Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need 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.
Aetna PPO (CA and Non-CA)
Plan Information
Plan Name: Aetna PPO (CA and Non-CA)
Policy Number: 805870
Effective Date: 01/01/2024
Provider Network: Aetna
In-Network Benefit Highlights
Deductible (Individual/Family)
$200/$400
Out-of-Pocket Max (Individual/Family)
$2,200/$4,400
Preventive Care
$0 (deductible waived)
Primary Care Visit
$20 copay (deductible waived)
Specialist Visit
$20 copay (deductible waived)
Urgent Care
$25 copay (deductible waived)
Emergency Room
10% after $100 copay; deductible waived; (copay waived if admitted)
Benefit Highlights
In-Network
Deductible (Individual/Family)
$200/$400
Out-of-Pocket Max (Individual/Family)
$2,200/$4,400
Preventive Care
$0 (deductible waived)
Primary Care Visit
$20 copay (deductible waived)
Specialist Visit
$20 copay (deductible waived)
Urgent Care
$25 copay (deductible waived)
Emergency Room
10% after $100 copay (deductible waived; copay waived if admitted)
Retail RX (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Non-Preferred Brand
$45 copay
Mail-Order RX (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$90 copay
Out-of-Network
Deductible (Individual/Family)
$200/$400
Out-of-Pocket Max (Individual/Family)
$5,200/$10,400
Preventive Care
30% after deductible
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Urgent Care
30% after deductible
Emergency Room
10% after $100 copay (deductible waived; copay waived if admitted)
Retail RX (Up to 30-Day Supply)
Generic
20% coinsurance
Preferred Brand
20% coinsurance
Non-Preferred Brand
20% coinsurance
Mail-Order RX (Not covered)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Documents
Contact Information
Aetna HMO (CA Only)
Plan Information
Plan Name: Aetna HMO (CA Only)
Policy Number: 805870
Effective Date: 01/01/2024
Provider Network: Aetna
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
None
Out-of-Pocket Max (Individual/Family)
$1,000/$2,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist 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
$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 Documents
Contact Information
Kaiser HMO (CA Only)
Plan Information
Plan Name: Kaiser HMO (CA Only)
Policy Number: CA – North: 39413
CA – South: 231727
Effective Date: 01/01/2024
Provider Network: Kaiser
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network
Deductible (Individual/Family)
None
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$40 copay
Urgent Care
$20 copay
Emergency Room
$150 copay (waived if admitted)
Retail RX (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$35 copay
Non-Preferred Brand
$35 copay
Mail-Order RX (Up to a 100-Day Supply)
Generic
$30 copay
Preferred Brand
$70 copay
Non-Preferred Brand
$70 copay