Pechanga 2013-2014 Benefits Guide

Medical Plan Comparison

Aetna Open Access Managed Choice Plan (OAMC) Network Non-Network

Aetna HMO Gold Plan

Aetna HMO Silver Plan

Benefit Provision

Deductible (calendar year) Out-Of-Pocket Maximum (calendar year)

None

None

$250 individual/$500 family

$1,000 individual $2,000 family max

$1,000 individual $2,000 family max

$1,000 individual $2,000 family max

$3,000 individual $6,000 family max

Lifetime Maximum

Unlimited

Unlimited

Unlimited

Preventive Benefits Annual Routine Physical Well Baby Immunizations

100% covered 100% covered

100% covered 100% covered

100% covered 100% covered

Physician Services Office Visit

$10 copay $20 copay $20 copay

$20 copay $30 copay $30 copay

$15 copay $20 copay 10% copay

30% 30% 30% 30%

Specialist

Diagnostic X-ray Maternity/OB Visits

$10 copay (initial visit only)

$20 copay (initial visit only)

$20 copay (initial visit only)

Hospital Services Inpatient Surgery Outpatient Surgery

100% covered $500 copay (per admit) 100% covered $250 copay (per surgery)

10% 10% 10%

30% 30% 30%

Detoxification

Outpatient: $20 copay Inpatient: No charge

Outpatient: $30 copay Inpatient: $500 copay (per admit)

Other Benefits Emergency Services

$150 copay

$150 copay

$75 copay; no deductible

Urgent Care Ambulance

$35 copay; PCP referral $35 copay; PCP referral

$15 copay

30%

No charge

No charge

10%

Durable Medical Equipment 20% of contracted amt 20% of contracted amt

10%

30% 30%

Chiropractic

$15 copay; 30 visits/year

$15 copay; 30 visits/year

$20 copay

20 visits/year combined

Vision Services Annual Exam & Refraction

100%

100%

100%

30%

Prescription Drugs Through Catamaran Retail (30-day supply) OTC* $0 copay

$0 copay $10 copay $25 copay $50 copay $50 copay $0 copay $20 copay $50 copay $100 copay $0 copay $20 copay $50 copay $100 copay

$0 copay $10 copay $25 copay $50 copay $50 copay $0 copay $20 copay $50 copay $100 copay $0 copay $20 copay $50 copay

Generic

$10 copay $25 copay $50 copay $50 copay $0 copay $20 copay $50 copay $100 copay $0 copay $20 copay $50 copay $100 copay

Coverage at network pharmacies only

Preferred Brand**

Non-Preferred Brand** Specialty Pharmacy

Retail 90 (84-90 day supply) OTC*

Generic

Coverage at network pharmacies only

Preferred Brand**

Non-Preferred Brand** Mail Order (90-day supply) OTC*

Generic

Coverage at network pharmacies only

Preferred Brand**

Non-Preferred Brand** $100 copay *Covered Over-the-Counter (OTC) drugs are: Prilosec OTC®; Prevacid® 24HR; Omeprazole OTC; Zegerid OTC and Non-sedating antihistamines (OTC) such as Zyrtec or (D) cetirizine; Claritin or (D) loratadine; Allegra or (D) fexofenadine in all forms to include chewables and syrups and approved contraceptives . You MUST have a written prescription from your physician for these drugs to be covered under the plan. In addition, oral generic anti-diabetic medications such as metformin and “certain” generic high blood pressure medications are available for a $0 copay. **If you or your physician chooses a Brand when a Generic is available, you will pay the difference in price between the Brand and the Generic PLUS the appropriate Brand copay. Note : Branded PPIs such as Nexium, Aciphex, Vimovo and Dexilant are not covered by the plan. Alternatives are lansoprazole, pantoprazole, omeprazole 20mg and 40mg, and the covered OTCs. Branded non-sedating antihistamines such as Xyzal and Clarinex are also not covered by the plan. Pristiq is excluded.

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