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
Plan Information
Plan Name: Kaiser HMO
Policy Number: 702476
Effective Date: 01/01/2025
Provider Network: Kaiser
In-Network Benefit Highlights
Deductible
(Individual/Family)
$0/$0
Out-of-Pocket Max
(Individual/Family)
$ 1,500/$ 3,000
Preventive Care
$0
Primary Care Visit
$ 15
Specialist Visit
$ 15
Emergency Room
$ 100
Benefit Highlights
In-Network
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$15 copay
Emergency Room
$100 per visit
Retail RX (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Non-Preferred Brand
$25 copay
Mail-Order RX (Up to 100-Day Supply)
Generic
$20 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$50 copay
Plan Documents
Year Carrier Document Name
Contact Information
In-Network Benefit Highlights
Deductible
(Individual/Family)
$0/$0
Out-of-Pocket Max
(Individual/Family)
$ 1,500/$ 3,000
Preventive Care
$0
Primary Care Visit
$ 15
Specialist Visit
$ 15
Emergency Room
$ 100
In-Network
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$15 copay
Emergency Room
$100 copay (waived if admitted)
Retail RX (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$25 copay
Non-Preferred Brand
$25 copay (same as preferred brand drugs)
Supply Limit
30 days
Mail-Order RX (Up to 30-Day Supply)
Generic
$20 copay
Preferred Brand
N/A
Non-Preferred Brand
Not Covered
Supply Limit
100 days
Plan Documents
Contact Information
Aetna OAEC EPO
Plan Information
Plan Name: Aetna OAEC EPO
Policy Number: 192863
Effective Date: 01/01/2025
Provider Network: Aetna
In-Network Benefit Highlights
Deductible
(Individual/Family)
$500/$1,000
Out-of-Pocket Max
(Individual/Family)
$5,000/$10,000
Preventive Care
$0
Primary Care Visit
$XX
Specialist Visit
$25
Emergency Room
$300 per visit + 10% (waived if admitted)
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$5,000/$10,000
Preventive Care
$0
Primary Care Visit
$25
Specialist Visit
$50
Emergency Room
$300 per visit + 10% (waived if admitted)
Retail RX (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$85 copay
Mail-Order RX (Up to 100-Day Supply)
Generic
$30 copay
Preferred Brand
$100 copay
Non-Preferred Brand
$170 copay
Plan Documents
Year Carrier Document Name
Contact Information
In-Network Benefit Highlights
Deductible
(Individual/Family)
$500/$1,000
Out-of-Pocket Max
(Individual/Family)
$5,000/$10,000
Preventive Care
$0
Primary Care Visit
$XX
Specialist Visit
$25
Emergency Room
$300 per visit + 10% (waived if admitted)
In-Network
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$5,000/$10,000
Preventive Care
$0
Primary Care Visit
$25
Specialist Visit
$50
Emergency Room
$300 per visit + 10% (waived if admitted)
Retail RX (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$85 copay
Supply Limit
30 days
Mail-Order RX (Up to 30-Day Supply)
Generic
$30 copay
Preferred Brand
$100 copay
Non-Preferred Brand
$170 copay
Supply Limit
31-90 days
Plan Documents
Contact Information
Aetna OAMC PPO
Plan Information
Plan Name: Aetna OAMC PPO
Policy Number: 192863
Effective Date: 01/01/2025
Provider Network: Aetna
In-Network Benefit Highlights
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$3,000/$4,500
Preventive Care
$0
Primary Care Visit
$25
Specialist Visit
$50
Emergency Room
$350 per visit (waived if admitted)
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$3,000/$4,500
Preventive Care
$0
Primary Care Visit
$25
Specialist Visit
$50
Emergency Room
$350 per visit (waived if admitted)
Retail RX (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$85 copay
Mail-Order RX (Up to 90-Day Supply)
Generic
$30 copay
Preferred Brand
$100 copay
Non-Preferred Brand
$170 copay
Out-of-Network
Deductible (Individual/Family)
$1,500/$4,500
Out-of-Pocket Max (Individual/Family)
$10,000/$30,000
Preventive Care
30% after deductible
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Emergency Room
$350 per visit (waived if admitted)
Retail RX (Up to 30-Day Supply)
Generic
20% up to $250
Preferred Brand
20% up to $250
