b'Healthcare ElectionsMEDICAL BENEFITS SUMMARYEach Aetna plan covers the same services and utilizes the same Choice POS II network of providers, but differs in the amount deducted from your paycheck, your cost when you receive care, and how care is covered in-network versus out-of-network.PLATINUM PLUS PLATINUM GOLDMedical Benefits In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-NetworkDeductibleIndividual $250 $1,000 $500 $1,500 $1,500 $3,000Family $500 $2,000 $1,000 $3,000 $3,000 $6,000Out-of-Pocket MaximumIndividual $2,000 $4,000 $3,000 $6,000 $4,000 $8,000Family $4,000 $8,000 $6,000 $12,000 $8,000 $10,000Plan ResponsibilityThe plan pays % shown 100% 70% 90% 70% 90% 70%Amounts shown below are the amounts that Employee paysHospital / Deductible Deductible Deductible then 10% Deductible then 30% Deductible then 10% Deductible then 30%Inpatient Services then $300 copay then $300 copayOutpatient Facility Deductible thenDeductible then 30% Deductible Deductible thenDeductible then 10% Deductible then 30%Services 100% covered then 100% covered 100% coveredPrimary Care $10 copay per visit Deductible then 30% $20 copay per visit Deductible then 30% Deductible then 10% Deductible then 30%Specialist $20 copay per visit Deductible then 30% $40 copay per visit Deductible then 30% Deductible then 10% Deductible then 30%Emergency Room $150 copay Treated as $150 copay Treated as Deductible then 10% Deductible then 30%in-network in-networkUrgent Care $20 copay per visit Deductible then 30% $50 copay per visit Deductible then 30% Deductible then 10% Deductible then 30%Express Scripts Rx 30-day Retail (90-day Mail Order Supply)Rx Copays Medical Deductible AppliesGeneric $7 copay ($14 copay) $7 copay ($14 copay) $7 copay ($14 copay)Preferred $30 copay ($60 copay) $30 copay ($60 copay) $30 copay ($60 copay)Non-Preferred $55 copay ($110 copay) $55 copay ($110 copay) $55 copay ($110 copay)Specialty 20% up to a max of $100 20% up to a max of $100 20% up to a max of $100Medical Benefit Costs (These costs are per pay period)Employee Only $106.49 $83.87 $74.71Two-Party $211.88 $166.87 $148.65Family $271.79 $214.04 $190.675'