CLARKSTOWN CENTRAL SCHOOL DISTRICT Side By Side

Aetna Value Plus

In-Network Only Out-of-Network In-Network Out-of-Network In-Network Only In-Network Out-of-Network

Annual Deductible (single/family)

$1,500 Ind./$3,000 Family

$2,000 Ind./$4,000 Family N/A $1,250 Ind./$2,500 Family N/A No Deductible

$1,250 Per Member plus

$250 Per Member for Managed

Physical Medicine Program

Health Savings Fund n/a

Coinsurance (single/family)

None after deductible 20% after deductible None 20% after deductible None None

Office: 20% after deductible

Inpt/Outpt Facility: 10% after

deductible

Managed Physical Medicine: 50%

after deductible

Out-of-Pocket Maximum (medical/rx combined

maximum)

$6,350 Individual or $12,700 Family

(including deductible)

$6,600 Individual or $13,200

Family (including deductible)

$6,350 Individual or

$12,700 Family

$5,000 Individual or $10,000

Family (including deductible)

$6,350 Individual or $12,700

Family

Individual: $8,700 ($5,650 Med + $3,050

Rx): Family: $17,400 ($11,300 Med +

$6,100 Rx)

$3,750 Coinsurance Maximum Per

Member (excludes deductible)

Physician Office Visits Copay

$20, after deductible Deductible & Coins $25 Deductible & Coins $25 $25 Deductible & Coins

Specialty Care Copay

$40, after deductible Deductible & Coins $45 Deductible & Coins $45 $25 Deductible & Coins

Preventive Care, Screenings & Immunizations

No Charge Deductible & Coins No Charge Deductible & Coins No Charge No Charge

Most services not covered out of

network

No Charge Deductible & Coins No Charge Deductible & Coins No Charge

1 Routine Exam per 12 Months

$200 Vision Hardware

Reimbursement per 24 Months

Hospital Care - Inpatient Copay

100% after deductible Deductible & Coins 100% Deductible & Coins 100% 100% Deductible & Coins

Hospital Care - Outpatient Copay 100% after deductible Deductible & Coins 100% Deductible & Coins 100%

$50 Outpt Diagnostic Radiology/Lab

$95 Outpt Surgery ($50 Non-Hospital

Location)

Deductible & Coins

Home Health Care

100% after deductible Deductible & Coins 100% Deductible & Coins 100% 100% Deductible & 50% Coins

Hospice Care

100% after deductible Deductible & Coins 100% Deductible & Coins 100% 100% Deductible & Coins

Chiropractic Care

100% after deductible Deductible & Coins 100% Deductible & Coins

$45 Copay

$25 Deductible & 50% Coins

Speech/Occupational/Physical Therapy

100% after deductible

(90 visits/year)

Ded & Coins (90 visits/year) 100% (90 visits/year) Ded & Coins (90 visits/year) $45 Copay (60 visits/year)

$25 Deductible & 50% Coins

Skilled Nursing Facility

100% after deductible

(180 days/year)

Ded & Coins (180 days/year) 100% (180 days/year) Ded & Coins (180 days/year) 100% (180 days/year)

100% (120 days/year) Deductible & Coins

Emergency Room (Cert. Req. w/in 48hrs) $75 Copay, after deductible

$75 Copay, after deductible $100 Copay $100 Copay $100 Copay

Prescription Drug Card Copay

Generic

$10 copay after deductible

($20 Mail)

$10 Copay ($20 Mail) $10 Copay ($20 Mail)

30 Day Supply: $5 Copay

31-90 Day Supply: $10 Retail, $5 Mail

Preferred (Formulary) Brand

$35 copay after deductible

($70 Mail)

$35 Copay ($70 Mail) $35 Copay ($70 Mail)

30 Day Supply: $30 Copay

31-90 Supply Day: $60 Retail, $55 Mail

Non-Preferred (Non-Formulary) Brand

$55 copay after deductible ($110

Mail)

$55 Copay ($110 Mail) $55 Copay ($110 Mail)

30 Day Supply: $60 Copay

31-90 SupplyDay: $120 Retail, $110 Mail

Hearing Aids

Covered 100% after deductible (Max

$5,000/3 Yrs)

