Copay, Deductible and Coinsurance Amounts:

For Active Employees and non-Medicare Retirees

Below is the summary of various out-of-pocket expenses you may expect under the State of Maine's Point of Service health plan.  There are some exceptions to the tables below; please see the Summary of Benefits (MS-Word) for a more complete explanation of coverage.

Type of Office Visit or Test

Copay Amount
Office visit with primary care doctor at a practice which is preferred by the State of Maine
$0
Office visit with an Aetna participating primary care doctor
$20
Office visith with a specialist who is a member of the Aetna network (no referral required)
$25
Participating walk-in clinic or urgent care facility
$25
Emergency room (waived if admitted)
$150
Emergency room (waived if admitted) *Effective July 1, 2014*
$300
High tech imaging (MRI, CT scan, PET scan)
$50

 

Medication Category
30-Day Supply Copay Amount
90-Day Supply Copay Amount
Generic medications
$10
$15
Formulary brand-name medications
$30
$45
Non-formulary brand-name medications
$45
$70
Lifestyle medications (infertility and impotency)
$50
$75

 

Individual out-of-pocket expense
In-Network
Out-of-Network
Calendar year deductible
$500
$2,500
Coinsurance
20%
40%
Coinsurance - services billed by a preferred hospital or specialist
10%
n/a
Annual maximum out-of-pocket expense
(deductible + coinsurance + medical copays)
$2,000
$5,000

 

Family out-of-pocket expense (two or more members)
In-Network
Out-of-Network
Calendar year deductible
$1,000
$5,000
Coinsurance
20%
40%
Coinsurance - services billed by a preferred hospital or specialist
10%
n/a
Annual maximum out-of-pocket expense
(deductible + coinsurance + medical copays)
$4,000
$10,000

 

Aetna Point of Service Member Services 1-855-850-0039
www.AetnaStateOfMaine.com

State of Maine Statute: Title 5 285, 285-A and 286