|
Through ABG Business Associates, LTD
RENEWAL Product Package
Rate Sheet
HMO #4
| Primary
office visit copay |
$20 |
$20 |
| Specialist
copay |
$20 |
$20 |
| SPU
Surgery copay |
$0 |
$0 |
| Hospitalization
I/P copay |
$0 |
$0 |
| Emergency
Room copay |
$50 |
$50 |
| Mental
Health O/P copay |
$25
20 visits/year |
$25
20 visits/year |
| Routine
Eye Exam copay |
$20 |
$20 |
| Routine
GYN Exam copay |
$20
2 visits/cal year |
$20
2 visits/cal year |
| Lens
Reimbursements |
$100
for 24 visits |
$100
for 24 visits |
| Prescription
Drugs (30 days) |
$10/$20/$35 |
$10/$20/$35 |
| 31-90
day supply |
2
copays (MOD only) |
2
copays (MOD only) |
| Rx
Deductible |
N/A |
$100/$300 |
| Chiropractic
copay |
$20 |
$20 |
| DME |
20%
of Ref |
20%
of Ref |
| Open
Access |
|
|
| PPID |
3213457 |
3213465 |
| Single |
$352.70 |
$350.90 |
| Parent
and Child(ren) |
$623.20 |
$619.90 |
| Couple |
$706.00 |
$702.20 |
| Family |
$1,042.60 |
$1,038.60 |
1. Rates are subject to Aetna's final
approval.
2. Rates are for New York subscribers (subscribers who choose a Primary
Care Physician located in NY)
3. Circle the rate and rider for the specific plan design you are
requesting
Effective Date: ____________
| _____________________________ |
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| Employer Name
|
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| _____________________________ |
___________________ |
| Employer Signature
|
Date
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| ____________________ |
_________________________ |
| Title |
Group Number |
Rates are for illustrative purposes only
and apply only to the benefit level stated above. Any changes in benefit
level may require a change in rates.
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50 Employee Plans | Aetna
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