Aetna High Deductible Health Plan (HDHP) with a Health Savings Account (HSA)

A national PPO network, no referrals and a tax-free account

2025 Biweekly rates for zip code 20002

These rates do not apply to all Enrollees. If you are in a special enrollment category, please refer to the PSHB Program website or contact the agency which maintains your health benefits enrollment.

Table of rates.
Aetna HealthFund® HDHP with HSA	Code	Biweekly Premium
Self Only:	G3D	$174.38
Self +1:	G3F	$377.42
Self & Family:	G3E	$342.76

Looking to save? Check out the MHBP Consumer Option (HDHP with HSA) »

How does your HDHP with a HSA work?

STEP 1: You get a HSA*
Your HDHP comes with an HSA, which you can use to help pay for your qualified health care expenses. The Plan contributes money to your HSA each month. You can contribute pre-tax dollars to the HSA too. All of that money in your HSA earns interest tax-free. And all unused money is yours to keep - even if you leave the plan.

How much do you get in your HSA?
The Plan adds money each month: Self Only: $800 a year ($66.67 a month) Self Plus One or Self and Family: $1,600 a year ($133.34 a month)

STEP 2: You have a deductible
A deductible is the amount you need to pay out of your pocket before the Plan starts to pay for covered services. You can use the money in your HSA to pay your deductible or save it for the future.

What is your deductible amount?	In network	Out of network
Self Only:	$1,800	$2,600
Self Plus One or Family:	$3,600	$5,200

To lower your costs, use network providers.

STEP 3: You may have coinsurance
Coinsurance is how much the Plan and you pay for health care expenses. It is a shared amount. We pay the larger part. You pay the smaller part.

Coinsurance starts after you have met your deductible.

What is your coinsurance amount?	We Pay	You Pay
In network:	85%	15%
Out of network:	60%	40%

Plus

MinuteClinic^® or Walk in clinic - $0 after deductible (In network)
CVS Health^® Virtual Care™ - $0 after deductible

You get in network preventive care at no additional cost to you!
Examples include wellness screenings and exams, dental cleanings and routine eye exams. If you see network providers, nothing comes out of your pocket (or your HSA).

Built-in pharmacy, dental and vision benefits, too

Table of rates.
Type of coverage	What you get
Pharmacy coverage, when Medicare not primary	Copays after you meet your deductible. For a 30-day supply in-network, pay $10 (preferred generic), 50% max of $200 (preferred brand), 50% max of $300 (preferred generic or brand).† Your plan requires the use of generic medication when a generic equivalent exists.* Mail-order delivery or at a CVS Pharmacy^® location. For maintenance prescriptions (medicine you need for 90+ days), $20 for preferred generics, 50% max of $400 for preferred brand name, 50% max of $600 for non preferred (generic or brand name) formulary.†
Dental	Cleanings and X-rays covered 100% when you see network dentists.
Vision	Routine eye exams covered at 100% when you visit network doctors. $100 allowance every 24 months to pay for prescription eyewear. Discounts on eyeglasses, contact lenses and more.

Aetna HealthFund HDHP Prescription drug benefits when you’re enrolled in Medicare Part A and/or B: Aetna Medicare Rx offered by SilverScript

Members with Medicare Part A and/or Part B primary will be automatically enrolled into Aetna Medicare Rx^® offered by SilverScript^®. This is a Medicare Part D prescription drug option offering significant savings. Your drugs will still be covered, but copays and coinsurance are lower. See benefits below.

Table of rates.
Benefit	What you'll pay
30-day Supply through Retail	Preferred generic: $0 Generic: $4 from a preferred pharmacy ($5 from a standard pharmacy) Preferred brand: $40 Non-preferred brand: $100 Specialty: 25% up to $150
90-day Supply through Retail or Mail	Preferred Generic: $0 Generic: $8 from preferred mail order or pharmacy ($10 from standard mail order or pharmacy) Preferred Brand: $80 Non-Preferred Brand: $200 Specialty Limited to a one-month supply
Out of Pocket Maximum for prescription drugs	Once you have paid $2,000 in out of pocket costs for covered prescription drugs, you will pay $0 for covered prescription drugs for the remainder of the calendar year under this Medicare Part D Prescription Drug Plan. This $2,000 will also apply to the medical plan’s total calendar year out-of-pocket maximum.

