Medical Plan Options Chart

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	HEALTHSAVER PLUS¹		HEALTHSAVER¹		POINT-OF-SERVICE (POS)
	In-Network	Out-Of-Network²	In-Network	Out-Of-Network²	In-Network	Out-Of-Network²
Coverage Information
Annual deductible (calendar-year basis; does not include non-covered services)	$1,650 single $3,300 family	$3,000 single $6,000 family	$1,700 single $3,400 family	$3,400 single $6,800 family	$750 single $1,500 family⁴	$1,500 single $3,000 family⁴
Coinsurance	80% after deductible	60% after deductible	80% after deductible	60% after deductible	80% after deductible	60% after deductible
Annual out-of-pocket maximum (includes deductibles and prescriptions; does not include non-covered services)	$3,500 single $7,000 family³	$7,000 single $14,000 family³	$4,500 single $9,000 family³	$9,000 single $18,000 family³	$2,750 single $5,500 family⁴	$5,500 single $11,000 family⁴
Lifetime maximum	Unlimited		Unlimited		Unlimited
Pre-existing condition exclusion	None		None		None
Precertification requirements	Yes, for specific services. Always check with your physician.	Precertification is your responsibility (unauthorized care is not covered and does not apply to the deductible or out-of-pocket maximum). You must call Aetna within 48 hours of an emergency admittance.	Yes, for specific services. Always check with your physician.	Precertification is your responsibility (unauthorized care is not covered and does not apply to the deductible or out-of-pocket maximum). You must call Aetna within 48 hours of an emergency admittance.	Yes, for specific services. Always check with your physician.	Precertification is your responsibility (unauthorized care is not covered and does not apply to the deductible or out-of-pocket maximum). You must call Aetna within 48 hours of an emergency admittance.
PREVENTIVE CARE
Routine physical exam (once per calendar year, including X-ray and laboratory)	100% with no deductible	60% after deductible	100% with no deductible	60% after deductible	100% with no deductible	60% after deductible
Well-baby/child care, including immunizations	100% with no deductible	60% after deductible	100% with no deductible	60% after deductible	100% with no deductible	60% after deductible
Routine screenings in accordance with preventive care schedule (e.g., colonoscopy, mammography, Pap test, PSA, sigmoidoscopy)	100% with no deductible	60% after deductible	100% with no deductible	60% after deductible	100% with no deductible	60% after deductible
Routine vision exam (once per calendar year)	100% with no deductible	60% after deductible	100% with no deductible	60% after deductible	100% with no deductible	60% after deductible
Routine hearing exam (once per calendar year)	100% with no deductible	60% after deductible	100% with no deductible	60% after deductible	100% with no deductible	60% after deductible
Physician Services
Primary care or specialist office visit	90% after deductible	60% after deductible	90% after deductible	60% after deductible	Primary: 100% after $10 copay per visit Specialist: 100% after $45 copay per visit	60% after deductible
X-ray and laboratory as part of medical/ diagnostic care	80% after deductible	60% after deductible	80% after deductible	60% after deductible	80% after deductible	60% after deductible
Screenings as part of medical/ diagnostic care (e.g., colonoscopy, mammography, Pap test, PSA, sigmoidoscopy)	80% after deductible	60% after deductible	80% after deductible	60% after deductible	80% after deductible	60% after deductible
Physician hospital services	80% after deductible	60% after deductible	80% after deductible	60% after deductible	80% after deductible	60% after deductible
Surgery – inpatient and outpatient	80% after deductible	60% after deductible	80% after deductible	60% after deductible	80% after deductible	60% after deductible
Surgery – physician’s office	90% after deductible	60% after deductible	90% after deductible	60% after deductible	100% after $45 copay	100% after $45 copay
Maternity care – delivery and postnatal	80% after deductible	60% after deductible	80% after deductible	60% after deductible	80% after deductible	60% after deductible
Allergy testing and injections	80% after deductible	60% after deductible	80% after deductible	60% after deductible	80% after deductible	60% after deductible
Chiropractic care	80% after deductible	60% after deductible	80% after deductible	60% after deductible	100% after $25 copay	60% after deductible
