You have several options to choose from. Each option is available at different costs. When you enroll, you’ll find plenty of resources to help you choose.

Medical Coverage Level Options

	HMSA Gold	Kaiser Gold	HMSA Platinum	Kaiser Platinum

Type
Option Type	PPO	HMO	PPO	HMO

Annual Deductible
In-network (individual / family)	Combined in-network and out-of-network: $200/$600	$200/$400	N/A	N/A
Out-of-network (individual / family)	Combined in-network and out-of-network: $200/$600	Not covered	$100/$300	Not covered

Annual Out-of-Pocket Maximum
In-network (individual / family)	Combined in-network and out-of-network: $2,200/$6,600	$2,200/$4,400	Combined in-network and out-of-network: $2,500/$7,500	$2,500/$7,500
Out-of-network (individual / family)	Combined in-network and out-of-network: $2,200/$6,600	N/A	Combined in-network and out-of-network: $2,500/$7,500	N/A

In-Network Benefits
Preventive care	100% covered; deductible waived for most services	100% covered; deductible waived	100% covered	100% covered
Doctor's office visit	You pay $12	You pay $15	You pay $12	You pay $15
Emergency room	You pay 20% after deductible	You pay 20%; deductible waived	You pay 20%	You pay $75
Urgent care	You pay $12	You pay $15	You pay $12	You pay $15
Inpatient care	You pay 20% after deductible	You pay 10% after deductible	You pay 10%	You pay $75 per day
Outpatient care	Cost share based on place of service	Cost share based on place of service	Cost share based on place of service	Cost share based on place of service

Prescription Drug Coverage

	HMSA Gold	Kaiser Gold	HMSA Platinum	Kaiser Platinum

Type
Preventive Drugs	You pay $0*	You pay $0*	You pay $0*	You pay $0*
Prescription Drug Annual Out-of-Pocket Maximum (individual/ family)	$3,000/$7,200	Included in medical out-of-pocket maximum	$3,000/$5,700	Included in medical out-of-pocket maximum

30-Day Retail Supply
Tier 1 (generally lowest cost options)	You pay $7	You pay $5 for generic maintenance drugs; $10 for other generic drugs	You pay $5	You pay $5 for generic maintenance drugs; $10 for other generic drugs
Tier 2 (generally medium cost options)	You pay $35	You pay $35	You pay $30	You pay $35
Tier 3 (generally highest cost options)	You pay $75	You pay $35 (if authorized)	You pay $70	You pay $35 (if authorized)

90-Day Mail-Order Supply
Tier 1 (generally lowest cost options)	You pay $14	You pay $10 for generic maintenance drugs; $20 for other generic drugs	You pay $10	You pay $10 for generic maintenance drugs; $20 for other generic drugs
Tier 2 (generally medium cost options)	You pay $70	You pay $70	You pay $60	You pay $70
Tier 3 (generally highest cost options)	You pay $150	You pay $70 (if authorized)	You pay $140	You pay $70 (if authorized)

These charts may not take into account how each coverage level covers any state-mandated benefits, its plan administration capabilities, or the approval from the state Department of Insurance of the benefits offered by the plan. If you have questions about a specific benefit, contact the insurance carrier for additional information. In the event that there is a discrepancy between this site and the official plan documents, the official plan documents will control.

These charts are a high-level listing of commonly covered benefits across carriers and coverage levels for the Aon Benefit Experience. They are intended to provide you with a snapshot of benefits provided across coverage levels. In general, carriers have agreed to the majority of standardized plan benefits recommended by BenX. Individual carriers may offer coverage that differs slightly from the standard coverage reflected here.

For a more detailed look at these and additional coverages, go to the PetSmart Benefits Portal at digital.alight.com/petsmart. It does account for any carrier adjustments to standardized plan benefits. To see summaries when you enroll online, check the boxes next to the options you want to review and click Compare. In order to get the most comprehensive information about any specific coverage, you will need to call the carrier directly.

Note: For additional comparison, you may find Summaries of Benefits and Coverage on the PetSmart Benefits Portal.

Important! If you choose HMSA as your insurance carrier, you’ll have a separate and additional out-of-pocket maximum for prescription drugs. That means your medication costs will not count toward your medical out-of-pocket maximum (and vice versa).

How Does the Deductible and Out-of-Pocket Maximum Work?

The HMSA Gold and Kaiser Gold options have a traditional deductible. Once a covered family member meets the individual deductible, your insurance will begin paying benefits for that family member. Charges for all covered family members will continue to count toward the family deductible. Once the family deductible is met, your insurance will pay benefits for all covered family members.
All medical options have a traditional out-of-pocket-maximum. Once a covered family member meets the individual out-of-pocket maximum, your insurance will pay the full cost of covered charges for that family member. Charges for all covered family members will continue to count toward the family out-of-pocket maximum. Once the family out-of-pocket maximum is met, your insurance will pay the full cost of covered charges for all covered family members.

Going Out of Network?

If you choose HMSA, seeing out-of-network providers will cost you more than seeing in-network providers. For example, you could pay more through a higher deductible, higher coinsurance, and the entire amount that exceeds the maximum allowed amount, which is typically based on the amount Medicare pays.
If you choose Kaiser Permanente as your insurance carrier, you must designate a primary care physician to coordinate your care and out-of-network care is not covered.