Page 10 - Sample Calendar Layout EE Guide

KAISER AETNA
PLAN NAME HMO OAMC/PPO
NETWORK NAME KAISER PERMANENTE OPEN ACCESS MANAGED NON-NETWORK*
CHOICE NETWORK
NETWORK
Deductible (per calendar year)
Individual / Family $1,000 / $2,000 $250 / $500 $500 / $1,000
Out-of-Pocket Maximum (per calendar year)
Individual / Family None $2,250 / $4,500 $4,500 / $9,000

Covered Services
Office Visits (physician / specialist) $20 Copay / $30 Copay $10 Copay 30% after deductible
Routine Preventive Care Covered 100% Covered 100% Not Covered
Telemedicine Covered 100% $10 Copay Not Covered
Coinsurance (Plan Pays) 100% 90% 70%
Outpatient Diagnostic Lab & X-Ray Copay applies at office visit, other- Covered 100% 30% after deductible
(physician’s office / other facility) wise, 0% after deductible
Complex Imaging Copay applies at office visit, other-
(physician’s office / other facility) wise, 0% after deductible 10% after deductible 30% after deductible
Emergency Room $200 Copay $100 Copay $100 Copay
(copay waived if admitted)
Urgent Care Facility $40 Copay $50 Copay 30% after deductible
Inpatient Hospital Stay 0% after deductible 10% after deductible 30% after deductible

Outpatient Surgery 0% after deductible 10% after deductible 30% after deductible
Chiropractic Discounts apply $10 Copay, 20 visits/year 30% after deductible

* Non-Network providers do not have a contract and therefore can charge you any amount. Aetna will reimburse you up to an allowed amount based on a % of Medicare.
You are responsible for any amount above the above the allowed amount, commonly known as balanced billing.