AREF 2017 Benefit Guide

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Type of Plan
Select Providers
(Tier 1)
PPO Providers (PHCS)
(Tier 2)
Non- Participating Providers
(Tier 3)
Deductible
Individual $200 $1,200 $2,400
Family $600 $3,600 $7,200
Individual $1,200 $3,200 $6,400
Family $3,600 $9,600 $19,200
Lifetime Maximum Unlimited
(Some benefits may have limitations)
Unlimited
(Some benefits may have limitations)
Unlimited
(Some benefits may have limitations)
Coinsurance
Plan Pays 90% after
Annual Deductible
Plan Pays 80%, after
Annual Deductible
Plan Pays 60%, after
Annual Deductible
Primary Care $30 Copay $40 Copay
Plan Pays 60% after
Deductible
Specialty Care $40 Copay $50 Copay
Plan Pays 60% after
Deductible
Preventive Plan pays 100% $40 or $50 Copay
Plan Pays 60% after
Annual Deductible
Maternity
(Obstetrician / Midwife)
Plan pays 100%
Plan Pays 80% after
Annual Deductible
Plan Pays 60% after
Annual Deductible
Inpatient Facility Charge
Plan Pays 90% after
Annual Deductible
Plan Pays 80% after
Annual Deductible
Plan Pays 60% after
Annual Deductible
Outpatient Facility Charge
Plan Pays 90% after
Annual Deductible
Plan Pays 80% after
Annual Deductible
Plan Pays 60% after
Annual Deductible
After- Hours Urgent Care $50 Copay, per visit $60 Copay, per visit
Plan Pays 60% after
Annual Deductible
Emergency Room $200 Copay, per visit
(waived if admitted)
$200 Copay, per visit
(waived if admitted)
$200 Copay, per visit
(waived if admitted)
Generic Drugs $15 Copay $20 Copay $20 Copay
Brand Preferred Drugs $30 Copay $50 Copay $50 Copay
Non-Preferred Drugs $45 Copay $75 Copay $75 Copay
Eligibility Date
Contact Information 404-261-2590
888-865-5813 toll free
Date of Hire
Medical Coverage - Kaiser Multi Choice
Prescription Drugs - Mail Order Available. Contact Kaiser Permanente Customer Service for more detail. Network pharmacies
include Walgreens and Rite Aid.
Out of Pocket Maximum
Physician's Office Visits