Page 7 - Kate Somerville Benefits Guide 2020 CA FINAL

Medical Plan Choices (HMO)

Aetna Whole Health (AWH) Aetna Narrow AVN Aetna Full
Plan Name HMO HMO HMO
Network Name Network Network Network
Health Benefits
Lifetime Maximum Unlimited Unlimited Unlimited
Deductible (Annual)
- Individual $0 $0 $0
- Family $0 $0 $0
Out-of-Pocket Maximum
- Individual $2,000 $2,000 $2,000
- Family $4,000 $4,000 $4,000
Co-Insurance (Plan Pays) 100% 100% 100%
Office Visit Copay
- Preventive Care No Charge No Charge No Charge
- Primary Care Physician $20 Copay $20 Copay $10 Copay
- Specialist Office Visit $20 Copay $20 Copay $10 Copay
- Urgent Care $20 Copay $20 Copay $10 Copay
- Telemedicine $20 Copay $20 Copay $10 Copay
Hospitalization
- Inpatient 20% 20% 20%
- Outpatient No Charge No Charge No Charge
Lab and X-Ray
- Diagnostic No Charge No Charge No Charge
- Complex No Charge No Charge No Charge
Emergency Services $100 Copay $100 Copay $100 Copay
Chiropractic $15 Copay $15 Copay $10 Copay
30 Visits/Year 30 Visits/Year 30 Visits/Year
Pharmacy Benefits
Pharmacy Deductible
- Individual / Family $150 / $300 $150 / $300 $150 / $300
(waived for generics)
Retail Pharmacy
- Generic Formulary $15 Copay $15 Copay $15 Copay
- Brand Name Formulary $30 Copay $30 Copay $30 Copay
- Non-Formulary $45 Copay $45 Copay $45 Copay
- Supply Limit 30 Days 30 Days 30 Days
Mail Order Pharmacy
- Generic Formulary $30 Copay $30 Copay $30 Copay
- Brand Name Formulary $60 Copay $60 Copay $60 Copay
- Non-Formulary $90 Copay $90 Copay $90 Copay
- Supply Limit 90 Days 90 Days 90 Days

Cost Per Pay Period (24 per year) Aetna Whole Health (AWH) Aetna Narrow AVN Aetna Full
HMO HMO HMO
- Employee $21.42 $35.07 $48.75
- Employee + spouse $107.03 $133.32 $169.07
- Employee + child(ren) $78.49 $100.58 $128.97
- Employee + family $171.24 $207.00 $259.32

KATE SOMERVILLE EMPLOYEE BENEFITS 7