Page 8 - Willscot I Mobile Mini Open Enrollment Guide

Medical and
Prescription Drug Coverage
Review Your Medical Plan Options
Aetna (Choice POSII Network) Prescription: Aetna (CVS Caremark)
Medical Plan Summary
The following benefits are included in your plan options. Unless otherwise noted, benefits are per insured person and after deductible.
$1,500 Deductible
$3,000 Deductible
Health Savings Account
HSA Eligible Yes
Individual $1,500
Individual $5,200
Plan Coinsurance 80% Primary Care Visit 80% Inpatient Hospital 80%
Yes
$3,000 $3,000
$10,400 $6,550
60% 70% 60% 70% 60% 70%
$6,000
$13,100
50% 50% 50%
HSA Employer Funding
$650 / Individual Only
$1,300 / Individual + Spouse $1,300 / Individual + Child(ren) $1,500 / Individual + Family
$1,050 / Individual Only $2,150 / Individual + Spouse $2,150 / Individual + Child(ren) $2,400/ Individual + Family
In-network
Out-of-network
In-network
Out-of-network
Annual Deductible
Family
$3,000
$6,000
$6,000
$12,000
Out-of-pocket Maximum
Family
$6,850
$13,700
$13,100
$26,200
Medical Benefits Coverage
Preventive Care
100%
60%
100%
50%
Specialist Visit
80%
60%
70%
50%
Outpatient Hospital
80%
60%
70%
50%
Urgent Care
80%
60%
70%
50%
Emergency Room
80%
80%
70%
70%
Retail Prescriptions (30-day supply)
Tier 1
80%**
80%
70%**
70%
80%** 80%
80%** Not covered **Deductible waived for some medications
70%** 70%
70%** Not covered
Tier 2
Tier 3
80%**
80%
70%**
70%
Mail-order Prescriptions (90-day supply)
Tier 1
80%**
Not covered
70%**
Not covered
Tier 2
Tier 3
80%**
Not covered
70%**
Not covered
*Deductible does not apply
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