Page 6 - 5.11 Benefit Guide 2018 CA PRINT

MEDICAL

AETNA AETNA AETNA
HSA PLAN PPO PLAN HMO PLAN
NETWORK Network Non-Network Network Non-Network Network

HEALTH BENEFITS
Lifetime Maximum Unlimited Unlimited Unlimited
Annual Deductible
• Employee $2,000 $4,000 $1,250 $3,000 None
• Family $4,000 $8,000 $2,500 $6,000 None
• Individual within Family $2,700 $4,000 $1,250 $3,000 None
5.11 HSA Annual Contribution
• Employee $500 None None
• Employee + Spouse $750 None None
• Employee + Children $750 None None
• Employee + Family $1,200 None None

Coinsurance (Plan Pays) 90% 60% 90% 60% 100%
Physician Office Visit
• PCP Ded, 90% Ded, 60% $40 Copay Ded, 60% $35 Copay
• Specialist Ded, 90% Ded, 60% $50 Copay Ded, 60% $50 Copay
Out-of-Pocket Maximum Includes Deductible Includes Deductible
• Employee $4,200 $8,000 $5,000 $10,000 $2,000
• Family $6,300 $12,000 $10,000 $20,000 $4,000
• Individual within Family $4,200 $8,000 $5,000 $10,000 $2,000
Hospitalization
• Inpatient Ded, 90% Ded, 60% $100 Copay, Ded, 60% $500 Copay
Ded, 90%
• Outpatient Surgery Ded, 90% Ded, 60% Ded, 90% Ded, 60% $200 Copay
Emergency Services Ded, 90% $150 Copay, 90% $100 Copay
Urgent Care Ded, 90% Ded, 60% $40 Copay Ded, 60% $50 Copay
Preventive Care 100% Ded, 60% 100% Not Covered 100%
Chiropractic Ded, 90% Ded, 60% $40 Copay Ded, 60% $15 Copay
Max 20 Visits/Year Max 20 Visits/Year Max 20 Visits/Year
PHARMACY BENEFITS

Annual Deductible Applies to Brand/Non-Formulary
• Employee Health Deductible Applies $100 None
• Family Health Deductible Applies $300 None
Retail (30 Day Supply)
• Generic $10 Copay 60% $10 Copay Copay+50% $10 Copay
• Brand Name $25 Copay 60% $30 Copay Copay+50% $30 Copay
• Non-Formulary $40 Copay 60% $50 Copay Copay+50% $50 Copay
Mail Order (90 Day Supply)
• Generic $20 Copay Not Covered $20 Copay Not Covered $20 Copay
• Brand Name $50 Copay Not Covered $60 Copay Not Covered $60 Copay
• Non-Formulary $80 Copay Not Covered $100 Copay Not Covered $100 Copay

6