|
COMMON MEDICAL EVENT |
SERVICES YOU MAY NEED |
Your Cost Sharing |
|
Kaiser |
Anthem
|
Aetna |
|
If you are sick and go to the
doctor's office or need other services? |
Primary care
physician office visit |
$50 Copay after deductible |
$40 Copay |
Visits 1-3 $50 copay; deductible waived.
Visits 4+ member pays 100% Aetna discount applies Aetna pays 100% once OOP
is met |
|
Specialty
physician office visit |
$50 Copay after deductible |
$40 Copay |
Visits 1-3 $50 copay; deductible waived.
4+ member pays 100% Aetna discount applies. Aetna pays 100% once OOP is met
|
|
Outpatient X-rays /lab
testing/imaging |
$10 Copay after deductible |
no charge (after out of pocket maximum) |
30% Coinsurance after deductible (Non-Preventive) |
|
If you go for a checkup
visit? |
Periodic health exam |
No charge (deductible waived) |
No Charge |
No Charge |
|
If you need minor surgery? |
|
30% after deductible |
40% Coinsurance after deductible |
40% after deductible |
|
If you stay overnight in the
hospital? |
Hospitalization |
30% after deductible |
40% Coinsurance after deductible |
40% Coinsurance after deductible |
|
If you have an emergency? |
Emergency room fees |
$150 Copay after deductible (waived if admitted) |
$100 Copay (waived if admitted), plus 40% Coinsurance
after deductible |
$100 Copay (waived if admitted), plus 30% Coinsurance
after deductible |
|
If you need drugs? |
PURCHASE FROM PHARMACY: |
|
Generic Drugs |
Not Covered |
|
$20 Copay |
|
Brand Drugs |
Not Covered |
|
Not
Covered |
|
Non-formulary Drugs |
Not Covered |
|
Not
Covered |
|
Prescription Drugs (other
coverage) |
Not Available |
25% Coinsurance for Specialty/Self-administered
injectable drugs after deductible |
Not Available |
|
PURCHASE FROM MAIL ORDER: |
|
Generic Drugs |
Not Available |
$45 Copay |
$40 Copay |
|
Brand Drugs |
Not Available |
$120 Copay after deductible |
Not Covered |
|
Non-formulary Drugs |
Not Available |
Not Covered |
Not Covered |
|
Prescription Drugs
(other coverage) |
Not Available |
Not Covered |
Not Available |
|
Mail order days supply |
Not Available |
90 days |
60 days |
|
Is there a drug deductible? |
|
None |
$7500 Individual applies to Brand, Non-Formulary |
None |
|
What drugs are covered in the
formulary? |
|
Check the Formulary
|
No Link Provided |
Check the Formulary |
|
If you have mental health or
substance abuse needs? |
Mental health coverage |
$50 Copay Individual Visit / $25 Copay Group Visit, 20
Visits per year (after deductible) |
Not Covered |
Inpatient and Outpatient: coverage is
only provided for severe, biologically based mental or nervous disorders.
Deductible and co-insurance/copay apply. |
|
Substance Abuse Coverage |
$50 per visit after deductible/$5 group visit after
deductible Inpatient Detoxification: 30% coinsurance after deductible |
Not Covered |
Inpatient and Outpatient: coverage is
only provided for treatment of drug and alcohol dependencies associated with
severe, biologically based mental or nervous disorders. Deductible and
co-insurance/copay apply. |
|
If you become pregnant? |
Prenatal and postnatal care |
Not Covered |
Not Covered |
Not Covered (except for pregnancy
complications) |
|
Labor & Delivery hospital stay |
Not Covered |
Not Covered |
Not Covered (except for pregnancy
complications) |
|
Well Baby Care |
No charge (deductible waived)
|
No Charge |
No Charge |
