Keeping You Healthy
Protecting Your Income
Promoting a healthy lifestyle is what Pacsun is all about. That’s why we offer associates important medical benefits, including prescription coverage. Please take the time to review each plan and compare them against individual plan requirements for your state in selecting health plan coverage. For both in- and out-of-network providers, you are required to meet the annual deductible before the plans’ coinsurance begins. Read more about your medical plan options below…
Aetna HRA – Summary Plan Description, Summary of Benefits & Coverage
Aetna PPO – Summary Plan Description, Summary of Benefits & Coverage
Kaiser Permanente (CA) – Evidence of Coverage, Summary of Benefits & Coverage
Kaiser Permanente (WA) – Evidence of Coverage, Summary of Benefits & Coverage
TripleS – Summary of Benefits & Coverage
In-network physicians and facilities will submit claims for you and have agreed not to charge more than Aetna’s allowed amount for covered services. If you receive treatment from an out-of-network physician or facility, they may require you to pay the entire amount at the time of service and then you can submit a claim for reimbursement. If they charge more than the allowed amount, you will be responsible for anything over and above that amount.
You may choose to visit in or out-of-network providers and facilities. However, you will have lower out-of-pocket costs when care is received in-network.
Coverage for specific preventive care services is free when you see an in-network provider. A list of preventive services is available at
www.healthcare.gov/coverage/preventive-care-benefits.
To help evaluate your medical plan selections, visit the Aetna website to see if your doctor is in-network or to find a doctor. Click on the links below for more information, or follow the step-by-step instructions below.
The Triple-S Salud plan offers access to a broad provider network. There is no in-network deductible. However, a deductible would apply for out-of-network services.
You may choose to have your treatment provided by an in or out-of-network provider. However, you will have lower out-of-pocket costs when care is received from an in-network physician.
| BI-WEEKLY RATES | TOBACCO USER | |
|---|---|---|
| Associate Only | $27.82 | $73.82 |
| Associate + Spouse | $67.82 | $113.82 |
| Associate + Child(ren) | $59.36 | $105.36 |
| Associate + Family | $82.97 | $128.97 |
| BENEFIT | MEDICAL & HOSPITAL (IN-NETWORK) | MAJOR MEDICAL (OUT-OF-NETWORK) |
|---|---|---|
| Annual Deductible – DED | $100 per person; $300 family maximum | None |
| Out-of-Pocket Maximum | Medical/Hospital/Rx: $6,350 per person; $12,700 family maximum Major Medical: $2,000 per person; $4,000 family maximum | Unlimited |
| Lifetime Maximum | Unlimited | Unlimited |
| Preventive Care | 100% covered | DED then you pay 20% |
| Office Visit (Primary (PCP) / Specialist) | $10 copay | DED then you pay 20% |
| Virtual doctor | Not covered (Nurseline) | Not covered (Nurseline) |
| Outpatient Surgery | $100 copay | DED then you pay 20% |
| Inpatient Hospitalization | $100 copay | DED then you pay 20% |
| Emergency Room | Illness Visit: $50 copay Accident Visit: No charge | Illness Visit: $50 copay Accident Visit: No charge |
Because an emergency can happen anytime and anywhere, Blue Card Program® and Blue Card Worldwide® provide access to medical healthcare whether you are in the United States or around the world.
The Blue Card Program provides access to medical services in the United States. If you have major medical coverage, Blue Card World Wide offers access to emergency hospital services at Blue Cross and Blue Shield Centers around the world.
Coverage for specific preventive care services is free when you see an in-network provider. A list of preventive services is available at
www.healthcare.gov/coverage/preventive-care-benefits.
Follow the instructions below to visit the Triple-S Salud website to see if your doctor is in-network or to find a new doctor:
Triple-S Salud plan members can benefit from online access to general information, as well as guidelines for the recognition and treatment of the health conditions below. Visit www.ssspr.com to learn more about:
Through the Total Well-Being Program you have access to services in disease management, prenatal education, and health education. The disease management program is geared towards the management of the chronic conditions that are most common among Puerto Ricans:
If you have any of these conditions, this program will be greatly beneficial. The disease management program includes services such as clinical treatment (provided by your physician) and follow-up and guidance by nursing professionals and health educators.