Aetna Medicare Rx Resources and Contact Information

Call Members Services at 1-833-251-9749 (TTY: 711), Monday through Friday, 8 AM to 8 PM ET or go online at AetnaRetireeHealth.com/PSHBP

You can get more money in your HSA!

You can earn an additional $75 for Self Only or $150 for Self Plus One or Family (enrollee and spouse only) by completing the Health Risk Assessment, one wellness program and your biometric screening. Log in to your Aetna member website to complete the Health Risk Assessment and enroll in a wellness program. The money goes directly into your HSA when completed!

Why choose Aetna HDHP?

Large nationwide Aetna PPO Network
Coverage in network or out — and no referrals needed
Earn up to $75/self or $150/self plus one and family in wellness credits
An HSA that you own — use the tax-free money to pay for qualified health expenses now or save it for future expenses
24 hours / 7 days a week access to doctors via video with CVS Virtual Care
Discounts on eyewear, LASIK laser eye surgery, gym memberships, massage, acupuncture, weight-loss programs and more

*To open an HSA, you must meet certain IRS eligibility requirements. If you don't, let us know by calling 1-877-459-6604 (TTY:711). You can enroll in a similar plan called HDHP with HRA. See the official plan brochure for details.
**For specialty drug information, see the official plan brochure
***If you choose the brand name drug over the generic equivalent, you will owe the corresponding copay plus the difference between the generic and brand name costs. Please see the plan brochure for details.

† See Aetna.com for a list of participating pharmacies.

Aetna, CVS Pharmacy^® and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic-branded walk-in clinics) are part of the CVS Health^® family of companies. This is a brief description of the features of this Aetna health benefits plan. Before making a decision, please read the Plan's official brochure(s). All benefits are subject to the definitions, limitations, and exclusions set forth in the official brochure.

For a complete list of other participating pharmacies log in to your member website to use our provider search tool. Includes select MinuteClinic services. Not all MinuteClinic services are covered. Please consult benefit documents to confirm which services are included. Members enrolled in qualified high-deductible health plans must meet their deductible before receiving covered non-preventive MinuteClinic services at no cost-share. However, such services are covered at negotiated contract rates. This benefit is not available in all states. For your best health, we encourage you to have a relationship with a primary care physician or other doctor. Tell them about your visit to MinuteClinic, or MinuteClinic can send a summary of your visit directly to them. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services.

This material does not contain legal or tax advice. You should contact your legal counsel or tax advisor if you have any questions or need additional information. Inspira Financial does not provide any payment or service in violation of any United States economic or trade sanctions. This material contains only a partial, general description of plan benefits or programs and is not a contract. If this material conflicts with the plan documents, the plan documents will govern. Eligible expenses may vary from employer to employer. Please read the plan’s applicable federal brochure(s) for more information about your covered benefits. There may be fees associated with a health savings account (“HSA"). These are the same types of fees you may pay for checking account transactions. Please see the HSA fee schedule online.

For more information about Inspira, go to InspiraFinancial.com.

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

This is a brief description of the features of this Aetna health benefits plan. Before making a decision, please read the Plan's official brochure(s). All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure.

Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional.

Incentive-based activity awards will only be given for completing select wellness programs as determined by the plan sponsor. Plan features and availability may vary by location and are subject to change. Pharmacy clinical programs such as precertification, step therapy, and quantity limits may apply to your prescription drug coverage. Aetna’s Drug Guide is subject to change.

For information about our plans available through the Federal Employees Dental and Vision Insurance Program (FEDVIP), please visit our Dental PPO Plan site or our Aetna Vision™ Preferred site.

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