Page 11 - B12797-ITDR-Enrollment-Guide-2020

Low PPO plan option**
Aetna Aexcel® Open Access®
AexcelPlus Open Access® Managed Choice® POS Tiered
Aetna HMO plan option
Kaiser Permanente HMO plan option
Low Option Network
$733.51 $1,467.02
National–based In network $3,950
$7,900
$6,250 $12,500 Covered 100% 20%
30%
20%
20%
up to 30-day supply
$0
0%
25% up to $250 50% up to $250 0%
0%
25% up to $250 50% up to $250
on location
Out of network
$3,950 $7,900 $10,000 $30,000 Covered 40% 40%
40% 40% 40%
up to 90-day supply
$0
0%
25% up to $500 50% up to $500 n/a
n/a
n/a
n/a
up to
100-day supply
n/a
n/a
**If you live outside of the service area for the Low Option Network plan, you will be offered an alternative plan with benefits and rates similar to the Low Option Network plan. For details, contact the Caltech Retiree Service Center at 1-855-251-0910.
11
Aetna HMO
Kaiser Permanente Traditional
$1,084.56
$764.10
$2,169.13
$1,528.18
National–based on location
CA residents only
Network only
Network only
$0
$0
$1,500
$1,500
$3,000
$3,000
Covered 100%
Covered 100%
$10
$15
$10
$30
$100 per admission
$250 per admission
$100
$150
up to 30-day supply
up to 90-day supply
$0
$0
$0
$15
$30
$10
$25
$50
$35
$40
$80
n/a
$15
n/a
$35 up to a 30 day supply
$15
n/a
n/a
$25
$40
n/a
n/a
$35 up to a 30 day supply
n/a
n/a
You pay the amount in excess of $150 allowance every 24 months for eyewear purchased at plan medical offices or plan optical sales offices
n/a
n/a