Page 5 - Nortek California Employee Guide
P. 5
Nortek
Let’s take a look at the key features of each plan.
Health Reimbursement
Arrangement Health Savings Account Kaiser HMO
Out-of- Out-of-
In-Network Network In-Network Network Network
Calendar Year Deductible
Individual $1,750 $3,500 $3,000 $6,000 None
Family $3,500 $7,000 $6,000 $12,000 None
Coinsurance 80% 60% 80% 60% 100%
Out-of-Pocket Maximum Includes Deductible Includes Deductible
Individual $3,500 $7,000 $6,000 $12,000 $1,500
Family $7,000 $14,000 $12,000 $24,000 $3,000
Preventive Care 100% Not Available 100% Not Available 100%
Ofice Visit Copay
Primary Care Physician $30 copay Ded/60% Ded/80% Ded/60% $20 copay
Specialist $60 copay Ded/60% Ded/80% Ded/60% $35 copay
Hospital Services
Inpatient Ded/80% Ded/60% Ded/80% Ded/60% $250 per admittance
Outpatient Ded/80% Ded/60% Ded/80% Ded/60% $35 per procedure
$200 copay; $200 copay;
Emergency Room Ded/80% Ded/80% Ded/80% Ded/80% $100 per visit
Urgent Care $60 copay Ded/60% Ded/80% Ded/60% $20 copay
Prescription Drugs
Pharmacy Out-of-Pocket Maximum
Individual $3,100 N/A Pharmacy expenses are Pharmacy expenses are included
included in your medical out of in your medical out of pocket
Family $6,200 N/A pocket maximum maximum
Retail
Tier 1 $10 copay $10 copay Ded/80% Ded/60% Supply Limit 30 days
Tier 2 $30 copay $30 copay Ded/80% Ded/60% Generic $10 copay
Tier 3 $60 copay $60 copay Ded/80% Ded/60% Brand $35 copay
Tier 4 $90 copay $90 copay Ded/80% Ded/60% Self-Injectables Varies by drug
Mail Order
Tier 1 $20 copay Ded/80% Supply Limit 90 days
Tier 2 $60 copay Not Available Ded/80% Not Available Generic $20 copay
Tier 3 $120 copay Ded/80% Brand $70 copay
Tier 4 Not Available Not Available Self-Injectables Not covered
Please refer to your Summary Plan Description (SPD) for complete details of plan beneits, limitations, and exclusions. In the event of a conlict
between the SPD and this description, the terms of the SPD will prevail .
5
Let’s take a look at the key features of each plan.
Health Reimbursement
Arrangement Health Savings Account Kaiser HMO
Out-of- Out-of-
In-Network Network In-Network Network Network
Calendar Year Deductible
Individual $1,750 $3,500 $3,000 $6,000 None
Family $3,500 $7,000 $6,000 $12,000 None
Coinsurance 80% 60% 80% 60% 100%
Out-of-Pocket Maximum Includes Deductible Includes Deductible
Individual $3,500 $7,000 $6,000 $12,000 $1,500
Family $7,000 $14,000 $12,000 $24,000 $3,000
Preventive Care 100% Not Available 100% Not Available 100%
Ofice Visit Copay
Primary Care Physician $30 copay Ded/60% Ded/80% Ded/60% $20 copay
Specialist $60 copay Ded/60% Ded/80% Ded/60% $35 copay
Hospital Services
Inpatient Ded/80% Ded/60% Ded/80% Ded/60% $250 per admittance
Outpatient Ded/80% Ded/60% Ded/80% Ded/60% $35 per procedure
$200 copay; $200 copay;
Emergency Room Ded/80% Ded/80% Ded/80% Ded/80% $100 per visit
Urgent Care $60 copay Ded/60% Ded/80% Ded/60% $20 copay
Prescription Drugs
Pharmacy Out-of-Pocket Maximum
Individual $3,100 N/A Pharmacy expenses are Pharmacy expenses are included
included in your medical out of in your medical out of pocket
Family $6,200 N/A pocket maximum maximum
Retail
Tier 1 $10 copay $10 copay Ded/80% Ded/60% Supply Limit 30 days
Tier 2 $30 copay $30 copay Ded/80% Ded/60% Generic $10 copay
Tier 3 $60 copay $60 copay Ded/80% Ded/60% Brand $35 copay
Tier 4 $90 copay $90 copay Ded/80% Ded/60% Self-Injectables Varies by drug
Mail Order
Tier 1 $20 copay Ded/80% Supply Limit 90 days
Tier 2 $60 copay Not Available Ded/80% Not Available Generic $20 copay
Tier 3 $120 copay Ded/80% Brand $70 copay
Tier 4 Not Available Not Available Self-Injectables Not covered
Please refer to your Summary Plan Description (SPD) for complete details of plan beneits, limitations, and exclusions. In the event of a conlict
between the SPD and this description, the terms of the SPD will prevail .
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