Decide

Take some time and review the many new choices, programs and resources available to help keep you and your family healthy. See your guide for details.

Your medical plans are offered through Aetna and in-network preventative care is covered at 100%.

Benefits	Basic Managed Care (You Pay)	Managed Care (You Pay)	HCRA Plan (You Pay)	Premium Managed Care (You Pay)
Comparison to Marketplace plans	Bronze	Silver Plus	Gold	Gold Plus
In-network preventive care covered at 100%	Yes	Yes	Yes	Yes
Well-being resources and special programs	Yes	Yes	Yes	Yes
Provider network	Broad or APCN Plus	Broad or APCN Plus	Broad or APCN Plus	Broad or APCN Plus
Use of in- and out-of- network providers	Yes	Yes	Yes	Yes
Must select a Primary Care Physician (PCP)	No	Yes	No	Yes
PCP referrals needed for specialty care	No	Yes	No	Yes
HCRA Funded	No	No	Yes	No
In-network deductible	Yes	Yes	Yes	Yes
Out-of-pocket maximum for in-network care	$6,500 single $13,000 family	$3,000 single $6,000 family	$3,750 single $7,500 family	$1,500 single $3,000 family

Note: Prescription drug coverage is included in the medical plan. Prescription drug expenses are not subject to the medical plan deductible

Comparison to Marketplace plans

In-network Medical Services

Benefits	Basic Managed Care (You Pay)	Managed Care (You Pay)	HCRA Plan (You Pay)	Premium Managed Care (You Pay)
Office Visits Primary Care Physician (PCP)/Specialist (SPC)	$30 PCP copay (after deductible) $45 SPC (after deductible)	$30 PCP copay $45 SPC	Deductible and Coinsurance	$30 PCP copay $45 SPC copay
Emergency Room	$150 copay (after deductible)	$150 copay	Deductible and Coinsurance	$150 copay
Urgent Care Facility	$45 copay (after deductible)	$40 copay	Deductible and Coinsurance	$45 copay
Deductible	$2,750 single $5,500 family	$1,000 single $2,000 family	$2,250 single $4,500 family	$2,000 single $4,000 family
HCRA Fund	N/A	N/A	$1,500 single $3,000 family	N/A
Deductible after HCRA Fund	N/A	N/A	$750 single $1,500 family	N/A
Coinsurance	35%	10%	10%	10%
Annual Out-of-Pocket Maximum	$6,500 single $13,000 family	$4,000 single $8,000 family	$3,750 single $7,500 family	$2,000 single $4,000 family

Note: Prescription drug coverage is included in the medical plan. Prescription drug expenses are not subject to the medical plan deductible

Comparison to Marketplace plans

Out-of-Network Medical Services

Benefits	Basic Managed Care (You Pay)	Managed Care (You Pay)	HCRA Plan (You Pay)	Premium Managed Care (You Pay)
Office Visits and Preventative Care	Deductible and Coinsurance	Deductible and Coinsurance	Deductible and Coinsurance	Deductible and Coinsurance
Emergency Room	$150 copay (after deductible)	$150 copay	Deductible and Coinsurance	$150 copay
Deductible	$7,500 single $15,000 family	$1,500 single $3,000 family	$4,000 single $8,000 family	$2,000 single $4,000 family
Coinsurance*	50%	30%	40%	40%
Annual Out-of-Pocket Maximum	$12,500 single $25,000 family	$6,000 single $12,000 family	$8,000 single $16,000 family	$5,000 single $10,000 family

* The plan pays out-of-network benefits based on Medicare reimbursement levels of 140% of Medicare. In addition to your coinsurance, and any deductible, you are responsible for amounts that exceed these levels.

Prescription Drugs: Managed Care Plan, HCRA Plan and Premium Care Plan*

Type of Drug	Definition	Retail Pharmacy (Non-ShopRite)	ShopRite Pharmacies or Spotswood Mail-Order
		For a 30-day Supply	For a 90-day Supply
Generic	Drug with same active ingredients as brand name, with lower cost	$10	$10
Preferred Brand**	Drug marketed under a specific trademark or name by specific drug manufacturer and included on Aetna's drug list.	$30	$30
Non Preferred Brand** (No generic available)	Drug marketed under a specific trademark or name by specific drug manufacturer and NOT included on Aetna's drug list.	$50	$50
Specialty Brand***	High-cost prescription medications used to treat complex, chronic conditions	$100	Contact your local pharmacy for more information.

* The cost of prescriptions under the Basic Managed Care Plan uses coinsurance. You pay 30% of the cost for Generic and Preferred Brand and 50% of the Non-Preferred Brand (not subject to the medical plan deductible).
** If you or your physician requests a brand-name medication when a generic is available, you will pay the applicable copay plus the difference between the cost of the generic and brand-name drug.
***Specialty Brand drugs must be filled at CVS Specialty Pharmacy.

Dental Plans

Weekly Employee Contributions:
Single: $1.29
Family: $3.67

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Active PPO with PPOII and ExtendSM Networks	In-Network You Pay	Out-of-Network You Pay
Annual Deductible - Individual*	$25	$25
Annual Deductible - Family**	$75	$75
Preventative Services	100%	100%
Basic Services	85%	80%
Major Services	65%	60%
Annual Benefit Maximum	$2,500	$2,500
Office Visit Copay	N/A	N/A
Orthodonic Services**	50%	50%
Orthodonic Deductible	None	None
Orthodonic Lifetime Maximum	$2,500	$2,500

* The deductible applies to Basic and Major Services only.
** Orthodontia is covered only for children (appliance must be placed prior to age 20).

Vision Plans

Weekly Employee Contributions:
Single: $0.00
Team Member + 1: $2.64
Family: $2.92

Benefit	In-Network Member Cost	Out-of-Network Reimbursement
Exam (one every 12 months)	No copay	Up to $28
Frames (one every 24 months)	No copay; $180 allowance + 20% off balance over $180	$90
Lenses (one every 12 months)
Single Vision Bifocal Trifocal	No copay No copay No copay	Up to $25 Up to $39 Up to $63
Contact Lenses (one order every 12 mos.)
Conventional	No copay; $180 allowance + 15% balance over $180	Up to $144
Disposable	No copay; $180 allowance	Up to $144
Medically Necessary	No copay; Paid in Full	Up to $200

DECIDE