Medical Benefits

Your employer offers medical insurance to protect the health of you and your family. It covers medical expenses such as visits to the doctor’s office, emergency care, and prescription drugs. It’s important to have a medical plan that meets your needs and the needs of your family. Keep in mind that your out-of-pocket costs will be lower if you receive care from an in-network doctor and facility.

The Medical Administrator is Gravie. Gravie utilizes the Aetna network. If your provider accepts Aetna medical insurance, they will accept Gravie medical insurance. Please kindly remind your provider to file claims with Gravie, not Aetna. If you have questions, please contact the Gravie Customer Care team via (800) 501-2920. Please do not contact Aetna Customer Service. Aetna will have no record of your benefits.

• To find an in-network Doctor, please visit aetna.com/asa
• To find an in-network Pharmacy, please visit https://www.caremark.com/memberportal/pharmacy-locator?fastStyle=OE
• To review the list of Prescription Drug Costs, please visit https://www.caremark.com/memberportal/check-drug-cost?fastStyle=OE&logintype=oe&tokenID=2D67FC221C1237A89D53E918F3F5489E
• To review the Gravie Rx Formulary and learn more about Specialty Rx, please visit https://www.gravie.com/pbm-faq/

Aetna Signature Adminstrators Network	In-Network
Deductible (Individual/Family)	$1,600/ $3,200
Out-of-Pocket Max (Individual/Family)	$6,000/ $12,000
Member Coinsurance	20%
Office Visit (Designated Network)	$30 Copay
Specialist Visit	$50 Copay
Preventive/Wellness Exams	100% Covered
Virtual Visits	$0
Inpatient Hospitalization	Deductible + 20% Coinsurance
Outpatient Surgery	Deductible + 20% Coinsurance
Lab & X-Rays	Deductible + 20% Coinsurance
Urgent Care	$75 Copay
Emergency Room	$500 Copay + 20% Coinsurance

Prescriptions	In-Network
Retail Prescriptions (30-day supply)
Tier 1 - Generic Preferred	$10
Tier 2 - Preferred Brand	$50
Tier 3 - Non-Preferred	50%
Tier 4 - Specialty	No Cost with Prudent Rx
Mail Order Prescriptions (90-day supply)
Tier 1 - Generic Preferred	$20
Tier 2 - Preferred Brand	$100
Tier 3 - Non-Preferred	50%
Tier 4 - Specialty	No Cost with Prudent Rx

	Per Pay Period Cost (Weekly)
Employee Only	$76.92
Employee + Spouse	$278.02
Employee + Child(ren)	$234.97
Employee + Family	$420.26

Downloads

Summary of Benefits

Summary of Benefits-Spanish

Gravie Aetna Benefit Guide

Gravie Aetna Benefit Guide-Spanish

Prescription Drug List

Aetna Signature Adminstrators Network	In-Network
Deductible (Individual/Family)	$5,000/ $10,000
Out-of-Pocket Max (Individual/Family)	$7,900/ $15,800
Member Coinsurance	20%
Office Visit	$30 Copay
Specialist Visit	$50 Copay
Preventive/Wellness Exams	100% Covered
Virtual Visits	$0
Inpatient Hospitalization	Deductible + 20% Coinsurance
Outpatient Surgery	Deductible + 20% Coinsurance
Lab & X-Rays	Deductible + 20% Coinsurance
Urgent Care	$75Copay
Emergency Room	$500 Copay + Deductible + 20% Coinsurance

Prescriptions	In-Network
Retail Prescriptions (30-day supply)
Tier 1 - Generic Preferred	$10
Tier 2 - Preferred Brand	$50
Tier 3 - Non-Preferred	50%
Tier 4 - Specialty	No Cost with Prudent Rx
Mail Order Prescriptions (90-day supply)
Tier 1 - Generic Preferred	$20
Tier 2 - Preferred Brand	$100
Tier 3 - Non-Preferred	50%
Tier 4 - Specialty	No Cost with Prudent Rx