|
Through ABG Business Associates, LTD
Managed Choice Rates
| Bronx,
Nassau, Queens Counties |
| |
MC-1 |
MC-2 |
MC-3 |
MC4
OA |
| Single |
221.82 |
261.96 |
301.58 |
327.68 |
| Employee/Spouse |
510.18 |
602.52 |
693.64 |
753.66 |
| Employee/Child(ren) |
399.27 |
471.53 |
542.85 |
589.82 |
| Family |
687.64 |
812.09 |
934.90 |
1,015.81 |
| Kings
County |
| |
MC-1 |
MC-2 |
MC-3 |
MC4
OA |
| Single |
217.63 |
257.02 |
295.89 |
321.50 |
| Employee/Spouse |
500.56 |
591.15 |
680.55 |
739.44 |
| Employee/Child(ren) |
391.74 |
462.64 |
532/60 |
578.69 |
| Family |
674.67 |
796.76 |
917.26 |
996.64 |
| Richmond
County |
| |
MC-1 |
MC-2 |
MC-3 |
MC4
OA |
| Single |
213.45 |
252.08 |
290.20 |
315.31 |
| Employee/Spouse |
490.93 |
579.78 |
667.46 |
725.22 |
| Employee/Child(ren) |
384.21 |
453.74 |
522.36 |
567.57 |
| Family |
661.69 |
781.44 |
899.61 |
977.47 |
| Rockland,
Westchester Counties |
| |
MC-1 |
MC-2 |
MC-3 |
MC4
OA |
| Single |
200.89 |
237.25 |
273.13 |
296.77 |
| Employee/Spouse |
462.05 |
545.67 |
628.20 |
682.56 |
| Employee/Child(ren) |
361.61 |
427.05 |
491.64 |
534.18 |
| Family |
622.77 |
735.47 |
846.70 |
919.98 |
| Dutchess,
Orange, Putman Counties |
| |
MC-1 |
MC-2 |
MC-3 |
MC4
OA |
| Single |
179.97 |
212.54 |
244.68 |
265.85 |
| Employee/Spouse |
413.92 |
488.83 |
562.76 |
611.46 |
| Employee/Child(ren) |
323.94 |
382.56 |
440.42 |
478.54 |
| Family |
557.90 |
658.86 |
758.51 |
824.14 |
| Manhattan
County |
| |
MC-1 |
MC-2 |
MC-3 |
MC4
OA |
| Single |
242.75 |
286.68 |
330.03 |
358.59 |
| Employee/Spouse |
558.31 |
659.36 |
759.08 |
824.76 |
| Employee/Child(ren) |
436.94 |
516.02 |
594.06 |
645.47 |
| Family |
752.51 |
888.70 |
1,023.10 |
1,111.64 |
| Sullivan,
Ulster Counties |
| |
MC-1 |
MC-2 |
MC-3 |
MC4
OA |
| Single |
163.23 |
192.77 |
221.92 |
241.12 |
| Employee/Spouse |
375.42 |
443.36 |
510.41 |
554.58 |
| Employee/Child(ren) |
293.81 |
346.98 |
399.45 |
434.02 |
| Family |
506.00 |
597.57 |
687.95 |
747.08 |
| Suffolk
County |
| |
MC-1 |
MC-2 |
MC-3 |
MC4
OA |
| Single |
226.00 |
266.91 |
307.27 |
333.86 |
| Employee/Spouse |
519.81 |
613.88 |
706.73 |
767.88 |
| Employee/Child(ren) |
406.81 |
480.43 |
553.09 |
600.95 |
| Family |
700.61 |
827.41 |
952.54 |
1,034.97 |
| MC
1 |
Preferred |
$25
PCP, $50 Spec Copay, $1000 Ded (2x), $500 Hosp Copay, $100 ER
Copay, 70% Coins with $3000 Individual Limit (3x) |
| Non-Preferred |
$2000
Deductible (2x), $1000 Hosp. Copay, $50 ER Copay, 50%
Conisurance with $6000 individual limit (3x) |
| MC
2 |
Preferred |
$25
PCP, $50 Spec Copay, $500 Hosp Copay, $50 ER Copay, 80%
Coinsurance with $3000 Individual Limit (3x) |
| Non-Preferred |
$2000
Deductible (2x), $1000 Hosp. Copay, $50 ER Copay, 60%
Conisurance with $6000 individual limit (3x) |
| MC
3 |
Preferred |
$20
PCP, $30 Spec Copay, $500 Hosp Copay, $50 ER Copay, 80%
Coinsurance with $2000 Individual Limit (3x) |
| Non-Preferred |
$3000
Deductible (2x), $1000 Hosp. Copay, $50 ER Copay, 60%
Conisurance with $4000 individual limit (3x) |
MC
4
Open Access |
Preferred |
$20
PCP, $30 Spec Copay, $500 Hosp Copay, $50 ER Copay, 90%
Coinsurance with $2000 Individual Limit (3x) |
| Non-Preferred |
$4000
Deductible (2x), $1000 Hosp. Copay, $50 ER Copay, 70%
Conisurance with $4000 individual limit (3x) |
Rx on all plans - $10 Formulary
Generic, $20 Formulary Non-Generic, $35 Non-Formulary with $100
Deductible
Rates are non-binding and subject to
change without notice. Actual rates may vary contingent upon
demographics of the enrolling groups and Aetna's underwriting review.
This preliminary rate should be read in conjunction with materials that
provide more detailed product and benefits descriptions, exclusions and
limitations, and underwriting guidelines.
"Aetna" is the brand name used for products and services
provided by one or more of the Aetna group of subsidiary companies.
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