Medical – Clone

As an eligible employee of XYZ Companies, you may choose benefit coverage that fits you and your family’s needs. Below is a summary of the cost to you for each benefit.

Costs shown are per pay period, and deductions are taken 26 times per year. Payroll deductions for Medical and Dental Premiums are deducted on a pre-tax basis through the Section 125 Plan.

Medical Costs

Level of Coverage	Employee	Employee + Spouse	Employee + Children	Employee + Family
No coverage	($000.00)	N/A	N/A	N/A
Kaiser DHMO	$000.00	$000.00	$000.00	$000.00
Kaiser HMO	$000.00	$000.00	$000.00	$000.00
Kaiser Multi-Choice	$000.00	$000.00	$000.00	$000.00
Kaiser Out-of-Area PPO**	$000.00	$000.00	$000.00	$000.00
** You must meet certain criteria to enroll in this plan. Please see Accounting Department for more information.

Deductible HMO

Benefit	Network
Annual Deductible
Individual	$000
Family	$000
Annual Out-of-Pocket Maximum
Individual (Includes deductible and medical copays)	$0000
Family (Includes deductible and medical copays)	$0000
Lifetime Maximum	No Lifetime Maximum
Physician Office Visit
1) Primary Care Physician	1) $00 copay per visit
2) Specialist Physician	2) $00 copay per visit (applies to out-of-pocket only)
Preventative Care
Immunizations, routine physicals and preventive screenings	Covered at 000%
Maternity
1) Prenatal care	1) Covered at 00%
2) Delivery & inpatient well baby care	2) 0% after deductible
Prescription Drugs (30 Day Supply) (deductible and out-of-pocket do not apply)
1) Generic	1) $00 copay
2) Brand	2) $00 copay
3) Specialty	3) 00% to $000 maximum
Inpatient Hospital	00% after deductible
Outpatient/Ambulatory Surgery	00% after deductible
Laboratory & X-Ray Services
1) Lab	1) Office - Covered at 000%
2) X-Ray	2) Outpatient - 00% after deductible
3) MRI, nuclear medicine and other high tec services	3) 00% after deductible
Ambulance	00% up to $000 maximum per trip 00% after deductible
Emergency Care	$00 copay per visit
After-Hours Care	00% after deductible
Vision (performed by an Optometrist)	$00 copay per visit for eye wellness and refraction exam; No coverage for hardware

Traditional HMO

Benefit	Network
Annual Deductible
Individual	No Deductible
Family	No Deductible
Annual Out-of-Pocket Maximum
Individual (Includes deductible and medical copays)	$0000
Family (Includes deductible and medical copays)	$0000
Lifetime Maximum	No Lifetime Maximum
Physician Office Visit
1) Primary Care Physician	1) $00 copay per visit
2) Specialist Physician	2) $00 copay per visit (applies to out-of-pocket only)
Preventative Care
Immunizations, routine physicals and preventive screenings	$00 copay per visit
Maternity
1) Prenatal care	1) $00 copay per visit
2) Delivery & inpatient well baby care	2) $000 hospital copay per admission
Prescription Drugs (30 Day Supply) (deductible and out-of-pocket do not apply)
1) Generic	1) $00 copay
2) Brand	2) $00 copay
3) Specialty	3) 00% to $000 maximum
Inpatient Hospital	$00 copay per admission
Outpatient/Ambulatory Surgery	$00 copay per visit
Laboratory & X-Ray Services
1) Lab	1) Covered at 000%
2) X-Ray	2) Diagnostic - Covered at 00%; Therapeutic- $00 copay per visit
3) MRI, nuclear medicine and other high tec services	3) $00 copay per visit
Ambulance	00% up to $000 maximum per trip
Emergency Care	$00 copay per visit
After-Hours Care	$00 copay per visit
Vision (performed by an Optometrist)	$00 copay per visit for eye wellness and refraction exam; No coverage for hardware

