Page 11 - Work Life and Benefits Booklet 2020 - Global Post

PLAN NAME KAISER AETNA AETNA
HMO OAMC/PPO PPO/HSA
KAISER OPEN ACCESS OPEN ACCESS
NETWORK NAME GRANDFATHERED FOR LEGACY MANAGED CHOICE NON-NETWORK* MANAGED CHOICE NON-NETWORK*
ABOL EMPLOYEES NETWORK NETWORK
Deductible (per calendar year)
Individual / Family $1,000 / $2,000 $250 / $500 $500 / $1,000 $1,400 / $2,800 $2,800 / $5,600
Out-of-Pocket Maximum (per calendar year)
Individual / Family None $2,250 / $4,500 $4,500 / $9,000 $3,000 / $6,000 $8,000 / $16,000
Covered Services

Office Visits (physician / specialist) $20 Copay / $30 Copay $20 Copay Deductible, 30% Deductible, 10% Deductible, 30%
Routine Preventive Care Covered 100% Covered 100% Not Covered Covered 100% Deductible, 30%
Virtual Visit Covered 100% $20 Copay Not Covered Deductible, 10% Not Covered
Coinsurance (Plan Pays) 100% 90% 70% 90% 70%
Outpatient Diagnostic Lab & X-Ray Copay applies at office visit, Covered 100% Deductible, 30%
(physician’s office / other facility) otherwise, 0% after deductible Deductible, 10% Deductible, 30%
Complex Imaging $30 Copay / 0% after deductible Covered 100% Deductible, 30%
(physician’s office / other facility) Deductible, 10% Deductible, 30%
Emergency Room $200 Copay $100 Copay $100 Copay
(copay waived if admitted) Deductible, 10% Deductible, 10%
Urgent Care Facility $40 Copay $50 Copay Deductible, 30% Deductible, 10% Deductible, 30%

Inpatient Hospital Stay 0% after deductible Deductible, 10% Deductible, 30% Deductible, 10% Deductible, 30%

Outpatient Surgery 0% after deductible Deductible, 10% Deductible, 30% Deductible, 10% Deductible, 30%

Chiropractic (20 visits/year) Discounts apply $20 Copay Deductible, 30% Deductible, 10% Deductible, 30%

* Non-Network providers do not have a contract and therefore can charge you any amount. Aetna will reimburse you up to an allowed amount based on a percentage of
Medicare. You are responsible for any amount above the above the allowed amount, commonly referred to as balanced billing.