Page 7 - Ria Benefits Guide 2020 FINAL CA

Medical Plan Choices (HMO)

Kaiser Permanente Aetna AVN
Plan Name HMO HMO
Health Benefits
Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $0 $250
- Family $0 $500
Out-of-Pocket Maximum
- Individual $1,500 $1,500
- Family $3,000 $3,000
Co-Insurance (Plan Pays) 100% 100%
Office Visit Copay
- Preventive Care No Charge No Charge
- Primary Care Physician $20 Copay $30 Copay
- Specialist Office Visit $20 Copay $45 Copay
- Urgent Care $20 Copay $35 Copay
- Telemedicine $0 Copay $40 Copay

Hospitalization
- Inpatient No Charge 100%, after ded.
- Outpatient $20 Copay 100%, after ded.
Lab and X-Ray
- Diagnostic No Charge 100%,
- Complex No Charge $100 copay
Emergency Services $100 Copay $100 copay; after ded.
Chiropractic none $15 Copay
20 Visits/Year
Pharmacy Benefits
Pharmacy Deductible
- Individual / Family None $100 individual / $200 family
(waived for generics)
Retail Pharmacy
- Generic Formulary $15 Copay $15 Copay
- Brand Name Formulary $35 Copay $35Copay
- Non-Formulary $35 Copay $50 Copay
- Supply Limit 30 Days 30 Days
Mail Order Pharmacy
- Generic Formulary $30 Copay $30 Copay
- Brand Name Formulary $70 Copay $70 Copay
- Non-Formulary $70 Copay $100 Copay
- Supply Limit 100 Days 90 Days

Employee contribution per pay date Kaiser Permanente Aetna AVN
HMO HMO
- Employee $60.00 $25.00
- Employee + spouse $255.00 $185.00
- Employee + child(ren) $210.00 $150.00
- Employee + family $365.00 $240.00

RIA EMPLOYEE BENEFITS 2020 7