Multi-Choice Plan

Benefit	Network	PHCS Network	Out-of-Network
Annual Deductible
Individual	$000	$000	$000
Family	$000	$000	$000
Annual Out-of-Pocket Maximum
Individual (Includes deductible and medical copays)	$0000	$0000	$0000
Family (Includes deductible and medical copays)	$0000	$0000	$0000
Lifetime Maximum	No Lifetime Maximum	No Lifetime Maximum	No Lifetime Maximum
Physician Office Visit
1) Primary Care Physician	1) $00 copay per visit	1) $00 copay per visit	00% after deductible
2) Specialist Physician	2) $00 copay per visit	2) $00 copay per visit	00% after deductible
Preventative Care
Immunizations, routine physicals and preventive screenings	Covered at 000%	Covered at 000%	$00 copay per visit
Maternity
1) Prenatal care	1) $00 copay per visit	1) $00 copay per visit	1) $00 copay per visit
2) Delivery & inpatient well baby care	2) $000 hospital copay per admission	2) $000 hospital copay per admission	2) $000 hospital copay per admission
Prescription Drugs (30 Day Supply) (deductible and out-of-pocket do not apply)
1) Generic	1) $00 copay	1) $00 copay	Not Covered
2) Brand	2) $00 copay	2) $00 copay	Not Covered
3) Non-Preferred	3) 00%	3) 00%	Not Covered
4) Specialty	4) 00% to $000 maximum	4) 00% to $000 maximum	Not Covered
Inpatient Hospital	00% after deductible	00% after deductible	00% after deductible
Outpatient/Ambulatory Surgery	00% after deductible	00% after deductible	00% after deductible
Laboratory & X-Ray Services
1) Lab	1) Office - Covered at 000%	00% after deductible	00% after deductible
2) X-Ray	2) Outpatient - Covered at 00%; Therapeutic- $00 copay per visit	00% after deductible	00% after deductible
3) MRI, nuclear medicine and other high tec services	3) 00% after deductible	00% after deductible	00% after deductible
Ambulance	00% after In-Network Deductible	00% after In-Network Deductible	00% after In-Network Deductible
Emergency Care	00% after In-Network Deductible	00% after In-Network Deductible	00% after In-Network Deductible
After-Hours Care	$00 copay per visit	$00 copay per visit	00% after deductible
Vision (performed by an Optometrist)	$00 copay per visit for eye wellness and refraction exam; No coverage for hardware	Not covered	Not covered

Out-of-Area PPO Plan

Benefit	PHCS Network	Out-of-Network
Annual Deductible
Individual	$000	$000
Family	$000	$000
Annual Out-of-Pocket Maximum
Individual (Includes deductible and medical copays)	$0000	$0000
Family (Includes deductible and medical copays)	$0000	$0000
Lifetime Maximum	No Lifetime Maximum	No Lifetime Maximum
Physician Office Visit
1) Primary Care Physician	1) $00 copay per visit	00% after deductible
2) Specialist Physician	2) $00 copay per visit (applies to out-of-pocket only)	00% after deductible
Preventative Care
Immunizations, routine physicals and preventive screenings	Covered at 000%	$00 copay per visit
Prescription Drugs (30 Day Supply) (deductible and out-of-pocket do not apply)
1) Generic	1) $00 copay	Not covered
2) Brand	2) $00 copay	Not covered
3) Non-preferred	3) $00	Not covered
4) Specialty	4) 00% to $00 maximum	Not covered
5) Mail Order	5) 2x retail copay for 90 day supply	Not covered
Inpatient Hospital	00% after deductible	00% after deductible
Outpatient/Ambulatory Surgery	00% after deductible	00% after deductible
Laboratory & X-Ray Services
1) Lab	00% after deductible	00% after deductible
2) X-Ray	00% after deductible	00% after deductible
3) MRI, nuclear medicine and other high tec services	00% after deductible	00% after deductible
Emergency Care	00% after In-Market deductible	00% after In-Market deductible
After-Hours Care	00% after deductible	00% after deductible
Vision (performed by an Optometrist)	$00 copay; No coverage for hardware	00% after deductible; No coverage for hardware

Standard HMO

Benefit	Network
Annual Deductible
Individual	$000
Family	$000
Annual Out-of-Pocket Maximum
Individual (Includes deductible and medical copays)	$0000
Family (Includes deductible and medical copays)	$0000
Lifetime Maximum	No Lifetime Maximum
Physician Office Visit
1) Primary Care Physician	1) $00 copay per visit
2) Specialist Physician	2) $00 copay per visit (applies to out-of-pocket only)
Preventative Care
Immunizations, routine physicals and preventive screenings	Covered at 000%
Prescription Drugs (30 Day Supply) (deductible and out-of-pocket do not apply)
1) Generic	1) $00 copay
2) Brand	2) $00 copay
Inpatient Hospital	$000 per admission
Outpatient/Ambulatory Surgery	$000 per admission
Laboratory & X-Ray Services
1) Lab and X-Ray	1) $00 per encounter
2) MRI, nuclear and other high tec services	2) $00 per encounter
Ambulance	$000 per trip
Emergency Care	$00 copay per visit
After-Hours Care	$000 copay per visit
Vision (performed by an Optometrist)	N/A

Note: This is a summary of benefits, please see XYZ Companies Resources for detailed plan description. Member pays percent started after deductible is met.

These are considered grandfathered plans.

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