Page 6 - 5.11 Benefit Guide 2019 CA

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
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) 80% 50% 80% 50% 100%
Physician Office Visit
• PCP Ded, 80% Ded, 50% $40 Copay Ded, 50% $35 Copay
• Specialist Ded, 80% Ded, 50% $50 Copay Ded, 50% $50 Copay
Out-of-Pocket Maximum Includes Deductible Includes Deductible
• Employee $4,200 $8,000 $5,000 $10,000 $2,250
• Family $6,300 $12,000 $10,000 $20,000 $4,500
Hospitalization
• Inpatient Ded, 80% Ded, 50% $150 Copay, Ded, 50% $750 Copay
Ded, 80%
• Outpatient Surgery Ded, 80% Ded, 50% Ded, 80% Ded, 50% $200 Copay
Emergency Services Ded, 80% $150 Copay, 80% $150 Copay
Urgent Care Ded, 80% Ded, 50% $50 Copay Ded, 50% $50 Copay
Preventive Care 100% Ded, 50% 100% Not Covered 100%
Chiropractic Ded, 80% Ded, 50% $50 Copay Ded, 50% $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 Ded, Copay+50% $10 Copay Copay+50% $10 Copay
• Brand Name $25 Copay Ded, Copay+50% $30 Copay Copay+50% $30 Copay
• Non-Formulary $40 Copay Ded, Copay+50% $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

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