Page 9 - Hitachi Benefit Guide February 2018

Medical Plans

Medical Plan Aetna Silver PPO Aetna Gold PPO Aetna Platinum PPO

Network Name OAMC Non-Network OAMC Non-Network OAMC Non-Network
Health Benefits
Lifetime Maximum Unlimited Unlimited Unlimited
Annual Deductible
Individual $500 $1,500 $250 $750 $100 $500
Family $1,000 $3,000 $500 $1,500 $200 $1,000
Co-Insurance (Plan Pays) 80% 60% 90% 70% 100% 70%
Preventive Care 100% Ded, 60% 100% Ded, 70% 100% Ded, 70%
Physician Office Visit
$25 Copay Ded, 60% $20 Copay Ded, 70% $15 Copay Ded, 70%
PCP
Specialist $35 Copay Ded, 60% $30 Copay Ded, 70% $25 Copay Ded, 70%
Out-of-Pocket Maximum Deductible Applies Deductible Applies Deductible Applies
Individual $3,000 $6,000 $2,000 $4,000 $2,000 $2,000
Family $6,000 $12,000 $4,000 $8,000 $4,000 $4,000
Hospitalization
Inpatient $150 copay, Ded, $150 copay, Ded, Ded, 90% Ded, 70% 100% Ded, 70%
80% 60%
Outpatient Ded, 80% Ded, 60% Ded, 90% Ded, 70% 100% Ded, 70%
Emergency Services $150 Copay, 80% $150 Copay, 80% $100 Copay, 90% $100 Copay, 90% $50 Copay $50 Copay

Urgent Care $35 Copay $35 Copay $35 Copay $35 Copay $35 Copay $35 Copay
Chiropractic $25 Copay Ded, 60% $20 Copay Ded, 70% $15 Copay Ded, 70%
12 visits/year 12 visits/year 12 visits/year 12 visits/year 12 visits/year 12 visits/year
Durable Medical Ded, 90% Ded, 90% Ded, 90% Ded, 90% Ded, 50% Ded, 50%
Equipment
Pharmacy Benefits
Pharmacy Deductible
Individual None None None None None None
Family None None None None None None
Retail Pharmacy
Generic $5 Copay Copay, 50% $5 Copay Copay, 50% $5 Copay Copay, 50%
Brand Name $30 Copay Copay, 50% $30 Copay Copay, 50% $30 Copay Copay, 50%
Non Formulary $55 Copay Copay, 50% $55 Copay Copay, 50% $55 Copay Copay, 50%
Retail Supply Limit 30 Days 30 Days 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
Generic $10 Copay In-Network $10 Copay In-Network $10 Copay In-Network
Brand Name $60 Copay Only $60 Copay Only $60 Copay Only
Non Formulary $110 Copay $110 Copay $110 Copay
Mail Order Supply Limit 90 Days 90 Days 90 Days

Hitachi Solutions America Employee Benefits Guide | 2018 9