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Benefits

Medical Insurance

Kaiser Permanente Aetna
HMO HMO

Network Name Kaiser Facili es Only HMO
Health Benefits

Life me Maximum Benefit Unlimited Unlimited

Deduc ble (Annual)
- Individual $0 $0
- Family $0 $0

Co-Insurance (Plan Pays) 100% 100%
Office Visit Copay
- Primary Care Physician $25 Copay $25 Copay
- Specialist Office Visit $40 Copay $30 Copay
Out-of-Pocket Maximum
- Individual $1,500 $1,500
- Family $3,000 $3,000

Hospitaliza on
- Inpa ent 100% 100%
- Outpa ent $40 Copay 100%
Lab and X-Ray
- Diagnos c 100% 100%
- Complex 100% $100 Copay
Emergency Services $50 Copay $100 Copay
Urgent Care $25 Copay $20 Copay

Preven ve Care 100% 100%
Chiroprac c Not Covered $20 Copay
20 Visits/Year
Pharmacy Benefits

Retail Pharmacy
- Generic Formulary $15 Copay $15 Copay
- Brand Name Formulary $35 Copay $35 Copay
- Non-Formulary $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 $100 Copay
- Supply Limit 100 Days 90 Days

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