Medical
Medical coverage provides healthcare protection for you and your family. You can visit any provider, but in-network doctors offer the highest level of benefits and lower out-of-pocket costs by charging reduced, contracted rates. Out-of-network providers set their own fees, so you may be responsible for charges above the Reasonable and Customary (R&C) limits. Preventive care—such as physical exams, flu shots, and screenings—is covered at 100% when you use in-network providers. The main differences between plan options are how much you pay per paycheck and what you pay when you receive care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums– the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Kaiser HMO (CA Only)
Benefit Highlights
In-Network
Deductible (Individual/Family)
$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Primary Care Visit
$20 copay
Urgent Care
$20 copay
Emergency Room
$100 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$20 copay
Specialty
$20 copay
Mail-Order Rx (Up to 100-Day Supply)
Generic
$20 copay
Preferred Brand
$40 copay
Specialty
$20 copay
All specialty RX comes via Kaiser’s Preferred Specialty Pharmacy with a max of 30 days per RX.
Plan Cost
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX
Aetna HMO (CA Only)
Benefit Highlights
In-Network
Deductible (Individual/Family)
$0
Out-of-Pocket Max (Individual/Family)
$1,000/$2,000
Primary Care Visit
$20 copay
Urgent Care
$35 copay
Emergency Room
$100 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Non-Preferred Brand
$40 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$80 copay
Plan Cost
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX
Aetna PPO
Benefit Highlights
In-Network
Deductible (Individual/Family)
$250/$500
Out-of-Pocket Max (Individual/Family)
$2,250/$4,500
Primary Care Visit
$15 copay
Specialist Visit
$15 copay
Urgent Care
$35 copay
Emergency Room
10% after $100 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Non-Preferred Brand
$40 copay
Specialty
20% up to $150
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$80 copay
Specialty
20% coinsurance
All Specialty RX comes via Aetna’s Preferred Specialty Pharmacy with a max of 30 days per RX.
Out-of-Network
Deductible (Individual/Family)
$250/$500
Out-of-Pocket Max (Individual/Family)
$10,500 + balance billing /$21,000 + balance billing
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
10% after $100 copay (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
30% of submitted cost. Max of $250
Preferred Brand
30% of submitted cost. Max of $250
Non-Preferred Brand
30% of submitted cost. Max of $250
Specialty
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Specialty
Not covered
Plan Cost
Employee Only: $XX
Employee and Spouse: $XX
Employee and Child(ren): $XX
Employee and Family: $XX