The Hawaii Medical Assurance Association (HMAA) PPO plan offers access to HMAA’s provider network. For both in and out-of-network providers, you must meet the annual deductible before the plan’s coinsurance begins.
With the PPO plan, you have a choice every time you need care. Your network physicians will submit claims for you. If you receive treatment from an out-of-network physician, they may require you to pay the entire amount at the time of service and then submit a claim for reimbursement.
You may choose to have your treatment provided by an in or out-of-network provider. However, you will have lower out-of-pocket costs when care is received from an in-network physician.
Coverage Waiver Requirements
If you choose not to enroll in medical coverage with Pacsun, you are required to complete the State of Hawaii’s Form HC-5 every calendar year. Select the link below to complete your form and submit to the Benefits Team by your enrollment deadline.
| BI-WEEKLY RATES | |
|---|---|
| Associate Only | $5.66 |
| Associate + Spouse | $75.65 |
| Associate + Child(ren) | $82.52 |
| Associate + Family | $106.60 |
| BENEFIT | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Calendar Year Deductible | Associate: $100 Associate + Dependent(s): $300 | Associate: $100 Associate + Dependent(s): $300 |
| Calendar Year Out-of-Pocket Maximum | Medical: $2,000 per person; $6,000 family max Prescription: $5,500 per person; $9,000 family max | Medical/Hosptial/Rx: $6,350 per person; $12,700 family max Major Medical: $2,000 per person; $4,000 family max |
| Lifetime Maximum | Unlimited | Unlimited |
| Preventive Care | 100% covered | No charge |
| Office Visit (Primary (PCP) / Specialist) | $15 copay | $15 copay |
| Virtual doctor (HiDoc) | 100% covered | N/A |
| Urgent Care | $25 copay | $25 copay |
| Emergency Room | You pay 20% | You pay 20% |
| Outpatient Surgery | You pay 20% | You pay 20% |
| Inpatient Hospitalization | You pay 20% | You pay 20% |
Coverage for specific preventive care services is free when you see an in-network provider. A list of preventive services is available at
www.healthcare.gov/coverage/preventive-care-benefits.
Follow the instructions below to to see if your doctor is in-network or to find a new doctor:
In line with national healthcare trends, Pacsun is implementing a spousal surcharge. Associates who choose to cover a spouse who has the option to elect healthcare coverage through his/her own employer will pay a $46 surcharge per pay period.
You will be asked to attest to whether or not your covered spouse has declined benefits through his or her employer when you complete your online enrollment in UKG Pro.
To help you determine if the surcharge applies to your situation, please select the “+” to open each topic below.
If you or your enrolled spouse are tobacco users, you will not receive the non-tobacco discount on your medical premiums. If either of you would like help cutting the tobacco habit, contact the Benefits Team to learn more about our Tobacco Cessation program. Once you complete the program, you will be eligible to receive the non-tobacco discount.
In the Health Reimbursement Account (HRA) plan, you may see a provider in the Aetna HealthFund Choice POS II HRA network or outside of the network. However, providers outside of the network are more expensive so you’ll spend the money in your HRA Fund more quickly using these providers. Please take the time to review both plans and compare them against individual plan requirements for your state in selecting health plan coverage.
So how does the HRA Plan work? You might think of the HRA Plan as a “pay-as-you-go” medical plan. Pacsun puts money into a health fund “account” for you, and you use that money to pay for your benefit expenses (such as deductibles). When company money runs out, you are responsible for paying out of pocket, up to the remaining deductible. Once you’ve met the deductible, the plan pays a percentage of your medical expenses and you pay “coinsurance.” You are rewarded for seeing network providers: your plan pays 90% and you pay 10% for in-network care, whereas you pay 50% for out-of-network care.