Non-Preferred Brand
20% up to $250
Mail-Order RX
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Documents
Year Carrier Document Name
Contact Information
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
In-Network
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$3,000/$4,500
Preventive Care
$0
Primary Care Visit
$25
Specialist Visit
$50
Emergency Room
$350 per visit (waived if admitted)
Retail RX (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$85 copay
Supply Limit
30 days
Mail-Order RX (Up to 30-Day Supply)
Generic
$30 copay
Preferred Brand
$100 copay
Non-Preferred Brand
$170 copay
Supply Limit
90 days
Out-of-Network
Deductible (Individual/Family)
$1,500/$4,500
Out-of-Pocket Max (Individual/Family)
$10,000/$30,000
Preventive Care
You pay 30% after deductible
Primary Care Visit
You pay 30% after deductible
Specialist Visit
You pay 30% after deductible
Emergency Room
$350 per visit (waived if admitted)
Retail RX (Up to 30-Day Supply)
Generic
You pay 20% up to $250
Preferred Brand
You pay 20% up to $250
Non-Preferred Brand
You pay 20% up to $250
Supply Limit
30 days
Mail-Order RX (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Supply Limit
N/A
Plan Documents
Contact Information
Aetna OAMC HDHP
Plan Information
Plan Name: Aetna OAMC HDHP
Policy Number: 192863
Effective Date: 01/01/2025
Provider Network: Aetna
In-Network Benefit Highlights
Deductible (Individual/Family)
$2,000/$4,000
Out-of-Pocket Max (Individual/Family)
$4,000 /$8,000
Preventive Care
$0
Primary Care Visit
You pay 20% after deductible
Specialist Visit
You pay 20% after deductible
Emergency Room
You pay 20% after deductible
Benefit Highlights
In-Network
Deductible (Individual/Family)
$2,000/$4,000
Out-of-Pocket Max (Individual/Family)
$4,000 /$8,000
Preventive Care
$0
Primary Care Visit
20% after deductible
Specialist Visit
20% after deductible
Emergency Room
20% after deductible
Retail RX (Up to 30-Day Supply)
Generic
$10 copay after deductible
Preferred Brand
$30 copay after deductible
Non-Preferred Brand
$50 copay after deductible
Mail-Order RX (Up to 90-Day Supply)
Generic
$20 copay after deductible
Preferred Brand
$60 copay after deductible
Non-Preferred Brand
$100 copay after deductible
Out-of-Network
Deductible (Individual/Family)
$4,000 /$8,000
Out-of-Pocket Max (Individual/Family)
$8,000 $16,000
Preventive Care
40% after deductible
Primary Care Visit
40% after deductible
Specialist Visit
40% after deductible
Emergency Room
20% after deductible
Retail RX
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Mail-Order RX
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Documents
Year Carrier Document Name
Contact Information
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
In-Network
Deductible (Individual/Family)
$2,000/$4,000
Out-of-Pocket Max (Individual/Family)
$4,000 /$8,000
Preventive Care
$0
Primary Care Visit
You pay 20% after deductible
Specialist Visit
You pay 20% after deductible
Emergency Room
You pay 20% after deductible
Retail RX
(Up to 30-Day Supply)
Generic
$10 copay after deductible
Preferred Brand
$30 copay after deductible
Non-Preferred Brand
$50 copay after deductible
Supply Limit
30 days
Mail-Order RX (Up to 30-Day Supply)
Generic
$20 copay after deductible
Preferred Brand
$60 copay after deductible
Non-Preferred Brand
$100 copay after deductible
Supply Limit
90 days
Out-of-Network
Deductible (Individual/Family)
$2,000/$4,000
Out-of-Pocket Max (Individual/Family)
$4,000 /$8,000
Preventive Care
$0
Primary Care Visit
You pay 20% after deductible
Specialist Visit
You pay 20% after deductible
Emergency Room
You pay 20% after deductible
Retail RX (Up to 30-Day Supply)
Generic
$10 copay after deductible
Preferred Brand
$30 copay after deductible
Non-Preferred Brand
$50 copay after deductible
Supply Limit
30 days
Mail-Order RX (Up to 30-Day Supply)
Generic
$20 copay after deductible
Preferred Brand
$60 copay after deductible
Non-Preferred Brand
$100 copay after deductible
Supply Limit
90 days