Medical

Sample Company offers a choice of three medical plans. While the plans differ in some respects, they have one important similarity — a focus on prevention.

All three plans are administered by Aetna and offer preventive care at no cost (in-network only), help for plan participants managing chronic conditions and wellness-focused features. You can locate a doctor or facility through Aetna’s Find A Doctor Online Directory. Please keep in mind that the availability of any particular provider cannot be guaranteed.

EXCLUSIVE PROVIDER ORGANIZATION

With the Exclusive Provider Organization (EPO) option, you receive comprehensive coverage for a range of services. You must use in-network providers. There are no out-of-network benefits.

EPO at a Glance
  • Moderate monthly contribution
  • Low deductible and coinsurance
  • No claim forms
  • No out-of-network benefits
  • The EPO utilizes the Open Access Aetna Select network

PREFERRED PROVIDER ORGANIZATION

The Preferred Provider Organization (PPO) option offers the freedom to see any provider when you need care. When you use providers from within the Aetna PPO network, you receive benefits at the discounted network cost. If you use non-PPO providers, you will pay more for services.

PPO at a Glance
  • Higher monthly contribution
  • Freedom to go out-of-network
  • No claim forms for in-network services
  • Participants are responsible for amounts up to deductible and out-of-network charges in excess of Aetna contracted rates
  • The PPO utilizes the Aetna Choice POS II network

HIGH DEDUCTIBLE HEALTH PLAN

The HDHP is similar to the PPO in that you have the option to choose any provider when you need care. However, in exchange for a lower per-paycheck cost, you must satisfy a higher deductible that applies to almost all health care expenses, including those for prescription drugs.

With lower premiums and an out-of-pocket cap mandated by federal law, HSA-compatible health insurance plans like the Sample Company HDHP typically saves money compared to a PPO for both high- and low-frequency users of health care.

HDHP at a Glance
  • Lower monthly contribution
  • Freedom to go out-of-network
  • No claim forms for in-network services
  • Participants are responsible for amounts up to deductible and out-of-network charges in excess of Aetna contracted rate
  • The HDHP utilizes the Aetna Choice POS II network
  • 10% coinsurance will apply after deductible

If you select the High Deductible Health Plan, you may be eligible to participate in a Health Savings Account.

MEDICAL PLAN ENHANCEMENTS

Our health plans are designed to meet the diverse needs of our employees. Take a look a some of the featured covered medical procedures and health aids.

MEMORIAL SLOAN KETTERING (MSK) WORLD-CLASS CANCER CENTER

MSK Direct gives you accurate and comprehensive diagnoses and treatment plans, clinical trials access and MSK-IMPACT genomic testing, if clinically appropriate. You will receive personalized treatment planning and care, plus continuous support through the cancer journey, including:

  • Screening
  • Generic, emotional and social counseling
  • Oncology nursing
  • Integrative medicine
  • Medical nutrition therapy
  • Pain management
  • Palliative care
  • Survivorship programs

These programs are available to you on-site at MSK or remotely through video or phone. So you can choose what works best for your care.

HINGE HEALTH

Sample Company is offering Hinge Health at no additional cost for those enrolled in a Sample Company medical plan. Hinge Health is a digital exercise therapy program for back, knee, hip, neck or shoulder pain. It features wearable motion sensors to guide you through the program, a library of educational resources and a personalized health coach who will be there to support you every step of the way.

LYRA MENTAL HEALTH RESOURCES

Lyra is designed to help you with life’s challenges, whether you need mental health coaching (seven free sessions for employees and adult dependents), mental health therapy or medication management support, Lyra will help you quickly find the right provider.

This benefit is available to members and their dependents enrolled in a Sample Company medical plan.

You can create your profile, complete a wellness questionnaire and select your appropriate care path — digital tools, coaching, therapy or medication management — at example.com. Enter your health plan information and a payment card to cover any related costs for therapy and/or medication management services (out-of-pocket cost-share may apply consistent with other mental health services through Aetna). Schedule any coaching or therapy appointments, if recommended, and sessions may begin within six days.

If you have questions, contact the Lyra Care Team 24/7 by phone at 800-555-5555 or email at johndoe@example.com.

PROGYNY FERTILITY BENEFITS

With Progyny, you have access to the most advanced, effective fertility treatment possible. Progyny fertility benefits are available to all employees and covered spouses or domestic partners who are enrolled in a Sample Company Aetna medical plan. Progyny adoption and surrogacy benefits are available to all benefit eligible employees.

Sample Company’s benefit includes three Smart Cycles. Each Smart Cycle is a bundle of all services (appointments, tests, diagnostics, labs, anesthesia, etc.) used for comprehensive fertility treatments. You can utilize your Smart Cycles for whichever treatments you and your doctor determine are right for you, until you exhaust your Smart Cycle balance. 

You’ll have a dedicated Patient Care Advocate (PCA) who will guide you throughout the entire process. You can manage your Smart Cycle balance by contacting your PCA, who will provide access to the Progyny member portal. To get started, call 800-555-5555.