Page 10 - Work Life and Benefits Booklet 2018 - SDC.END.pub
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NON-NETWORK*   $500 / $1,000   $4,500 / $9,000   30% after deductible   Not Covered   Not Covered   70%   30% after deductible   30% after deductible   $100 Copay   30% after deductible   30% after deductible   30% after deductible   30% after deductible









                          AETNA   OAMC/PPO

                                 OPEN ACCESS MANAGED   CHOICE NETWORK   $250 / $500   $2,250 / $4,500   $10 Copay   Covered 100%   $10 Copay   90%   Covered 100%   10% after deductible   $100 Copay   $50 Copay   10% after deductible   10% after deductible   $10 Copay, 20 visits/year




                  Medical Plan Highlights








                                                                                                                You are responsible for any amount above the above the allowed amount, commonly known as balanced billing.




                          AETNA   FULL HMO   HMO    NETWORK   CA EMPLOYEES ONLY   None  $1,500 / $3,000   $10 Copay / $20 Copay   Covered 100%   $20 Copay   100%  Covered 100%   $100 Copay   $150 Copay   $10 Copay   $150 per day for the first 3  days, then covered 100%   $100 Copay   $10 Copay, 20 visits/year  * 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 % of Medicare.











                             DEDUCTIBLE HMO



                          AETNA   DEDUCTIBLE HMO     NETWORK   CA EMPLOYEES ONLY   $100 / $200   $1,500 / $3,000   $10 Copay   Covered 100%   $10 Copay   100%  Covered 100%   Covered 100%   $150 Copay after deductible   $10 Copay   No charge after deductible   No charge after deductible   $10 Copay, 20 visits/year










                                                Out-of-Pocket Maximum (per calendar year)











                             PLAN NAME   NETWORK NAME   Deductible (per calendar year)     Individual / Family   Individual / Family   Covered Services   Office Visits (physician / specialist)   Routine Preventive Care   Coinsurance (Plan Pays)  Outpatient Diagnostic Lab & X-Ray  (physician’s office / other facility)   Complex Imaging  (physician’s office / other facility)   Emergency Room   (copay waived if admitted)   Urgent Care Facility   Inpatient Hospital Stay   Outpatient Surgery







                                                                   Teladoc
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