Meritain Copay Plan Meritain CDHP Plan
Individual
$500 $1,500
Family
$1,200 $3,000
% Shared by Meritain and You
90% (Meritain) / 10% (You) 90% (Meritain) / 10% (You)
Individual
$3,000 $3,500
Family
$6,000 $7,000
Routine preventive physical exams,
$0 $0
Primary Care Provider (PCP)
$20 copay 10% coinsurance after deductible
Specialist
$35 copay 10% coinsurance after deductible
Urgent Care
$35 copay 10% coinsurance after deductible
Emergency Room (waived if admitted)
$250 copay, then 10% coinsurance after deductible 10% coinsurance after deductible
Ambulance Services
10% coinsurance after deductible 10% coinsurance after deductible
Physician Services
10% coinsurance after deductible 10% coinsurance after deductible
Hospital Outpatient
$150 copay, then 10% coinsurance after deductible 10% coinsurance after deductible
Hospital Inpatient
$250 copay, then 10% coinsurance after deductible 10% coinsurance after deductible
10% coinsurance after deductible 10% coinsurance after deductible
Outpatient
10% coinsurance after deductible 10% coinsurance after deductible
Inpatient
No Charge 10% coinsurance after deductible
$20 copay 10% coinsurance after deductible
10% coinsurance after deductible 10% coinsurance after deductible
Office Visits
$20 copay 1st visit, then $0 after deductible 10% coinsurance after deductible
Childbirth/delivery professional services
10% coinsurance after deductible 10% coinsurance after deductible
Childbirth/delivery facility services
$250 copay, then 10% coinsurance after deductible 10% coinsurance after deductible
Home Health Care
10% coinsurance after deductible 10% coinsurance after deductible
Rehabilitiation Services
$35 copay 10% coinsurance after deductible
Habilitation Services
$35 copay 10% coinsurance after deductible
Skilled Nursing Care
$250 copay, then 10% coinsurance after deductible 10% coinsurance after deductible
Durable Medical Equipment
10% coinsurance after deductible 10% coinsurance after deductible
Hospice Services
10% coinsurance after deductible 10% coinsurance after deductible
Generic
$10 10% coinsurance after deductible (max of $150)
Preferred Brand
$25 10% coinsurance after deductible (max of $150)
Non-Preferred Brand
$40 10% coinsurance after deductible (max of $150)
Preferred Formulary Specialty
$25 10% coinsurance after deductible (max of $150)
Non-Preferred Formulary Specialty
$40 10% coinsurance after deductible (max of $150)
Generic
$20 10% coinsurance after deductible (max of $450)
Preferred Brand
$50 10% coinsurance after deductible (max of $450)
Non-Preferred Brand
$80 10% coinsurance after deductible (max of $450)
Preferred Formulary Specialty
Not Covered through Mail Order Not Covered through Mail Order
Non-Preferred Formulary Specialty
Not Covered through Mail Order Not Covered through Mail Order
Cosmetic Surgery Long-term care Routine eye care (Adult & Child)
Dental Care (Adult & Child) Non-emergency care when traveling ouside the U.S. Routine foot care (except for metabolic or peripheral vascular disease)
Glasses (Adult & Child) Private-duty nursing (inpatient) Weight Loss Programs
Accupunture (24 visits per year) Chiropractic Care (24 visits per year Inferility (through Progyny only)
Bariatric Surgery Hearing Aids (1 per hearing impaired ear every 24 months) Private-duty nursing (outpatient)
Other Covered Services
Excluded Services
Excluded Services & Other Covered Services
Meritain Health (Aetna Network) Plan Comparision Chart
Coinsurance
Office Visits and Outpatient Services
Hospital Services
Laboratory and X-Ray Services
In-Network
Calendar Year Deductible
Annual Out-of-Pocket Maximum
Preventive Care
Mental Health & Substance Abuse/Chemical Dependency
Maternity Services
Retail (30-day supply)
Mail Order (90-day supply)
Additional Services
