Altius
An Aetna® Plan
2023 Biweekly rates for zip code 84003
These rates do not apply to all Enrollees. If you are in a special enrollment category, please refer to the FEHB Program website or contact the agency or Tribal Employer which maintains your health benefits enrollment.
| Altius Health Plan - HDHP | Code | Biweekly Premium |
|---|---|---|
| Self Only: | 9K4 | $107.15 |
| Self +1: | 9K6 | $191.15 |
| Self & Family: | 9K5 | $191.68 |
| Altius Health Plan - Standard | Code | Biweekly Premium |
|---|---|---|
| Self Only: | DK4 | $198.75 |
| Self +1: | DK6 | $441.92 |
| Self & Family: | DK5 | $401.05 |
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Your 2023 benefits - UT, ID, WY
| Plan Details | HDHP | Standard Option HMO |
|---|---|---|
| Deductible | $1,500 for self only $3,000 for self + one or self + family |
$100 for self only $200 for self + one or self + family |
| Health Savings Account deposits (annual) | $750 for self only $1500 for self + one or self + family |
N/A |
| Preventive Care copay (no deductible) | $0 | $0 |
| Primary care visit copay | $20 | $25 |
| Specialist Copay | $30 | $45 |
| Prenatal Care | $0 | $0 |
| Inpatient hospital care | 10% coinsurance | 15% coinsurance |
| Outpatient facility copay | $500 copay | $650 copay |
| Emergency room copay | $200 | $250 |
| Urgent care center copay | $30 | $45 |
| Lab/X-ray/diagnostic services | $30 copay (some tests are $175) | $45 copay (some tests are $250) |
| Prescription drugs
(for a 30-day supply at a retail pharmacy) See Aetna.com for a list of participating pharmacies. |
||
| Generic formulary* | $7 (after deductible) | $7 |
| Brand-name formulary* | $25 (after deductible) | $50 |
| Non-formulary* | $50 (after deductible) | 50% up to $240 max |
*For specialty drug information, see the federal plan brochure.
|
||
| Built-in Vision | ||
| Routine eye exam copay | $0 | $0 |
| Money toward prescription eyewear | You get $100 every 24 months | You get $100 every 24 months |
| Discounts on eyeglasses, contacts, eye exams and more | Included | Included |
Built-in dental coverage (High Option only) |
||
Why choose Altius Open Access HMO?
- Large Altius Network, use the network of doctors you trust
- 24 hours a day / 7 days a week access to doctors via phone or video with Teladoc®† telehealth services
- Built-in vision coverage
- Predictable costs
- No referrals to network specialists
- Discounts on eyewear, LASIK laser eye surgery, gym memberships, massage, acupuncture, weight-loss programs and more
*A formulary is a list of generic and brand-name drugs your health plan prefers.
** If you choose the brand name drug over the generic equivalent, you will owe the corresponding copay plus the difference between the generic and brand name costs. Please see the plan brochure for details.
*** Out of Network for cleanings, composite fillings and X-rays – you pay 50% of the negotiated rate plus any difference between our allowance and the billed amount.
†Teladoc® is covered at the member cost share. Please see plan brochure for details.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).
This is a brief description of the features of this Aetna health benefits plan. Before making a decision, please read the Plan's applicable Federal brochure(s). All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure. Teladoc® is not available to all members. Teladoc and Teladoc physicians are independent contractors and are not agents of Aetna. Visit Teladoc.com/Aetna for a complete description of the limitations of Teladoc services. Teladoc, Teladoc Health and the Teladoc Health logo are registered trademarks of Teladoc Health, Inc. DISCOUNT OFFERS ARE NOT INSURANCE. They are not benefits under your insurance plan. You get access to discounts off the regular charge on products and services offered by third-party vendors and providers. Aetna makes no payment to the third parties — you are responsible for the full cost. Check any insurance plan benefits you have before using these discount offers, as those benefits may give you lower costs than these discounts.
Pharmacy clinical programs such as precertification, step therapy, and quantity limits may apply to your prescription drug coverage. Aetna's Drug Guide is subject to change. Trademarks and logos displayed are the property of their respective owners. Information is believed to be accurate as of the production date; however, it is subject to change.
