Page 8 - Caltech

2021 Medical plans (for Medicare eligible retirees)
Traditional Choice plan option
Premier PPO plan option
Medium PPO plan option*
Plan name
Availability
Monthly premium per person
Medical
Network
Annual deductible
Out-of-pocket maximum
Preventive care
Physician/ PCP*** visit
Your out-of-pocket costs
Aetna Traditional Choice with Rx 1505
AetnaMedicareSM Plan(PPO) with ESA — Premier plan Medicare S02 ESA PPO with Rx 1337
Aetna MedicareSM Plan (PPO) — Medium plan Medicare C01 PPO with Rx1337
Available to all retirees
Available to all retirees
National – based on location
$640.96
$292.57
includes SilverSneakers
$250.27
includes SilverSneakers
Providers must be Medicare eligible/qualified
Same benefit level In network/ out of network
In network
Out of network
None
None
None
None
N/A
$6,700 per individual
$6,700 per individual
$10,000 per individual
Covered 100%
Covered 100%
Covered 100%
25%
$0****
$25 per visit
15% per visit
25% per visit
Specialist visit Inpatient
$0****
$0****
$25 per visit
15% per visit
25% per visit
hospital+ Outpatient
$250 per stay
$500 per stay
25% per stay
hospital
Pharmacy++
Deductible
Generics*****
Preferred brands
Nonpreferred brands
Other
Eyewear Hearing aids
Up to 30-day supply
$0****
$0
15%
25%
Up to 90-day supply
Up to 30-day supply
Up to 90-day supply
Up to 30-day supply
Up to 90-day supply
$0
$0
$0
$0
$0
$0
$5
$10
$4-$5
$8 - $10
$4 -$5
$8 -$10
$25
$50
$30
$60
$30
$60
$45
$90
$60
$120
$60
$120
n/a
n/a
n/a
One hearing aid every 36 months
Plan pays $500 once every 36 months
Plan pays $500 once every 36 months
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*If you live outside the Caltech Retiree Service Center area, you may be eligible for other plans. For details, contact the Caltech Retiree Service Center at 1-855-251-0910.
**The Kaiser Permanente Senior Advantage HMO is available at no cost to grandfathered retirees after age 65.
***Primary Care Physician (PCP) includes services of an internist, general physician, or family practitioner for routine care, as well as diagnosis and treatment of an illness or injury and in-office surgery.
****Plan pays up to the Medicare allowed amount.
*****$4/$8 copay at a Preferred pharmacy for Aetna plans, except the Value Plan.