Medical
Medical coverage provides healthcare protection for you and your family. You can visit any provider, but in-network doctors offer the highest level of benefits and lower out-of-pocket costs by charging reduced, contracted rates. Out-of-network providers set their own fees, so you may be responsible for charges above the Reasonable and Customary (R&C) limits. Preventive care—such as physical exams, flu shots, and screenings—is covered at 100% when you use in-network providers. The main differences between plan options are how much you pay per paycheck and what you pay when you receive care.
AVMC offers three medical plan options:
- EPO Plan (EPO Network)
- PPO Plan (PPO Network)
- Kaiser Permanente HMO Plan
Review your Benefits Guide for more information regarding your plan options.
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.
Prescription Drugs
If you enroll in either the EPO/PPO, you are automatically enrolled in the prescription drug plan administered by RxBenefits/Express Scripts Inc. (ESI). Kaiser members will receive prescriptions from Kaiser facilities.
EPO/PPO
- You will not be issued a separate prescription drug card; the prescription drug information is combined with your medical ID card.
- To access a complete listing of pharmacies near you, log onto express-scripts.com.
- No claim forms to fill out.
- Mail order program for maintenance medications is both convenient and cost-effective. You receive a three-month supply for only two months copays.
- To ensure maximum quality, efficacy, and affordability, step therapy and prior authorization for certain drugs may be required.
- Customer service can be reached at 800-334-8134.
Kaiser HMO
- Prescription drug information is printed on your ID card.
- To access a complete listing of pharmacies near you, log onto kaiserpermanente.org.
- You can obtain a 100-day supply through the mail order.
EPO
Effective January 1, 2027, EPO members are generally required to use AVMC facilities (Tier 1) for facility-based services available at AVMC. Tier 2 facility benefits are generally available when services are not available at AVMC, subject to applicable exceptions. Professional office visits and specialist visits are not subject to the mandatory Tier 1 facility requirement. PCP referrals are not required.
Benefit Highlights
Tier 1 – AVMC |
Tier 2 – EPO Network |
|---|---|
| Deductible (Individual/Family) None |
Deductible (Individual/Family) $1,000/$2,000 |
| Out-of-Pocket Max (Individual/Individual Within a Family/Family) $1,000/$2,000/$3,000 |
Out-of-Pocket Max (Individual/Individual Within a Family/Family) $4,000/$6,000/$10,000 |
| Primary Care Visit Not Available |
Primary Care Visit $20 copay |
| Specialist Visit Not Available |
Specialist Visit $30 copay |
| Urgent Care Not Available |
Urgent Care $20 copay |
| Emergency Room $100 copay (Waived if admitted) |
Emergency Room $100 copay (Waived if admitted) |
| Lab and Imaging No Charge |
Lab and Imaging Not covered when services are available at AVMC. 30% after deductible |
| Outpatient Surgery No Charge |
Outpatient Surgery Not covered when services are available at AVMC. If services are unavailable at AVMC, member must seek authorization and if approved, covered at 30% after deductible. |
| Inpatient Hospitalization No Charge |
Inpatient Hospitalization Not covered when services are available at AVMC. If services are unavailable at AVMC, member must seek authorization and if approved, covered at 30% after deductible. |
Prescription Drug Benefits: Tier 1 – AVOP |
Prescription Drug Benefits: Tier 2 – ESI Network |
Retail Rx – Up to 30-Day Supply |
Retail Rx – Up to 30-Day Supply |
| Generic $10 copay |
Generic $20 copay |
| Preferred Brand $25 copay |
Preferred Brand $35 copay |
| Non-Preferred Brand $35 copay |
Non-Preferred Brand $50 copay |
| Specialty 15%, up to $250 |
Specialty 20%, up to $250 |
Retail Rx – Up to 90-Day Supply |
Mail-Order Rx – Up to 90-Day Supply |
| Generic $20 copay |
Generic $40 copay |
| Preferred Brand $50 copay |
Preferred Brand $70 copay |
| Non-Preferred Brand $70 copay |
Non-Preferred Brand $100 copay |
| Specialty Not Covered |
Specialty Not covered |
EPO Plan Cost – SEIU Bargaining Unit Employees
Per Payperiod
Employee
Employee Only: $44.17
Employee + 1 Dependent: $97.17
Employee + Family: $132.48
Employer
Employee Only: $343.17
Employee + 1 Dependent: $755.62
