Medical
Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.
Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
Aetna OAMC HDHP
Plan Information
Plan Name: Aetna OAMC HDHP
Policy Number: 192863
Effective Date: 01/01/2025
Provider Network: Aetna Open Access Plans / Managed Choice POS (Open Access)
WI & ID Employees: Aetna Standard Plan / Open Choice PPO
UT Employees: If you are in Utah and want Intermountain Health providers, you must select the “AWH Connected Utah OAMC Active Plans.” If you choose to enroll in this plan, you will not have access to University of Utah providers/facilities.
For University of Utah access/coverage, select the standard OAMC plan.
To find an Intermountain provider: Aetna Whole Health Plans / Open Access / Choice POSII
Benefit Highlights
In-Network
Deductible (Individual/Family)
$2,000/$4,000
Out-of-Pocket Max (Individual/Family)
$4,000 /$8,000
Preventive Care
$0
Primary Care Visit
20% after deductible
Specialist Visit
20% after deductible
Emergency Room
20% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay after deductible
Preferred Brand
$30 copay after deductible
Non-Preferred Brand
$50 copay after deductible
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay after deductible
Preferred Brand
$60 copay after deductible
Non-Preferred Brand
$100 copay after deductible
Out-of-Network
Deductible (Individual/Family)
$4,000 /$8,000
Out-of-Pocket Max (Individual/Family)
$8,000/$16,000
Preventive Care
40% after deductible
Primary Care Visit
40% after deductible
Specialist Visit
40% after deductible
Emergency Room
20% after deductible
Retail Rx
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Mail-Order Rx
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Documents
Contact Information
Aetna OAMC PPO/POS
Plan Information
Plan Name: Aetna OAMC PPO/POS
Policy Number: 192863
Effective Date: 01/01/2025
Provider Network: Aetna Open Access Plans / Managed Choice PPO/POS (Open Access)
WI & ID Employees: Aetna Standard Plan / Open Choice PPO
UT Employees: If you are in Utah and want Intermountain Health providers, you must select the “AWH Connected Utah OAMC Active Plans.” If you choose to enroll in this plan, you will not have access to University of Utah providers/facilities.
For University of Utah access/coverage, select the standard OAMC plan.
To find an Intermountain provider: Aetna Whole Health Plans / Open Access / Choice POSII
Benefit Highlights
In-Network
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$3,000/$4,500
Preventive Care
$0
Primary Care Visit
$25
Specialist Visit
$50
Emergency Room
$350 per visit (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$85 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$30 copay
Preferred Brand
$100 copay
Non-Preferred Brand
$170 copay
Out-of-Network
Deductible (Individual/Family)
$1,500/$4,500
Out-of-Pocket Max (Individual/Family)
$10,000/$30,000
Preventive Care
30% after deductible
Primary Care Visit
30% after deductible
Specialist Visit
30% after deductible
Emergency Room
$350 per visit (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
20% up to $250
Preferred Brand
20% up to $250
Non-Preferred Brand
20% up to $250
Mail-Order Rx
Generic
Not covered
Preferred Brand
Not covered
Non-Preferred Brand
Not covered
Plan Documents
Contact Information
Aetna OAEC EPO
Plan Information
Plan Name: Aetna OAEC EPO
Policy Number: 192863
Effective Date: 01/01/2025
Provider Network: Aetna Open Access Plans / Elect Choice EPO (Open Access)
WI & ID Employees: Aetna Standard Plan / Open Choice PPO
UT Employees: If you are in Utah and want Intermountain Health providers, you must select the “AWH Connected Utah OAMC Active Plans.” If you choose to enroll in this plan, you will not have access to University of Utah providers/facilities.
For University of Utah access/coverage, select the standard OAMC plan.
To find an Intermountain provider: Aetna Whole Health Plans / Open Access / Choice POSII
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$500/$1,000
Out-of-Pocket Max (Individual/Family)
$5,000/$10,000
Preventive Care
$0
Primary Care Visit
$25
Specialist Visit
$50
Emergency Room
$300 per visit + 10% (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Preferred Brand
$50 copay
Non-Preferred Brand
$85 copay
Mail-Order Rx (Up to 100-Day Supply)
Generic
$30 copay
Preferred Brand
$100 copay
Non-Preferred Brand
$170 copay
Plan Documents
Contact Information
Kaiser HMO (CA)
Plan Information
Plan Name: Kaiser HMO (CA)
Policy Number: 702476
Effective Date: 01/01/2025
Provider Network: Kaiser
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,750/$3,500
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$25 copay
Emergency Room
$200 (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$30 copay
Specialty
20% coinsurance up to a maximum of $250
Mail-Order Rx (Up to 100-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$60 copay
Plan Documents
Contact Information
Kaiser HMO (CO)
Plan Information
Plan Name: Kaiser HMO (CO)
Policy Number: 47366
Effective Date: 01/01/2025
Provider Network: Kaiser
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,750/$3,500
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$25 copay
Emergency Room
$200 (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$60 copay
Specialty
20% coinsurance up to a maximum of $250
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$120 copay
Plan Documents
Contact Information
Kaiser HMO (GA)
Plan Information
Plan Name: Kaiser HMO (GA)
Policy Number: 10773
Effective Date: 01/01/2025
Provider Network: Kaiser
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,750/$3,500
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$25 copay
Emergency Room
$200 (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$60 copay
Specialty
20% coinsurance up to a maximum of $250
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$120 copay
Plan Documents
Contact Information
Kaiser HMO (Mid-Atlantic)
Plan Information
Plan Name: Kaiser HMO (Mid-Atlantic)
Policy Number: 34402
Effective Date: 01/01/2025
Provider Network: Kaiser
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,750/$3,500
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$25 copay
Emergency Room
$200 (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$60 copay
Specialty
20% coinsurance up to a maximum of $150
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$120 copay
Contact Information
Kaiser HMO (Northwest)
Plan Information
Plan Name: Kaiser HMO (Northwest)
Policy Number: 25951
Effective Date: 01/01/2025
Provider Network: Kaiser
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,750/$3,500
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$25 copay
Emergency Room
$200 (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$60 copay
Specialty
20% coinsurance up to a maximum of $250
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$120 copay
Plan Documents
Contact Information
Kaiser HMO (WA)
Plan Information
Plan Name: Kaiser HMO (WA)
Policy Number: 27554000
Effective Date: 01/01/2025
Provider Network: Kaiser
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0/$0
Out-of-Pocket Max (Individual/Family)
$1,750/$3,500
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$25 copay
Emergency Room
$200 (waived if admitted)
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Non-Preferred Brand
$60 copay
Specialty
20% coinsurance up to a maximum of $250
Mail-Order Rx (Up to 100-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Non-Preferred Brand
$120 copay