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retiree-aetna-options

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Retiree Medical Plan

Below is a high-level summary of the 2019 Retiree Medical Plan, provided through Aetna, for non-Medicare eligible participants. 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%

  • Physical therapy

20%

30%

  • Physician home visit

20%

30%

  • X-rays and lab

20%

30%

Vision Care    
  • Routine Exam
    (one/calendar year)

100% covered,
no deductible

30%

  • Eyeglasses

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    
  • Inpatient/Outpatient

10%

30%

  • Cosmetic

Not covered unless
medically necessary

Not covered unless
medically necessary

Mental Health / Substance Abuse    
  • Inpatient
    (treatment must be certified)

10%

30%

  • Outpatient

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

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