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 Deductible HMO (HDHP with HSA) – CA Only
Plan Information
Plan Name: Kaiser Deductible HMO (HDHP with HSA) – CA Only
Policy Number: 28563
Effective Date: 01/01/2025
Provider Network: Kaiser
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
Benefit Highlights
In-Network Only
Deductible (Individual/Member/Family)
$2,500/$3,300/$5,000
Out-of-Pocket Max (Individual/Member/Family)
$4,500/$4,500/$9,000
Preventive Care
$0 (deductible waived)
Primary Care Visit
$30 (after deductible)
Specialist Visit
$50 (after deductible)
Urgent Care
$30 (after deductible)
Emergency Room
$200 (after deductible)
Retail Rx (Up to 30-Day Supply)
Generic
$10 (after deductible)
Preferred Brand
$30 (after deductible)
Non-Preferred Brand
$30 (after deductible)
Specialty
20% Coinsurance, not to exceed $250
Mail-Order Rx (Up to 100-Day Supply)
Generic
$20 (after deductible)
Preferred Brand
$60 (after deductible)
Non-Preferred Brand
$60 (after deductible)
Specialty
Not covered
Plan Documents
Contact Information
Kaiser HMO – CA Only
Plan Information
Plan Name: Kaiser HMO – CA Only
Policy Number: 28563
Effective Date: 01/01/2025
Provider Network: Kaiser
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
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$20
Specialist Visit
$20
Urgent Care
$20
Emergency Room
$50
Retail Rx (Up to 30-Day Supply)
Generic
$10
Preferred Brand
$20
Non-Preferred Brand
$20
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20
Preferred Brand
$40
Non-Preferred Brand
$40
Contact Information
Aetna Managed Choice POS (HDHP/HSA)
Plan Information
Plan Name: Aetna Managed Choice POS (HDHP/HSA)
Policy Number: 143674
Effective Date: 01/01/2025
Provider Network: Aetna Managed Choice POS
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
Benefit Highlights
In-Network
Deductible (Individual/Member/Family)
$3,300/$3,300/$6,600
Out-of-Pocket Max (Individual/Member/Family)
$6,000/$6,000/$12,000
Preventive Care
$0
Primary Care Visit
20% (after deductible)
Specialist Visit
20% (after deductible)
Urgent Care
20% (after deductible)
Emergency Room
20% (after deductible)
Retail Rx (Up to 30-Day Supply)
Generic
$10 (after deductible)
Preferred Brand
$30 (after deductible)
Non-Preferred Brand
$50 (after deductible)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 (after deductible)
Preferred Brand
$60 (after deductible)
Non-Preferred Brand
$100 (after deductible)
Out-of-Network
Deductible (Individual/Member/Family)
$3,300/$3,300/$6,600
Out-of-Pocket Max (Individual/Member/Family)
$8,000/$8,000/$16,000
Preventive Care
40% (after deductible)
Primary Care Visit
40% (after deductible)
Specialist Visit
40% (after deductible)
Urgent Care
40% (after deductible)
Emergency Room
20% (after deductible)
Retail Rx (Up to 30-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Mail-Order Rx (Up to 90-Day Supply)
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Documents
Contact Information
Aetna HMO – CA Only
Plan Information
Plan Name: Aetna HMO – CA Only
Policy Number: 143674
Effective Date: 01/01/2025
Provider Network: Aetna HMO
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
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$2,500/$5,000
Preventive Care
$0
Primary Care Visit
$20
Specialist Visit
$30
Urgent Care
$35
Emergency Room
$150 copay, waived if admitted
Retail Rx (Up to 30-Day Supply)
Generic
$10
Preferred Brand
$30
Non-Preferred Brand
$50
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20
Preferred Brand
$60
Non-Preferred Brand
$100