Employee + Family: $1,036.93
EPO Plan Cost – CNA Bargaining Unit and Non-Bargaining Employees
Per Payperiod
Employee
Employee Only: $58.90
Employee + 1 Dependent: $129.57
Employee + Family: $176.64
Employer
Employee Only: $328.45
Employee + 1 Dependent: $723.22
Employee + Family: $992.77
PPO
Benefit Highlights
Tier 1 – AVMC |
Tier 2 – PPO Network |
Tier 3 – Out-of-Network |
|---|---|---|
| Deductible (Individual/Family) $250/$500 |
Deductible (Individual/Family) $1,200/$2,400 |
Deductible (Individual/Family) $2,400/$4,800 |
| Out-of-Pocket Max (Individual/Individual Within a Family/Family) $1,000/$2,000/$3,000 |
Out-of-Pocket Max (Individual/Individual Within a Family/Family) $3,000/$8,000 |
Out-of-Pocket Max (Individual/Individual Within a Family/Family) $8,000/$12,000/$20,000 |
| Primary Care Visit Not Available |
Primary Care Visit $20 copay |
Primary Care Visit 50% after deductible |
| Specialist Visit Not Available |
Specialist Visit $30 copay |
Specialist Visit 50% after deductible |
| Urgent Care Not Available |
Urgent Care 20% after deductible |
Urgent Care 50% after deductible |
| Emergency Room $100 copay + 20% after deductible |
Emergency Room $100 copay + 20% after deductible |
Emergency Room $100 copay + 20% after deductible |
| Lab and Imaging No charge after deductible |
Lab and Imaging 20% after deductible |
Lab and Imaging 50% after deductible |
| Outpatient Surgery No charge after deductible |
Outpatient Surgery Facility Charge: $500 copay + 20% after deductible Physician/Surgeon: 20% after deductible |
Outpatient Surgery Facility Charge: $500 copay + 50% after deductible Physician/Surgeon: 50% after deductible |
| Inpatient Hospital No charge after deductible |
Inpatient Hospital Facility Charge: $500 copay + 20% after deductible per admit Physician/Surgeon: 20% after deductible |
Inpatient Hospital Facility Charge: $500 copay + 50% after deductible per admit Physician/Surgeon: 50% after deductible |
Prescription Drug Benefits: Tier 1 – AVOP |
Prescription Drug Benefits: Tier 2 – ESI Network |
Prescription Drug Benefits: Tier 3 – OON |
Retail Rx – Up to 30-Day Supply |
Retail Rx – Up to 30-Day Supply |
Retail Rx – Up to 30-Day Supply |
| Generic $10 copay |
Generic $20 copay |
Generic $10 copay + 50% |
| Preferred Brand $25 copay |
Preferred Brand $35 copay |
Preferred Brand $25 copay + 50% |
| Non-Preferred Brand $35 copay |
Non-Preferred Brand $50 copay |
Non-Preferred Brand $40 copay + 50% |
| Specialty 15%, up to $250 |
Specialty 20%, up to $250 |
Specialty Not Covered |
Retail Rx – Up to 90-Day Supply |
Retail & Mail-Order Rx – Up to 90-Day Supply |
90-Day Out-of-Network Rx – Not Covered |
| Generic $20 copay |
Generic $40 copay |
Generic Not covered |
| Preferred Brand $50 copay |
Preferred Brand $70 copay |
Preferred Brand Not covered |
| Non-Preferred Brand $70 copay |
Non-Preferred Brand $100 copay |
Non-Preferred Brand Not covered |
| Specialty Not Covered |
Specialty Not Covered |
Specialty Not covered |
PPO Plan Cost – SEIU Bargaining Unit Employees
Per Payperiod
Employee
Employee Only: $87.97
Employee + 1 Dependent: $190.28
Employee + Family: $253.93
Employer
Employee Only: $498.57
Employee + 1 Dependent: $1,078.27
Employee + Family: $1,438.95
PPO Plan Cost – CNA Bargaining Unit and Non-Bargaining Employees
Per Payperiod
Employee
Employee Only: $117.31
Employee + 1 Dependent: $253.72
Employee + Family: $338.57
Employer
Employee Only: $469.24
Employee + 1 Dependent: $1,014.84
Employee + Family: $1,354.31
Kaiser HMO
Benefit Highlights
In-Network
Deductible (Individual/Family)
None
Out-of-Pocket Max (Individual/Family)
$3,500 /$7,000
Primary Care Visit
$30 copay
Specialist Visit
$50 copay
Urgent Care
$30 copay
Emergency Room
$350 copay
Retail Rx (Up to 30-Day Supply)
Generic
$15 copay
Brand Name
$35 copay
Specialty
30% up to $250 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$30 copay
Brand Name
$70 copay
Kaiser Plan Cost – SEIU Bargaining Unit Employees
Per Payperiod
Employee
Employee Only: $52.79
Employee + 1 Dependent: $116.14
Employee + Family: $158.37
Employer
Employee Only: $275.10
Employee + 1 Dependent: $605.21
Employee + Family: $825.29
Kaiser Plan Cost – CNA Bargaining Unit and Non-Bargaining Employees
Per Payperiod
Employee
Employee Only: $70.50
Employee + 1 Dependent: $155.09
Employee + Family: $211.49
Employer
Employee Only: $257.39
Employee + 1 Dependent: $566.26
Employee + Family: $772.17