If you don’t use all the money in your HRA Fund within the plan year, that money rolls over and is added to your health fund for the following year—up to a maximum of $2,250 for individuals and $4,500 for Associate + 1 or more dependents. If you “spend smart” on your benefits, you can save a lot of money using this plan. However, if you need major coverage, this plan is designed to give you and your family the protection you need.
For family coverage, the HRA plan has an aggregate, or collective, family deductible and an embedded out-of-pocket maximum. This means that if you enroll one or more family members, together you are required to meet the full family deductible before the plan starts to pay expenses for any one individual. However, each member only needs to meet the individual out-of-pocket maximum before the plan starts to pay 100% of eligible expenses for that individual.
| HRA BI-WEEKLY RATES | TOBACCO USER | |
|---|---|---|
| Associate Only | $32.02 | $78.02 |
| Associate + Spouse | $77.75 | $123.75 |
| Associate + Child(ren) | $69.98 | $115.98 |
| Associate + Family | $110.91 | $156.91 |
| BENEFIT | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Plan Year HRA Fund Contribution | Associate: $500 Associate + Dependent(s): $1,000 | Associate: $500 Associate + Dependent(s): $1,000 |
| Plan Year Deductible (aggregate) | Associate: $3,000 Associate + Dependent(s): $6,000 | Associate: $4,000 Associate + Dependent(s): $8,000 |
| Plan Year Out-of-Pocket Maximum | Associate: $6,000 Associate + Dependent(s): $12,000 | Associate: $8,000 Associate + Dependent(s): $16,000 |
| Lifetime Maximum | Unlimited | Unlimited |
| Preventive Care | 100% covered | DED then you pay 50% |
| Office Visit – Primary/Mental Health | DED then you pay 10% | DED then you pay 50% |
| Office Visit – Specialist | DED then you pay 10% | DED then you pay 50% |
| Lab & Radiology Services | DED then you pay 10% | DED then you pay 50% |
| Virtual Doctor (Teladoc) | DED then you pay 10% | N/A |
| Urgent Care | DED then you pay 10% | DED then you pay 50% |
| Inpatient Hospitalization | DED then you pay 10% | DED then you pay 50% |
| Outpatient Surgery | DED then you pay 10% | DED then you pay 50% |
| Emergency Room | $250 copay then DED then you pay 10% | $250 copay then DED then you pay 10% |
| Short-Term Rehabilitative Therapy (Physical, Occupational & Speech) | DED then you pay 10% (60 visit maximum per plan year for all therapies combined) | DED then you pay 50% (60 visit maximum per plan year for all therapies combined) |
| Chiropractic Services | DED then you pay 10% (30 visit maximum) | DED then you pay 40% (30 visit maximum) |
In the PPO plan, you may see any provider you wish, but you will pay less when you see healthcare providers in the Aetna Choice POS II PPO network. On the PPO plan, you pay a copay whenever you see a network provider for an office visit. Please take the time to review both plans and compare them against individual plan requirements for your state in selecting health plan coverage.
You continue to pay medical expenses until you meet your deductible, which is the amount you pay each year before your health plan begins to pay. Most copays are not subject to the deductible.
Once you’ve met the deductible, the plan pays a percentage of your medical expenses. You are rewarded for seeing in-network providers. If you receive network care, your plan pays 80% and you pay 20%. For out-of-network care, your plan pays 60% and you pay 40%. Your portion of costs is called coinsurance.
When the total that you pay for covered services including copays, deductible, and coinsurance reaches your out-of-pocket maximum, or the most you’d pay in a plan year for eligible services, the plan pays 100% of the cost of covered medical expenses for the rest of the plan period.
