Page 6 - C.J. Segerstrom 2022 Benefit Guide

MEDICAL PLANS

Kaiser HMO Aetna HMO

Medical Plan Provisions In-Network Only In-Network Only
Annual Deductible None None
(Individual/Family)
Out-of-Pocket Maximum $1,500/$3,000 $2,000/$4,000
(Includes Deductible)
Lifetime Maximum Unlimited Unlimited
Preventive Care No Charge No Charge

Primary Care Provider
Office Visit $25 copay $20 copay

Specialist Office Visit $45 copay $40 copay
Most X-Ray and Lab Services No Charge Covered at 100%
Inpatient Hospital Services $500 copay $250 copay

Outpatient Hospital Services $100 copay $100 copay
Urgent Care $25 copay $35 copay
Emergency Room Care $150 copay; waived if admitted $100 copay
$10 copay $15 copay
Chiropractic Care/Acupuncture
(30 visit limit/year combined) ($20 visit limit/year)

Prescription Drug Deductible None None
Retail pharmacy (up to a 30-day supply)
Generic $10 copay $10 copay
Brand Preferred $30 copay $30 copay
Brand Non-Preferred $30 copay $50 copay

Mail Order Pharmacy (90-day supply)
Generic $20 copay $20 copay
Brand Preferred $60 copay $60 copay
Brand Non-Preferred N/A $100 copay
Bi-weekly Cost (non-tobacco)**

Employee Only $44.84 $44.84
Employee + Spouse $126.45 $126.45
Employee + Child(ren) $101.04 $101.04

Employee + Family $204.79 $204.79
*After deductible is met
**If you use tobacco, you will be charged an additional $50 per month.
Note: This is a summary only of your coverage. In-network services are based on negotiated charges; out-of-network services are based on

How to Find a Kaiser Provider: How to Find a Aetna HMO Provider:

1. Go to https://Kp.org/newmember 1. Go to http://www.aetna.com/docfind/home.do
2. Click on choose a Doctor 2. Continue as Guests
3. Select California-Southern 3. Select Plan From an Employer

4. Enter your zip code 4. Enter your zip code and click Search
5. Click Search 5. Under Select a Plan look for Aetna Standard Plans and circle HMO
6. Under Category select first left box “Medical Doctors & Specialists”

7. Click on Doctors (Primary Care) box
8. Select your choice of Primary care physician
9. Write down (PCP) Primary Care ID no. (6 digits) to enter in Paycom
Self-Service, if left blank Aetna will auto-assign you a doctor.

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