WEBTPA PPO

The EHN service area applies to residents of Southern California and Dallas/Fort Worth as described on the prior page. If you reside in one of the EHN service areas listed on the prior page and choose one of the WebTPA medical plans, the following benefit chart applies to you for the 2027 plan year.

WEBTPA PPO

Plan Details

Carrier: WebTPA
Plan Type: PPO
Network: EHN / Aetna
Out-of-Network Coverage: Yes

Your Contributions

Coverage Tier	MONTHLY CONTRIBUTIONS
Employee Only	$360.97
Employee + Spouse	$879.92
Employee + Child(Ren)	$714.01
Employee + Family	$1,283.31

Coverage Tier: Employee Only
MONTHLY CONTRIBUTIONS: $360.97

Coverage Tier: Employee + Spouse
MONTHLY CONTRIBUTIONS: $879.92

Coverage Tier: Employee + Child(Ren)
MONTHLY CONTRIBUTIONS: $714.01

Coverage Tier: Employee + Family
MONTHLY CONTRIBUTIONS: $1,283.31

Covered Services

For Residents Within Designated EHN Service Area

Services	EHN PROVIDER	AETNA NETWORK	OUT-OF-NETWORK
Calendar Year Deductible & Coinsurance - Individual	$800	$1,400	$4,000
Calendar Year Deductible & Coinsurance - Family	$1,600²	$2,800²	$8,000²
Coinsurance (Plan Pays)	90%	70%	50%
Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Individual	$3,500	$4,500	Unlimited
Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Family	$7,000	$9,000	Unlimited
Preventive Care ^	No charge	No charge	50%**
Primary Care	$10	$30	50%**
Specialist Services	$50	$70	50%**
Urgent Care	$100	$150	50%**
Emergency Room	$200 + 20%*	$200 + 20%*	$200 + 20%*
Surgery	10%*	30%*	50%**
Surgery Through Lantern Surgery Care	0%****	0%****	N/A

Services: Calendar Year Deductible & Coinsurance - Individual
EHN PROVIDER: $800
AETNA NETWORK: $1,400
OUT-OF-NETWORK: $4,000

Services: Calendar Year Deductible & Coinsurance - Family
EHN PROVIDER: $1,600²
AETNA NETWORK: $2,800²
OUT-OF-NETWORK: $8,000²

Services: Coinsurance (Plan Pays)
EHN PROVIDER: 90%
AETNA NETWORK: 70%
OUT-OF-NETWORK: 50%

Services: Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Individual
EHN PROVIDER: $3,500
AETNA NETWORK: $4,500
OUT-OF-NETWORK: Unlimited

Services: Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Family
EHN PROVIDER: $7,000
AETNA NETWORK: $9,000
OUT-OF-NETWORK: Unlimited

Services: Preventive Care ^
EHN PROVIDER: No charge
AETNA NETWORK: No charge
OUT-OF-NETWORK: 50%**

Services: Primary Care
EHN PROVIDER: $10
AETNA NETWORK: $30
OUT-OF-NETWORK: 50%**

Services: Specialist Services
EHN PROVIDER: $50
AETNA NETWORK: $70
OUT-OF-NETWORK: 50%**

Services: Urgent Care
EHN PROVIDER: $100
AETNA NETWORK: $150
OUT-OF-NETWORK: 50%**

Services: Emergency Room
EHN PROVIDER: $200 + 20%*
AETNA NETWORK: $200 + 20%*
OUT-OF-NETWORK: $200 + 20%*

Services: Surgery
EHN PROVIDER: 10%*
AETNA NETWORK: 30%*
OUT-OF-NETWORK: 50%**

Services: Surgery Through Lantern Surgery Care
EHN PROVIDER: 0%****
AETNA NETWORK: 0%****
OUT-OF-NETWORK: N/A

*After Deductible
**After deductible and subject to out-of-network reimbursement limitations
****Deductible and coinsurance may be waived for surgeries performed through Lantern Surgery Care. Refer to the SPD for more information
2If you choose to enroll you and your dependents in the PPO or HDHP 2 plan, a family member can meet the individual deductible and the plan will begin paying benefits for that individual only. Once two or more covered family members’ combined expenses meet the family deductible the plan will begin paying benefits for any covered family member
^Please refer to the SPD for preventive services with a capped benefit

For Residents Outside of Designated EHN Service Area

Services	AETNA IN-NETWORK	OUT-OF-NETWORK
Calendar Year Deductible - Individual	$1,000	$4,000
Calendar Year Deductible - Family	$2,000²	$8,000²
Coinsurance (Plan Pays)	80%	50%
Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Individual	$4,100	Unlimited
Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Family	$8,900	Unlimited
Preventive Care^	No charge	50%**
Primary Care	$30	50%**
Specialist Services	$50	50%**
Urgent Care	$100	50%**
Diagnostic Care	20%*	50%**
Emergency Room	$200 + 20%*	$200 + 20%*
Surgery	20%*	50%**
Surgery Through Lantern Surgery Care	0%****	N/A

Services: Calendar Year Deductible - Individual
AETNA IN-NETWORK: $1,000
OUT-OF-NETWORK: $4,000

