ded
Blue Cross
2-08
PPO
500 / 1000
4500 / 9000
12 visits / $40 copay /
45% coinsurance
$15 / $25 / 150 $ded
Blue Cross
2-08
PPO
500 / 1000
4000 / 8000
12 visits / $30 copay /
45% coinsurance
$15 / $25 / 150 $ded
Blue Cross
2-08
PPO
750 / 1500
4500 / 9000
12 visits / $45 copay /
45% coinsurance
$15 / $/ 0 $ded
Blue Cross
2-08
PPO
500 / 1000
4000 / 8000
12 visits / $35 copay /
45% coinsurance
$15 / $/ 0 $ded
Blue Cross
2-08
PPO
250 / 500
3600 / 7200
12 visits / $25 copay /
45% coinsurance
$15 / $25 / 0 $ded
Blue Cross
2-08
PPO
250 / 500
3000 / 6000
12 visits / $20 copay /
40% coinsurance
$15 / $25 / 0 $ded
Blue Cross
2-08
PPO
250 / 500
2500 / 5000
12 visits / $10 copay /
30% coinsurance
$10 / $20 / 0 $ded
Blue Cross
2-08
PPO
500 / 1000
5000 / 10000
0 visits / $35 copay /
0% coinsurance
$10 / $30 / 250 $ded
Company
Name of
Plan
Effective
Network
In-Network Deductible
In-Network
Out/pocket max
In-Network
Office visits
Participating Pharmacy Drugs
Blue Cross
2-08
PPO
1000 / 2000
5000 / 10000
0 visits / $40 copay /
0% coinsurance
$10 / $35 / 350 $ded
Blue Cross
2-08
PPO
3500 / 7000
4000 / 7500
0 visits / $35 copay /
0% coinsurance
$10 / $25 / AD $ded
Blue Cross
2-08
PPO
2400 / 4800
3600 / 5500
0 visits / $35 copay /
0% coinsurance
$10 / $25 / AD $ded
Blue Cross
2-08
PPO
2000 / 4000
3100 / 5700
0 visits / $0 copay /
20% coinsurance
$10 / $25 / AD $ded
Blue Cross
2-07
PPO
750 / 1500
3250 / 6500
0 visits / $0 copay /
50% coinsurance
$15 / $/ 0 $ded
Blue Cross
2-07
PPO
1000 / 2000
3500 / 7000
0 visits / $0 copay /
50% coinsurance
$15 / $/ 0 $ded
Blue Cross
2-07
PPO
1250 / 2500
3750 / 7500
0 visits / $0 copay /
100% coinsurance
$15 / $/ 0 $ded
Blue Cross
2-08
HMO
500 / 1000
2250 / 4500
0 visits / $25 copay /
0% coinsurance
$15 / $25 / 150 $ded
Company
Name of
Plan
Effective
Network
In-Network Deductible
In-Network
Out/pocket max
In-Network
Office visits
Participating Drugs
Gen / Brand / Ded
Blue Cross
2-08
HMO
1500 / 3000
2250 / 4500
0 visits / $20 copay /
0% coinsurance
$10 / $25 / 150 $ded
Blue Cross
2-08
HMO
0 / 0
1750 / 3500
0 visits / $20 copay /
0% coinsurance
$10 / $25 / 150 $ded
Blue Cross
2-08
HMO
0 / 0
1750 / 3500
0 visits / $10 copay /
0% coinsurance
$10 / $20 / 150 $ded
Applications & Forms..... Group Medical Dental Life Insurance Vision
Company
Name of
Plan
Effective
Network
In-Network Deductible
In-Network
Out/pocket max
In-Network
Office visits
Participating Drugs
Gen / Brand / Ded
Blue Shield
PPO
4800 indiv /
9600 family
4800 indiv /
9600 family
0% copay /
0% coinsurance
$0 / $0 / 0 $ded
Blue Shield
PPO(SM) Savings Plan 3400*
Discontinued as of 2-08
7-08
PPO
3400 / 6800
4500 / 9000
30% copay /
0% coinsurance
$10 / $30 or 30% /
0 $ded
Blue Shield
PPO
2500 / 5000
4000 / 8000
20% copay /
0% coinsurance
$10 / $30 or 30% /
0 $ded
Blue Shield
PPO(SM) Savings Plan 3000/6000
or Select Previous Versions...
