Page 7 - Kate Somerville Benefits Guide 2020 NonCA

Medical Plan Choices (PPO)

Aetna OAMC POS Aetna OAMC POS
Plan Name PPO HSA
Network Name Network Non-Network Network Non-Network
Health Benefits
Lifetime Maximum Unlimited Unlimited
Deductible (Annual)
- Individual $500 $1,000 $3,000 $3,000
- Family $1,000 $2,000 $6,000 $6,000
Out-of-Pocket Maximum
- Individual $2,500 $5,000 $5,500 $10,000
- Family $5,000 $10,000 $11,100 $20,000
Co-Insurance (Plan Pays) 90% 70% 80% 60%
Office Visit Copay
- Preventive Care No Charge Not Covered No Charge Not Covered
- Primary Care Physician $15 Copay Deductible, 30% Deductible, 20% Deductible, 40%
- Specialist Office Visit $15 Copay Deductible, 30% Deductible, 20% Deductible, 40%
- Urgent Care $5 Copay Deductible, 30% Deductible, 20% Deductible, 40%
- Telemedicine $15 Copay N/A Deductible, 20%* N/A
Hospitalization
- Inpatient Deductible, $100 Deductible, 30% Deductible, 20% Deductible, 40%
Copay,10%
- Outpatient Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
Lab and X-Ray
- Diagnostic $15 Copay Deductible, 30% Deductible, 20% Deductible, 40%
- Complex Deductible, 10% Deductible, 30% Deductible, 20% Deductible, 40%
Emergency Services Deductible, $100 Copay, 10% Deductible, 20%
Chiropractic $15 Copay Deductible, 30% Deductible, 20% Deductible, 40%
30 Visits/Year 30 Visits/Year
Pharmacy Benefits
Pharmacy Deductible $150 / $300 $150 / $300 Medical Deductible Medical Deductible
- Individual / Family Applies Applies
(waived for generics)
Retail Pharmacy
- Generic Formulary $15 Copay 20% up to $250 $10 Copay 20% up to $250
- Brand Name Formulary $30 Copay 20% up to $250 $25 Copay 20% up to $250
- Non-Formulary $45 Copay 20% up to $250 $40 Copay 20% up to $250
- Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Generic Formulary $30 Copay Not Covered $20 Copay Not Covered
- Brand Name Formulary $60 Copay Not Covered $50 Copay Not Covered
- Non-Formulary $90 Copay Not Covered $80 Copay Not Covered
- Supply Limit 90 Days N/A 90 Days N/A

Cost Per Pay Period Aetna OAMC POS Aetna OAMC POS
(24 per year) PPO HSA
- Employee $56.80 $36.93
- Employee + spouse $215.82 $140.35
- Employee + child(ren) $162.81 $105.88
- Employee + family $335.09 $217.92

*The total telemedicine (Teladoc) cost for the Aetna OAMC POS HSA plan is $40 until the deductible is met. Then coinsurance
applies to the $40 (20% of $40).

KATE SOMERVILLE EMPLOYEE BENEFITS 7