Page 10 - B12797-ITDR-Enrollment-Guide-2020
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2020 Medical plans (for non-Medicare eligible retirees)
  High PPO plan option
Medium PPO plan option
     Plan name
Monthly premium
Retiree only Retiree + spouse
Medical
Availability Network
Annual deductible
Out-of-pocket maximum
Preventive care Physician visit Specialist visit Inpatient hospital Outpatient hospital
Pharmacy**
Deductible
Generics
Preferred brands
Nonpreferred brands
Specialty preferred generics Specialty nonpreferred generics Specialty preferred brands Specialty nonpreferred brands
Other
Eyewear
Hearing aids
High Option Network
Aetna Open Choice® PPO
Mid Option Network
Aetna Open Choice® PPO
        $1,622.94
$1,148.89
                $3,245.87
            Individual Family Individual Family
$1,200 $4,000
$2,297.79
      National–based on location
National–based on location
                 In network Out of network
In network
Out of network
                   $3,500
$5,500
                $2,400 $8,000
$7,000
$11,000
                      $2,800 $7,000
$6,000
$10,000
                   $5,600 $14,000
$12,000
$20,000
                   Covered 100% Covered 40%
Covered 100%
Covered 50%
                   20% 40%
30%
50%
                   20% 40%
30%
50%
                      20% 40%
30%
50%
                       20% 40%
 up to 30-day supply
up to 90-day supply
 $0 $0
30%
50%
       up to 30-day supply
up to 90-day supply
      $0
$0
                   $10 $30
$10
$10
                   $40 $120
$75
$75
                   40% up to $250 40% up to $500
50% up to $250
50% up to $500
                   $70 n/a
50% up to $250
n/a
                   $70 n/a
50% up to $250
n/a
                      $70 n/a
50% up to $250
n/a
                       40% up to $250 n/a
50% up to $250
n/a
          n/a
n/a
                 n/a
n/a
                 10
**Three-month (90 days) supply available through Aetna Rx Home Delivery mail order. When you obtain a 90-day supply at retail, you pay your mail-order cost share.
 



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