Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – The amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – The most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Kaiser HMO (CA Only)
Plan Information
Plan Name: Kaiser HMO (CA Only)
Policy Number: 600581
Effective Date: 06/01/2025
Provider Network: Kaiser
Benefit Highlights
In-Network Only |
|---|
| Deductible (Individual/Family) |
| $1,500/$3,000 |
| Out-of-Pocket Max (Individual/Family) |
| $4,000/$8,000 |
| Preventive Care |
| $0 copay |
| Primary Care Visit |
| $40 copay |
| Specialist Visit |
| $50 copay |
| Urgent Care |
| $40 copay |
| Emergency Room |
| 30% coinsurance |
Retail Rx (Up to 30-Day Supply) |
|---|
| Generic |
| $10 copay |
| Preferred Brand |
| $30 copay |
| Specialty |
| 20% coinsurance up to $250 per prescription |
Mail-Order Rx (Up to 90-Day Supply) |
|---|
| Generic |
| $20 copay |
| Preferred Brand |
| $60 copay |
| Specialty |
| Not covered |
Plan Documents
Contact Information
Aetna Value HMO – Low Plan
Plan Information
Plan Name: Aetna AVN HMO – Low Plan
Policy Number: 804745
Effective Date: 06/01/2025
Provider Network: Aetna Value Network HMO
Benefit Highlights
In-Network Only |
|---|
| Deductible (Individual/Family) |
| $3,000/$6,000 |
| Out-of-Pocket Max (Individual/Family) |
| $6,500/$13,000 |
| Preventive Care |
| $0 copay (1 exam every 12-months) |
| Primary Care Visit |
| $50 copay |
| Specialist Visit |
| $60 copay |
| Urgent Care |
| $75 copay |
| Emergency Room |
| $200 copay |
Retail Rx (Up to 30-Day Supply) |
|---|
| Generic |
| $20 copay |
| Preferred Brand |
| $40 copay |
| Non-Preferred Brand |
| $60 copay |
| Specialty |
| 30% up to $250 copay |
Mail-Order Rx (Up to 90-Day Supply) |
|---|
| Generic |
| $40 copay |
| Preferred Brand |
| $80 copay |
| Non-Preferred Brand |
| $120 copay |
| Specialty |
| Not covered |
Plan Documents
Contact Information
Aetna Value HMO – High Plan
Plan Information
Plan Name: Aetna AVN HMO – High Plan
Policy Number: 804745
Effective Date: 06/01/2025
Provider Network: Aetna Value Network HMO
Benefit Highlights
In-Network Only |
|---|
| Deductible (Individual/Family) |
| $1,000/$2,000 |
| Out-of-Pocket Max (Individual/Family) |
| $3,000/$6,000 |
| Preventive Care |
| $0 copay (1 exam every 12-months) |
| Primary Care Visit |
| $40 copay |
| Specialist Visit |
| $60 copay |
| Urgent Care |
| $35 copay |
| Emergency Room |
| $200 copay |
Retail Rx (Up to 30-Day Supply) |
|---|
| Generic |
| $20 copay |
| Preferred Brand |
| $40 copay |
| Non-Preferred Brand |
| $60 copay |
| Specialty |
| 30% up to $250 copay |
Mail-Order Rx (Up to 90-Day Supply) |
|---|
| Generic |
| $40 copay |
| Preferred Brand |
| $80 copay |
| Non-Preferred Brand |
| $120 copay |
| Specialty |
| Not covered |
Plan Documents
Contact Information
Aetna HMO (NV Only)
Plan Information
Plan Name: Aetna HMO (NV Only)
Policy Number: 804745
Effective Date: 06/01/2025
Provider Network: HMO – Nevada
Benefit Highlights
In-Network Only |
|---|
| Deductible (Individual/Family) |
| $1,000/$2,000 |
| Out-of-Pocket Max (Individual/Family) |
| $3,500/$7,000 |
| Preventive Care |
| $0 copay (1 exam every 12-months) |
| Primary Care Visit |
| $40 copay |
| Specialist Visit |
| $60 copay |
| Urgent Care |
| $50 copay |
| Emergency Room |
| $150 copay after deductible |
Retail Rx (Up to 30-Day Supply) |
|---|
| Generic |
| $10 copay |
| Preferred Brand |
| $30 copay |
| Non-Preferred Brand |
| $50 copay |
| Specialty |
| 30% up to $250 copay |
Mail-Order Rx (Up to 90-Day Supply) |
|---|
| Generic |
| $20 copay |
| Preferred Brand |
| $60 copay |
| Non-Preferred Brand |
| $100 copay |
| Specialty |
| Not covered |
Plan Documents
Contact Information
Aetna Managed Choice POS (All States)
Plan Information
Plan Name: Aetna Managed Choice POS (All States)
Policy Number: 804745
Effective Date: 06/01/2025
Provider Network: OA Managed Choice POS
Benefit Highlights
In-Network | Out-of-Network |
|---|---|
| Deductible (Individual/Family) | Deductible (Individual/Family) |
| $1,000/$2,000 | $2,000/$4,000 |
| Out-of-Pocket Max (Individual/Family) | Out-of-Pocket Max (Individual/Family) |
| $4,000/$8,000 | $8,000/$16,000 |
| Preventive Care | Preventive Care |
| $0 (1 exam every 12-months) | 40% after deductible |
| Primary Care Visit | Primary Care Visit |
| $25 copay | 40% after deductible |
| Specialist Visit | Specialist Visit |
| $50 copay | 40% after deductible |
| Urgent Care | Urgent Care |
| $50 copay | 40% after deductible |
| Emergency Room | Emergency Room |
| 20% after $300 copay | 20% after $300 copay |
Retail Rx (Up to 30-Day Supply) | Retail Rx (Up to 30-Day Supply) |
|---|---|
| Generic | Generic |
| $10 copay | Not covered |
| Preferred Brand | Preferred Brand |
| $30 copay | Not covered |
| Non-Preferred Brand | Non-Preferred Brand |
| $50 copay | Not covered |
| Specialty | Specialty |
| 30% coinsurance ($250 max) | Not covered |
Mail-Order Rx (Up to 90-Day Supply) | Mail-Order Rx (Up to 90-Day Supply) |
|---|---|
| Generic | Generic |
| $20 copay | Not covered |
| Preferred Brand | Preferred Brand |
| $60 copay | Not covered |
| Non-Preferred Brand | Non-Preferred Brand |
| $100 copay | Not covered |
| Specialty | Specialty |
| Not covered | Not covered |