Page 8 - Hitachi Benefit Guide 1.31.2019

Medical Plans

Aetna HMO Kaiser HMO Aetna High Deductible HSA
Medical Plan (California Only) (California 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 benefits.
Lifetime Maximum Unlimited Unlimited Unlimited

Annual Deductible Individual Plan: $1,500 Individual Plan: $1,500
Individual None None Indiv on Fam: $2,700 Indiv on Fam: $2,700
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
$20 Copay $20 Copay Ded, 80% Ded, 60%
PCP
Specialist $20 Copay $20 Copay Ded, 80% Ded, 60%
Out-of-Pocket Maximum Deductible Applies
Individual $1,500 $1,500 Individual Plan: $3,425 Individual 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/year 12 visits/year
Durable Medical 100% 80% Ded, 50% Ded, 50%
Equipment
Pharmacy Benefits
Pharmacy Deductible Health Deductible Applies
Individual None None You must pay the deductible medical plan
Family None None deductible before any benefits are paid.
Retail Pharmacy
Generic $10 Copay $10 Copay $10 Copay, Ded, 80% Ded, 50%
Brand Name $30 Copay $20 Copay $20 Copay, Ded, 80% Ded, 50%
Non Formulary $45 Copay n/a $35 Copay, Ded, 80% Ded, 50%
Retail Supply Limit 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
Generic $20 Copay $20 Copay $20 Copay, Ded, 80% In-Network
Brand Name $60 Copay $40 Copay $40 Copay, Ded, 80% Only
Non Formulary $90 Copay n/a $70 Copay, Ded, 80%
Mail Order Supply Limit 90 Days 100 Days 90 Days
Important: On the HSA medical plan, you must satisfy/pay the full plan deductible before Aetna pays any benefits. This includes prescription medication.

8 Hitachi Solutions America Employee Benefits Guide | 2019