Services: Calendar Year Deductible - Family
AETNA IN-NETWORK: $2,000²
OUT-OF-NETWORK: $8,000²

Services: Coinsurance (Plan Pays)
AETNA IN-NETWORK: 80%
OUT-OF-NETWORK: 50%

Services: Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Individual
AETNA IN-NETWORK: $4,100
OUT-OF-NETWORK: Unlimited

Services: Calendar Year Out-Of-Pocket Maximum (Includes Deductible) - Family
AETNA IN-NETWORK: $8,900
OUT-OF-NETWORK: Unlimited

Services: Preventive Care^
AETNA IN-NETWORK: No charge
OUT-OF-NETWORK: 50%**

Services: Primary Care
AETNA IN-NETWORK: $30
OUT-OF-NETWORK: 50%**

Services: Specialist Services
AETNA IN-NETWORK: $50
OUT-OF-NETWORK: 50%**

Services: Urgent Care
AETNA IN-NETWORK: $100
OUT-OF-NETWORK: 50%**

Services: Diagnostic Care
AETNA IN-NETWORK: 20%*
OUT-OF-NETWORK: 50%**

Services: Emergency Room
AETNA IN-NETWORK: $200 + 20%*
OUT-OF-NETWORK: $200 + 20%*

Services: Surgery
AETNA IN-NETWORK: 20%*
OUT-OF-NETWORK: 50%**

Services: Surgery Through Lantern Surgery Care
AETNA IN-NETWORK: 0%****
OUT-OF-NETWORK: N/A

*After Deductible
**After deductible and subject to out-of-network reimbursement limitations
****Deductible and coinsurance may be waived for surgeries performed through Lantern Surgery Care. Refer to the SPD for more information
2If you choose to enroll you and your dependents in the PPO or HDHP 2 plan, a family member can meet the individual deductible and the plan will begin paying benefits for that individual only. Once two or more covered family members’ combined expenses meet the family deductible the plan will begin paying benefits for any covered family member
^Please refer to the SPD for preventive services with a capped benefit

Pharmacy Benefits

For Residents Within Designated EHN Service Area

Tier	EHN PROVIDER	AETNA NETWORK	OUT-OF-NETWORK
Rx Calendar Year Out-Of-Pocket Maximum - Individual	$3,000	$3,000	N/A
Rx Calendar Year Out-Of-Pocket Maximum - Family	$6,000	$6,000	N/A
Generic	$10	$10	Not covered
Preferred Brand	$45	$45	Not covered
Non-Preferred Brand	$60	$60	Not covered

Tier: Rx Calendar Year Out-Of-Pocket Maximum - Individual
EHN PROVIDER: $3,000
AETNA NETWORK: $3,000
OUT-OF-NETWORK: N/A

Tier: Rx Calendar Year Out-Of-Pocket Maximum - Family
EHN PROVIDER: $6,000
AETNA NETWORK: $6,000
OUT-OF-NETWORK: N/A

Tier: Generic
EHN PROVIDER: $10
AETNA NETWORK: $10
OUT-OF-NETWORK: Not covered

Tier: Preferred Brand
EHN PROVIDER: $45
AETNA NETWORK: $45
OUT-OF-NETWORK: Not covered

Tier: Non-Preferred Brand
EHN PROVIDER: $60
AETNA NETWORK: $60
OUT-OF-NETWORK: Not covered

***90-day supply through mail order is available at 2.5x the retail copay for PPO and 2x the retail copay for HDHP1 and HDHP2

For Residents Outside of Designated EHN Service Area

Tier	AETNA IN-NETWORK	OUT-OF-NETWORK
Rx Calendar Year Out-Of-Pocket Maximum - Individual	$3,000	N/A
Rx Calendar Year Out-Of-Pocket Maximum - Family	$6,000	N/A
Generic	$10	Not covered
Preferred	$45	Not covered
Non-Preferred	$60	Not covered

Tier: Rx Calendar Year Out-Of-Pocket Maximum - Individual
AETNA IN-NETWORK: $3,000
OUT-OF-NETWORK: N/A

Tier: Rx Calendar Year Out-Of-Pocket Maximum - Family
AETNA IN-NETWORK: $6,000
OUT-OF-NETWORK: N/A

Tier: Generic
AETNA IN-NETWORK: $10
OUT-OF-NETWORK: Not covered

Tier: Preferred
AETNA IN-NETWORK: $45
OUT-OF-NETWORK: Not covered

Tier: Non-Preferred
AETNA IN-NETWORK: $60
OUT-OF-NETWORK: Not covered

***90-day supply through mail order is available at 2.5x the retail copay for PPO and 2x the retail copay for HDHP1 and HDHP2

Plan Notes

Which benefit chart applies depends on where you live: if you reside in a designated EHN county or ZIP code (Southern California or Dallas/Fort Worth) you use the EHN provider network; otherwise you access Aetna network providers.
If you have a pre-planned surgery and utilize Lantern, ACE will waive your deductible and coinsurance on the PPO plan.
The Prescription Drug Program for the WebTPA plans is coordinated through CVS/Caremark, with specialty pharmacy coordinated through Vivio.