Greeley-Evans School District 6
School District
Medical Cost & Benefits
Medical Cost
| Your Monthly Cost | Aetna HNO OA Copay Plan | Aetna HNO OA HSA Plan |
|---|---|---|
| Employee Only | $72.00 | $0.00 |
| Employee + Spouse | $841.00 | $765.00 |
| Employee + Child(ren) | $761.00 | $656.00 |
| Employee + Family | $1,201.00 | $1,092.00 |
Benefit Highlights
| Benefit Highlights | In-Network You Pay - HNO OA Copay Plan | In-Network You Pay - HNO OA HSA Plan |
|---|---|---|
| Plan Year Deductible | $750 Individual / $2,250 Family | $1,650 Individual / $3,300 Family |
| Plan Year Out-of-Pocket (OOP) Max | $3,500 Individual / $7,000 Family | $3,000 Individual / $6,000 Family |
| Coinsurance | 80% after deductible | 90% after deductible |
| Preventative Care | No Charge | No Charge |
| Routine Office Visit | $25 copay | Deductible then 10% |
| Specialist Office Visit | $50 copay | Deductible then 10% |
| Mental Health Visit | $50 copay | Deductible then 10% |
| Urgent Care | Deductible then $75 copay | Deductible then 10% |
| Emergency Room Visit | Deductible then $200 copay/visit | Deductible then 10% |
| Ambulance | Deductible then 20% | Deductible then 10% |
| Inpatient Hospital | $150 copay then deductible then 20% | Deductible then 10% |
| Outpatient Surgery | $75 copay/visit then deductible then 20% | Deductible then 10% |
| Diagnostic X-Ray/Lab | Deductible then 20% | Deductible then 10% |
| Complex Radiology (MRI, PET, CAT) | $150 copay/visit then deductible then 20% | Deductible then 10% |
RX Benefits
| Retail (30-day supply) | In-Network You Pay | Plan Deductible then Copays Apply |
|---|---|---|
| Tier 1 | $10 copay | $10 copay |
| Tier 2 | $40 copay | $30 copay |
| Tier 3 | $70 copay | $50 copay |
| Specialty | Copay as noted above for generic or brand | Copay as noted above for generic or brand |
| Mail Order (90-day supply) | 3x retail copay | 2.5x retail copay |
For more detailed information about each plan's medical benefits and limitations, please consult the plan Summary of Benefits and Coverage (SBC). You can find them at: bit.ly/D6BenefitsEnrolllment2025