Page 9 - Caltech

Value PPO plan option*
Aetna MedicareSM Plan (PPO) — Value plan Medicare V02 PPO with Rx 1201
National – based on location $63.76
includes SilverSneakers
In network None
$3,400 per individual
Covered 100% $15 per visit
$40 per visit $200 per day 1 – 7 $185
Up to 30-day supply
$260 20%
25% 45%
n/a
Plan pays $500 once every 36 months
Aetna HMO plan option
Kaiser Permanente HMO plan option
Kaiser Permanente Senior Advantage (HMO) (Includes Dental and Vision)
Availability based on retiree’s CA zip code
$215.98
includes Silver&Fit
Network only
None
$1,500 per individual
Covered 100%
$15 per visit
$15 per visit
$0
$15
Up to 100-day supply
$0
$10
$20
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
Plan pays up to $500 once every 36 months per aid
*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 member cost sharing applies to covered benefits incurred during a member’s inpatient stay.
††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.
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Aetna MedicareSM Plan (HMO) Medicare P02 HMO with Rx 1505
National – based on location
$322.52
includes SilverSneakers
Out of network
Network only
None
None
$10,000 per individual
$3,400 per individual
30%
Covered 100%
30% per visit
$10 per visit
30% per visit
$15 per visit
30% per stay
$0
30%
$0
Up to 90-day supply
Up to 30-day supply
Up to 90-day supply
$0
$0
20%
$4-$5
$8 - $10
25%
$25
$50
45%
$45
$90
n/a
Plan pays $500 once every 36 months