Chiropractic care	Limit of 30 visits per year combined in- and out-of-network		Limit of 30 visits per year combined in- and out-of-network		Limit of 30 visits per year combined in- and out-of-network
Hospital Services
Inpatient and outpatient services	80% after deductible	60% after deductible	80% after deductible	60% after deductible	80% after deductible	60% after deductible
Emergency care in emergency room	80% after deductible	80% after deductible	80% after deductible	80% after deductible	100% after $250 copay per visit (waived if admitted and inpatient coverage applies)
Urgent care	80% after deductible	60% after deductible	80% after deductible	60% after deductible	100% after $60 copay per visit (other services, such as lab and X-ray 80% after deductible)	60% after deductible
Ambulance (for emergency or precertified medically necessary care only)	80% after deductible		80% after deductible		80% after deductible
Other Services
Private duty nursing	80% after deductible	60% after deductible	80% after deductible	60% after deductible	80% after deductible	60% after deductible
Skilled nursing facility	80% after deductible	60% after deductible	80% after deductible	60% after deductible	80% after deductible	60% after deductible
Home health care	80% after deductible	60% after deductible	80% after deductible	60% after deductible	80% after deductible	60% after deductible
Home health care	Limit of 90 days per calendar year combined in- and out-of-network		Limit of 90 days per calendar year combined in- and out-of-network		Limit of 90 days per calendar year combined in- and out-of-network
Hospice	80% after deductible	60% after deductible	80% after deductible	60% after deductible	80% after deductible	60% after deductible
Durable medical equipment	80% after deductible	60% after deductible	80% after deductible	60% after deductible	80% after deductible	60% after deductible
Mental Health and Substance Use Disorder (MHSU) Treatment
Inpatient and intermediate care	80% after deductible	60% after deductible	80% after deductible	60% after deductible	80% after deductible	60% after deductible
Outpatient care (provider’s office)	90% after deductible	60% after deductible	90% after deductible	60% after deductible	100% after $10 copay per visit	60% after deductible
*Prescription Drugs (Subject to Formulary)**
RETAIL 30 (up to 30-day supply)
Preventive drugs	80%, not subject to deductible	Not covered	80%, not subject to deductible	Not covered	Generic: $20 Pref. brand: $50 Non-pref. brand: $100	Not covered
All other drugs	80% after deductible	Not covered	80% after deductible	Not covered	Generic: $20 Pref. brand: $50 Non-pref. brand: $100	Not covered
RETAIL 90 (90-day supply)
Preventive drugs	80%, not subject to deductible	Not covered	80%, not subject to deductible	Not covered	Generic: $60 Pref. brand: $150 Non-pref. brand: $300	Not covered
All other drugs	80% after deductible	Not covered	80% after deductible	Not covered	Generic: $60 Pref. brand: $150 Non-pref. brand: $300	Not covered
MAIL ORDER (90-day supply) Patient assistance may not apply to deductible and out-of-pocket maximums.
Preventive drugs	80%, not subject to deductible	Not covered	80%, not subject to deductible	Not covered	Generic: $40 Pref. brand: $100 Non-pref. brand: $200	Not covered
All other drugs	80% after deductible	Not covered	80% after deductible	Not covered	Generic: $40 Pref. brand: $100 Non-pref. brand: $200	Not covered

¹ These health plans meet Minimum Creditable Coverage standards.
² Precertification requirements apply when using out-of-network providers. Out-of-network services are covered at the applicable coinsurance based on Reasonable & Customary fees in a given geographic area.
³ The out-of-pocket maximum for an individual within family-level coverage is $7,000 in-network and $14,000 out-of-network.
⁴ For the POS plan, the single limit applies to an individual within family level coverage. For example, if you select family coverage and one member incurs claims of $750, that member will pay coinsurance (or 20%) on any claims above the $750 until the out-of-pocket maximum is reached.
*Under the Hasbro POS Plan, prescription drug coverage through Express Scripts has a separate annual out-of-pocket maximum of $3,350 for single coverage and $6,700 for family coverage.

Medical Plan Options Chart

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