In State POS Plan
for Active Employees and
Non-Medicare Retirees

In State Plan Summary of
Benefits & Coverage (SBC)
 Schedule of Benefits

The State Employee Health Commission each year reviews the health plan and makes changes that are effective as of July 1st. Please refer to the Summary of Benefits & Coverage and the Schedule of Benefits above for details on your In State Plan benefits.

Plan Structure: You have an in network benefit that includes a preferred primary care physician (PCP) level of coverage. Your plan requires that you pick a primary care physician. Picking a preferred PCP will be less cost out of your pocket for a copay. You also have out of network coverage but, at a higher cost.

No Referrals Required: Referrals are not required from your PCP in order to see a specialist.

Deductibles: There is a $600 individual or $1,200 family in network deductible. There is a $3,000 individual or $6,000 family out-of-network deductible.

Maximum Annual Out-of-Pocket: There is a $2000 individual or $4000 family out-of-pocket in-network maximum. There is a $5,000 individual or $10,000 family out-of-pocket out-of-network maximum. The out-of-pocket maximum includes your deductible plus coinsurance.

Routine Eye Exams: All covered members on your policy are eligible for a routine eye exam once per calendar year, regardless of age.

Ambulatory Surgery Centers: The co-insurance for services provided at an ambulatory surgery center (non-hospital) is 5%.

Urgent Care: There is a $25 copay for services received from an in network provider. (Please note the copay for the emergency room is $300)

Diagnostic Lab Work: Your coinsurance limit for diagnostic lab work done at an in network facility (hospital and non-hospital) will be 10% after deductible.


Find a PCP or doctor in the network



Out of State POS Plan
for Active Employees and
Non-Medicare Retirees

Out of State Plan Summary
of Benefits & Coverage (SBC)
 Schedule of Benefits

How the Out of State Plan works
This plan gives you a choice between in-network and out of network providers and professionals. It’s important to keep in mind that your out-of-pocket costs are typically higher when you go to an out-of-network provider. You can visit your Primary Care Physician (PCP); or any network doctor, without a referral. You don’t have to choose a PCP, but you may want to.

Plan Highlights
Calendar Year Deductible: Individual $500 / Family $1,000
(Benefits are paid after the deductible has been met)
Coinsurance (coinsurance applies to most covered services)
  • In-Network 80%
  • Out of Network 60%
Calendar Year Out of Pocket Limit: Individual $2,000 / Family $4,000


Find a PCP or doctor in the network



Medicare AdvantageSM Plans


How the Medicare Advantage PPO Plan works
The Aetna Medicare Advantage PPO plan allows you the option to use doctors and hospitals that are in or out of the Aetna Medicare network. (Please refer to attached benefit summary for copay/coinsurance details as you may have a higher cost share when using out of network providers.)
  • For preventive services such as annual wellness exams and cancer screenings, you will be covered 100% with NO copay
  • You will receive additional benefits beyond Original Medicare A & B coverage
  • Discounts on health-related products and services
  • No referrals for covered services
  • Inpatient hospitalization covered 100%
How the Medicare Advantage PPO ESA Plan works
The Aetna Medicare Advantage PPO ESA plan will allow you the option to use doctors and hospitals that are in or out of the Aetna Medicare network. That means you can go to any provider that is licensed, is willing to accept the plan and eligible to receive payment from Original Medicare.
  • For preventive services such as annual wellness exams and cancer screenings, you will be covered 100% with NO copay
  • You will receive additional benefits beyond Original Medicare A & B coverage
  • Discounts on health-related products and services
  • No referrals for covered services
  • Inpatient hospitalization covered 100%



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