Page 9 - Hitachi Benefit Guide 1.31.2019

Medical Plans

Medical Plan Aetna Silver PPO Aetna Gold PPO Aetna Platinum PPO

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 Pays) 80% 60% 90% 70% 100% 70%
Preventive Care 100% Ded, 60% 100% Ded, 70% 100% Ded, 70%
Physician Office Visit
$25 Copay Ded, 60% $20 Copay Ded, 70% $15 Copay Ded, 70%
PCP
Specialist $35 Copay Ded, 60% $30 Copay Ded, 70% $25 Copay Ded, 70%
Out-of-Pocket Maximum Deductible Applies Deductible Applies Deductible Applies
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 copay, Ded, $150 copay, Ded, Ded, 90% Ded, 70% 100% Ded, 70%
80% 60%
Outpatient Ded, 80% Ded, 60% Ded, 90% Ded, 70% 100% Ded, 70%
Emergency Services $150 Copay, 80% $150 Copay, 80% $100 Copay, 90% $100 Copay, 90% $50 Copay $50 Copay
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/year 12 visits/year 12 visits/year
Durable Medical Ded, 90% Ded, 90% Ded, 90% Ded, 90% Ded, 50% Ded, 50%
Equipment
Pharmacy Benefits
Pharmacy Deductible
Individual None None None None None None
Family None None None None None None
Retail Pharmacy
Generic $5 Copay Copay, 50% $5 Copay Copay, 50% $5 Copay Copay, 50%
Brand Name $30 Copay Copay, 50% $30 Copay Copay, 50% $30 Copay Copay, 50%
Non Formulary $55 Copay Copay, 50% $55 Copay Copay, 50% $55 Copay Copay, 50%
Retail Supply Limit 30 Days 30 Days 30 Days 30 Days 30 Days 30 Days
Mail Order Pharmacy
Generic $10 Copay In-Network $10 Copay In-Network $10 Copay In-Network
Brand Name $60 Copay Only $60 Copay Only $60 Copay Only
Non Formulary $110 Copay $110 Copay $110 Copay
Mail Order Supply Limit 90 Days 90 Days 90 Days

Our Aetna prescription drug coverage utilizes the Aetna Value Plus formulary. You can access the full formulary listing on Sterling’s website or at your Aetna member portal
to look up medications. If the medication is not covered, go to www.goodrx.com to price out drugs.

Hitachi Solutions America Employee Benefits Guide | 2019 9