Page 17 - OpenX 2022 Book of Benefits

Medical Plan Comparison:
See how the plans break down:

AETNA CDHP AETNA AETNA KAISER
W/HSA PPO HMO HMO

In Out of In Out of In Out of
Medical Plan Provisions
Network Network Network Network Network Network
$2,500/ $2,500/
Annual Deductible $500/ $500/
$2,800/ $2,800/ $0/$0 $0/$0
(Individual/Family) $1,000 $1,000
$5,000 $5,000
$4,000/ $8,000/
Out-of-Pocket Maximum $3,000/ $6,000/ $2,000/ $1,500/
$4,000/ $8,000/
(Includes Deductible) $6,000 $12,000 $4,000 $3,000
$8,000 $16,000
Covered Covered Covered Covered
Preventive Care 30% 40%
at 100% at 100% at 100% at 100%
AMOUNT YOU PAY AFTER DEDUCTIBLE

$20 copay
Primary Care Provider 10% after 30% after 40% after
(deductible $20 copay $20 co-pay
Office Visit deductible deductible deductible
waived)
$25 copay
10% after 30% after 40% after
Specialist Office Visit (deductible $30 copay $35 co-pay
deductible deductible deductible
waived)
Teladoc: Teladoc:
Teladoc: Up Teladoc: Up
Telemedicine Up to $47 Up to $47 $30 Copay No Charge
to $47 copay to $47 copay
copay copay
No Charge
10% after 30% after 20% after 40% after (Complex
X-Ray and Lab No charge
deductible deductible deductible deductible Labs; $100
copay)
10% after 30% after 20% after 40% after $500 per
Inpatient Hospital Services $500 per admit
deductible deductible deductible deductible admit
10% after 30% after 20% after 40% after $100 per
Outpatient Hospital Services $200 per visit
deductible deductible deductible deductible procedure
$35 copay
10% after 30% after 40% after
Urgent Care (deductible $35 co-pay $20 co-pay
deductible deductible deductible
waived)
Acupuncture 10% after 30% after
$25 copay $15 copay Not Covered
(20 visits per year) deductible deductible
10% after 30% after 40% after $15 copay;
$25 copay; $15 copay; 20
Chiropractic deductible; deductible; deductible; 20 annual
20 visits annual visits
20 visits 20 visits 20 visits visits

$250 copay + 20%
Emergency Room 10% after deductible $150 copay $100 copay
(deductible waived)

HEALTH CARE | 16