Deductible & Coins

Covered 100% (Max

$5,000/3 Yrs)

Deductible & Coins

Covered 100% (Max $5,000/

3 Yrs)

100% (Max $1,500/4 Yrs) Deductible and Coinsurance

Durable Medical Equipment

100% after deductible Deductible & Coins Covered 100% Deductible & Coins Covered 100% Covered 100% Deductible and 50% Coins

Mental Health:

Inpatient

100% after deductible Deductible & Coins Covered 100% Deductible & Coins Covered 100% No Copay Deductible and Coinsurance

Outpatient

$20 Copay, after deductible Deductible & Coins $25 Copay Deductible & Coins $25 Copay $25 Copay Deductible and Coinsurance

Substance Abuse:

Inpatient Rehab.

100% after deductible Deductible & Coins Covered 100% Deductible & Coins Covered 100% No Copay Deductible and Coinsurance

Outpatient Rehab.

$20 Copay, after deductible Deductible & Coins $25 Copay Deductible & Coins $25 Copay $25 Copay Deductible and Coinsurance

Above summarizes certain aspects of the CCSD medical benefits program. Complete descriptions of each benefit are available in the actual plan documents. Every effort has been made to ensure the above summary accurately describes these benefits. However, if there is a conflict between this information and the plan documents, the plan

documents will govern. Nothing above should be construed as a contract or offer to contract for employment for any specific time or under any particular terms and conditions. While it is CCSDs intent to continue these programs, we reserve the right to amend or terminate them at any time.

CLARKSTOWN CENTRAL SCHOOL DISTRICT

Side By Side Comparison. Please See Specific Plan Design for Details.

Effective 01/01/2022

Aetna CDHP (HDHP with HSA Fund) Aetna POS Plan NYSHIP (Empire PPO Plan)

$1,500 Individual or Family

n/a

$100 Copay

n/a

Routine Eye Exam N/A

1 Routine Exam per 12 Months

$200 Vision Hardware

Reimbursement per 24 Months

$200 Vision Hardware

Reimbursement per 24 Months

Monthly Employee Health Plan Contribution Rates Effective 1/1/2022 Annual Employee Health Plan Contribution Rates Effective 1/1/2022

To calculate the per pay period contribution: multiply below by 12, then divide by 19 paychecks To calculate the per pay period contribution: divide by 19 paychecks

NYSHIP 2022 NYSHIP 2022

Employee

Contribution %

High Deductible

w/ HSA

POS Value Plus EPO Empire PPO

Employee

Contribution %

High Deductible

w/ HSA

POS Value Plus EPO Empire PPO

Employee

30% $256.99 $354.09 $345.46 $358.84 Employee 30% $3,084 $4,249 $4,146 $4,306

Employee + Spouse

30% $565.37 $779.00 $760.00 $829.12 Employee + Spouse 30% $6,784 $9,348 $9,120 $9,949

Employee + Child(ren)

30% $488.28 $672.78 $656.37 $829.12 Employee + Child(ren) 30% $5,859 $8,073 $7,876 $9,949

Employee & Family

30% $758.11 $1,044.57 $1,019.09 $829.12 Employee & Family 30% $9,097 $12,535 $12,229 $9,949

NYSHIP 2022 NYSHIP 2022

Employee

Contribution %

High Deductible

w/ HSA

POS Value Plus EPO Empire PPO

Employee

Contribution %

High Deductible

w/ HSA

POS Value Plus EPO Empire PPO

Employee

33% $282.68 $389.50 $380.00 $394.72 Employee 33% $3,392 $4,674 $4,560 $4,737

Employee + Spouse

33% $621.90 $856.90 $836.00 $912.03 Employee + Spouse 33% $7,463 $10,283 $10,032 $10,944

Employee + Child(ren)

33% $537.11 $740.06 $722.01 $912.03 Employee + Child(ren) 33% $6,445 $8,881 $8,664 $10,944

Employee & Family

33% $833.92 $1,149.03 $1,121.00 $912.03 Employee & Family 33% $10,007 $13,788 $13,452 $10,944

Clarkstown Central School District - 2022 Employee Contributions

Aetna