Page 10 - Caltech

2021 Medical plans (for non-Medicare eligible retirees)
High PPO plan option
Medium PPO plan option
Plan name
Monthly premium
Retiree only Retiree + spouse
Medical
Availability Network
Annual deductible
Out-of-pocket maximum
Preventive care Physician visit Specialist visit Inpatient hospital Outpatient hospital
Pharmacy**
Deductible
Preferred generics
Preferred brands
Nonpreferred generics/brands Specialty preferred generics Specialty nonpreferred generics Specialty preferred brands Specialty nonpreferred brands
Other
Eyewear
Hearing aids
High Option Network
Aetna Open Choice® PPO
Mid Option Network
Aetna Open Choice® PPO
$1,581.81
$1,119.78
$3,163.62
Individual Family Individual Family
$1,200 $4,000
$2,239.56
National–based on location
National–based on location
In network Out of network
In network
Out of network
$3,500
$5,500
$2,400 $8,000
$7,000
$11,000
$2,800 $7,000
$6,000
$10,000
$5,600 $14,000
$12,000
$20,000
Covered 100% Covered 40%
Covered 100%
Covered 50%
20% 40%
30%
50%
20% 40%
30%
50%
20% 40%
30%
50%
20% 40%
Up to 30-day supply
Up to 90-day supply
$0 $0
30%
50%
Up to 30-day supply
Up to 90-day supply
$0
$0
$10 $30
$10
$10
$40 $120
$75
$75
40% up to $250 40% up to $500
50% up to $250
50% up to $500
$70 n/a
50% up to $250
n/a
$70 n/a
50% up to $250
n/a
$70 n/a
50% up to $250
n/a
40% up to $250 n/a
50% up to $250
n/a
n/a
n/a
n/a
n/a
10
**Three-month (90 days) supply available through Aetna Rx Home Delivery mail order. When you obtain a 90-day supply at retail, you pay your mail-order cost share.