Below is a high-level summary of the 2023 Retiree Medical Plan, provided through Aetna, for participants who are not eligible for Medicare. See the
summary plan description for details.
Note: If you are Medicare-eligible, you are not eligible for the Oxy Retiree Medical Plan. However, you are eligible for the Oxy Medicare Advantage PPO Plan. See the
summary plan description for details.
Plan Features
| |
Network |
Non-Network |
|
Annual Deductible1 |
|
|
|
Retiree Only
|
$400
|
$800 |
|
Retiree + One/Family
|
$800
|
$1,600 |
|
Out-of-Pocket (OOP) Maximum |
|
|
|
Retiree Only
|
$2,500
|
$5,000 |
|
Retiree + One/Family
|
$4,500
|
$9,000 |
1 If you were eligible for Medicare prior to January 1, 2000, refer to the
Retiree Medical SPD for additional information
Covered Services
| |
What You Pay* |
|
Office Visits |
Network |
Non-Network |
- Primary care physician
- Specialist
|
20%
|
30%
|
|
Preventive Care |
|
|
- Adult Routine Physical
- Well Child Care (up to age 18)
- Mammography
- PSA Test
- Cervical Cancer Screening
- Colorectal Cancer Screening
|
100% covered,
no deductible
|
30%
|
|
Other Outpatient Services |
|
|
- Acupuncture Therapy
Max: 26 visits/year
|
20%
|
30%
|
- Chiropractic Care
Max: 26 visits/year
|
20%
|
30%
|
- Hearing Aids
Max: $2,500 every 3 years
|
20%
|
30%
|
- Infertility
Lifetime limit: $20,000 medical; $10,000 prescription
|
20%
|
30%
|
|
|
20%
|
30%
|
|
|
20%
|
30%
|
|
|
20%
|
30%
|
|
Vision Care |
|
|
- Routine Exam
(one/calendar year)
|
100% covered,
no deductible
|
30%
|
|
|
Aetna Discount Program
|
Aetna Discount Program
|
|
Inpatient Hospital |
|
|
- Room and board
- Ancillary charges
- Special duty nursing
- Intensive care, cardiac care units
|
10%
|
30%
|
|
Skilled Nursing Facility |
|
|
- Room and board
- Ancillary charges
(Limited to 120 days/calendar year)
|
10% |
30% |
|
Surgery |
|
|
|
|
10%
|
30%
|
|
|
Not covered unless
medically necessary
|
Not covered unless
medically necessary
|
|
Mental Health / Substance Abuse |
|
|
- Inpatient
(treatment must be certified)
|
10%
|
30%
|
|
|
20%
|
30%
|
|
Emergency Room |
|
|
|
No benefits for non-emergency use of emergency room
|
10%
|
10%
|
|
Other Services |
|
|
- Ambulance
- Hospice care
- Home health care
- Durable medical equipment
- Prosthetic devices
|
20%
|
30%
|
*All benefit levels (what you pay) are after the deductible, except where noted.
Prescription Drugs (through Express Scripts)
| Benefit |
What You Pay |
|
Deductible
|
No deductible
|
|
Out-of-Pocket (OOP) Drug Limit
|
$1,500
|
|
Retail (up to 30-day supply) |
|
Generic
|
$10
|
|
Preferred Brand
|
25%, Min $10/ Max $50
|
|
Non-Preferred Brand
|
25%, Min $25/Max $100
|
|
Mail Order (up to 90-day supply) |
|
Generic
|
$20
|
|
Preferred Brand
|
25%, Min $20/Max $100
|
|
Non-Preferred Brand
|
25%, Min $50/Max $200
|
