Page 10 - Hitachi Benefits Booklet Final

Aetna HMO Kaiser HMO Aetna High Deductible HSA
Medical Plan (CA Only) (CA Only) (Individual or Family Plan)

Network Name HMO Network Kaiser HMO OAMC Non-Network
Health Benefits You must satisfy/pay the deductible before
Aetna pays any medical or drug benefits.

Lifetime Maximum Unlimited Unlimited Unlimited
Annual Deductible Single Plan: $1,500 Single Plan: $1,500
Individual / Single None None Indiv on Fam: $2,800 Indiv on Fam: $2,800
Family None None Family Plan: $3,000 Family Plan: $3,000

Co-Insurance (Plan Pays) 100% 100% 80% 60%
Preventive Care 100% 100% 100% ded. waived Ded, 60%
Physician Office Visit
PCP $20 copay $20 copay Ded, 80% Ded, 60%
Specialist $20 copay $20 copay Ded, 80% Ded, 60%
Out-of-Pocket Maximum Deductible Applies
Individual / Single $1,500 $1,500 Single Plan: $3,425 Single Plan: $10,500
Family $3,000 $3,000 Family Plan: $6,850 Family Plan: $21,000
Hospitalization
Inpatient 100% 100% Ded, 80% Ded, 60%
Outpatient 100% 100% Ded, 80% Ded, 60%

Emergency Services $100 copay $100 copay Ded, 80% Ded, 80%
Urgent Care $35 copay $20 copay Ded, 80% Ded, 80%
Chiropractic $15 copay Discounts Apply Ded, 80% Ded, 60%
20 visits/year 12 visits/yr 12 visits/yr
Prescription Drug $10/$30/$45 $10/$20 Ded, $10/$20/$35 Ded, $10/$20/$35
Tier 1, 2, 3

Finding a Contracted Medical Provider
Go to www.aetna.com
• HMO: HMO network
• PPO/HSA: Managed Choice® POS (Open Access) network
• PPO: Open Choice PPO Network (network applies to IA, ID, Educational Video
MO) Health Insurance Terms
http://
Kaiser: www.kp.org video.burnhambenefits.com/
terms