7-08 / Current
2-08
2-08 changes/updates
7-08
PPO
3000 / 6000
3000 / 6000
$0 copay /
0% coinsurance
$0 / $0 / 0 $ded
Blue Shield
PPO
2250 / 4500
4500 / 9000
20% copay /
0% coinsurance
$10 / $30 or 30% /
0 $ded
Blue Shield
PPO
1800 / 3600
1800 / 3600
$0 copay /
0% coinsurance
$0 / $0 / 0 $ded
Blue Shield
PPO
3000 / 6000
6000 / 12000
20% copay /
0% coinsurance
$15 / $30 or 30% / 500 $ded
Blue Shield
PPO
2000 indiv
5000 indiv
2 visits / $40 copay /
after 2 visits 100% coinsurance until max copay has been met - then 0% coinsurance
$15 / na / na $ded
Company
Name of
Plan
Effective
Network
In-Network Deductible
In-Network
Out/pocket max
In-Network
Office visits
Participating Drugs
Gen / Brand / Ded
Blue Shield
PPO
1500 per member combined
4500 per member for
pref prov
3 visits / $30 copay /
after 3 visits 100% coinsurance until max ded has been met - then 30% coinsurance
$15 / $30 or 30% /
0 $ded
Blue Shield
PPO
1000 indiv /
2000 family
5000 / 10000
$45 copay /
0% coinsurance
$10 / $30 / 250 $ded
Blue Shield
PPO
1000 per member
4000 per member
3 visits / $20 copay /
after 3 visits 100% coinsurance until max ded has been met - then 30% coinsurance
$15 / $30 or 30% /
0 $ded
Blue Shield
PPO
750 per member
4000 per member
3 visits / $15 copay /
after 3 visits 100% coinsurance until max ded has been met - then 30% coinsurance
$15 / $30 or 30% / 250 $ded
Blue Shield
PPO
500 / 1000
3500 / 7000
$35 copay /
0% coinsurance
$10 / $30 / 150 $ded
Blue Shield
PPO
500 / 1000
4000 / 8000
$40 copay /
0% coinsurance
$10 / $30 / 250 $ded
Blue Shield
PPO
500 indiv / 1000 2 pers / 1500 family
5000 per mem
$45 copay /
0% coinsurance
$15 / $30 / 250 $ded
Blue Shield
PPO
250 indiv /
500 family
2750 indiv /
5500 family
$15 copay /
0% coinsurance
$10 / $25 / 0 $ded
Company
Name of
Plan
Effective
Network
In-Network Deductible
In-Network
Out/pocket max
In-Network
Office visits
Participating Drugs
Gen / Brand / Ded
Blue Shield
PPO
250 / 500
3000 / 6000
$25 copay /
0% coinsurance
$10 / $30 / 0 $ded
Blue Shield
PPO
0 / 0
2000 / 4000
$10 copay /
0% coinsurance
$10 / $25 / 0 $ded
Blue Shield
PPO
0 / 0
5000 / 10000
$0 copay /
100% coinsurance
$15 / $30 or 30% / 250 $ded
Blue Shield
PPO
0 / 0
5000 / 10000
$0 copay /
100% coinsurance
$15 / $30 or 30% / 500 $ded
Blue Shield
HMO
0 / 0
4000 / 8000
$40 copay /
0% coinsurance
$15 / $30 / 250 $ded
Blue Shield
HMO
0 / 0
3500 / 7000
$30 copay /
0% coinsurance
$15 / $30 / 150 $ded