Page 11 - Hitachi Benefits Booklet Final

Aetna Silver PPO Aetna Gold PPO Aetna Platinum PPO
Medical Plan
Network Name OAMC Non-Network OAMC Non-Network OAMC Non-Network
Health Benefits

Lifetime Maximum Unlimited Unlimited Unlimited
Annual Deductible
Individual $500 $1,500 $250 $750 $100 $500
Family $1,000 $3,000 $500 $1,500 $200 $1,000
Co-Insurance (Plan 80% 60% 90% 70% 100% 70%
Pays)
Preventive Care 100% Ded, 60% 100% Ded, 70% 100% Ded, 70%

Physician Office Visit
PCP $30 copay Ded, 60% $25 copay Ded, 70% $20 copay Ded, 70%
$30 copay
Ded, 70%
Ded, 70%
$35 copay
Specialist $40 copay Ded, 60%
Out-of-Pocket Maximum
Individual $3,000 $6,000 $2,000 $4,000 $2,000 $2,000
Family $6,000 $12,000 $4,000 $8,000 $4,000 $4,000
Hospitalization
Inpatient $150, Ded, 80% $150, Ded, 60% Ded, 90% Ded, 70% 100% Ded, 70%
Outpatient Ded, 80% Ded, 60% Ded, 90% Ded, 70% 100% Ded, 70%
Emergency Services $150 copay, $150 copay, $100 copay, $100 copay, $50 copay $50 copay
80% 80% 90% 90%
Urgent Care $35 copay $35 copay $35 copay $35 copay $35 copay $35 copay

Chiropractic $25 copay Ded, 60% $20 copay Ded, 70% $15 copay Ded, 70%
12 visits/year 12 visits/year 12 visits/year 12 visits/yr 12 visits/yr 12 visits/yr

Prescription Drug $5/$30/$55 Ded, $5/$30/ $5/$30/$55 Ded, $5/$30/ $5/$30/$55 Ded, $5/$30/
Tier 1, 2, 3 $55 $55 $55

AETNA FEATURES
Register as a member and download the mobile app. Aetna’s mobile app has been updated to
make healthcare simple for you. As a member you can:

• View your ID card
• Houses all your claims activity and explanation of benefits (EOB)
• Help you located a contracted/network provider
• Access to a variety of discounts
• Earn gift cards and rewards by being an active healthcare users, complete health risk
assessments and more!

ATTAIN BY AETNA APP
SM
The Attain app combines your health history and Apple Watch® activity to offer personalized
goals*, achievable actions and big rewards – like an Apple Watch** or gift cards from popular
retailers. You can earn rewards by walking, going to the doctor, being active and much more!
Attain is a special program available only to Apple users at this time.