For family coverage, the Aetna Choice POS II (PPO) plan has an embedded family deductible and out-of-pocket maximum. This means that the family deductible and out-of-pocket maximum can be met by a combination of family members; however, no single individual within the family will be subject to more than the individual deductible or out-of-pocket maximum. Once the family deductible or out-of-pocket maximum is met, no matter if one member or multiple members help meet it, all family members will be considered as having met their deductible or out-of-pocket maximum for the remainder of the plan year.
| PPO BI-WEEKLY RATES | TOBACCO USER | |
|---|---|---|
| Associate Only | $95.05 | $141.05 |
| Associate + Spouse | $237.48 | $283.48 |
| Associate + Child(ren) | $212.24 | $258.24 |
| Associate + Family | $337.81 | $383.81 |
| BENEFIT | IN-NETWORK | OUT-OF-NETWORK |
|---|---|---|
| Plan Year Deductible | Associate: $1,500 Associate + Dependent(s): $3,000 | Associate: $3,000 Associate + Dependent(s): $6,000 |
| Plan Year Out-of-Pocket Maximum | Associate: $3,000 Associate + Dependent(s): $9,000 | Associate: $6,000 Associate + Dependent(s): $18,000 |
| Lifetime Maximum | Unlimited | Unlimited |
| Preventive Care | 100% covered | DED then you pay 40% |
| Office Visit – Primary/Mental Health (PCP) | $20 copay | DED then you pay 40% |
| Office Visit – Specialist | $40 copay | DED then you pay 40% |
| Lab & Radiology Services | DED then you pay 20% | DED then you pay 40% |
| Virtual Doctor (Teladoc) | 100% covered | Not covered |
| Urgent Care | $20 copay | DED then you pay 40% |
| Emergency Room | $250 copay then DED then you pay 20% | $250 copay then DED then you pay 20% |
| Inpatient Hospitalization | DED then you pay 20% | DED then you pay 40% |
| Outpatient Surgery | DED then you pay 20% | DED then you pay 40% |
| Chiropractic Services | $40 copay (30 visit maximum) | DED then you pay 40% (30 visit maximum) |
Regardless of which Aetna medical plan you select, you will also have access to supplemental programs to help you achieve your maximum wellness.
The online health assessment can give you an idea of the current state of your health. Based on your confidential responses, you will learn whether you are at risk for certain conditions like diabetes or high blood pressure. The health assessment and related tools are available at no extra cost to associates enrolled in an Aetna medical plan. After completing the assessment you will receive a custom action plan to help prevent health problems and feel your very best.
Your Health Assessments are secure and will not be shared with Pacsun or used to affect your health insurance costs. These programs provide the support you need to get healthy and stay healthy. To begin your health assessment, log on to www.aetna.com after your coverage begins.
The Aetna Maternity Program gives you the tools and information you need for a healthy pregnancy and helps you make good decisions for you and your baby. Get help from the time you start planning a family, through your pregnancy, and well after your baby is born. Once you’ve enrolled in the Aetna Maternity Program, you may receive:
Visit Aetna Women’s Health online at https://www.aetna.com/individuals-families/womens-health.html for more information.
| KAISER BI-WEEKLY RATES | TOBACCO USER | |
|---|---|---|
| Associate Only | 47.54 | $93.54 |
| Associate + Spouse/Domestic Partner | 119.08 | $165.08 |
| Associate + Child(ren) | 106.15 | $152.15 |
| Associate + Family | 168.92 | $214.92 |
| BENEFIT | IN-NETWORK CALIFORNIA HMO (ANAHEIM, CA) | IN-NETWORK WASHINGTON HMO (BELLEVUE, WA) |
|---|---|---|
| Plan Year Deductible | Associate: $1,000 Associate + Dependent(s): $2,000 | Associate: $1,000 Associate + Dependent(s): $2,000 |
| Plan Year Out-of-Pocket Maximum | Associate: $3,000 Associate + Dependent(s): $6,000 | Associate: $3,500 Associate + Dependent(s): $7,000 |
| Lifetime Maximum | Unlimited | Unlimited |
| Preventive Care | 100% covered | 100% covered |
| Office Visit – Primary/Mental Health | $20 copay | $20 copay |
| Office Visit – Specialist | $20 copay | $20 copay |
| Virtual Doctor (Kaiser) | 100% covered | 100% covered |
| Urgent Care | $20 copay | $25 copay |
| Emergency Room | DED then you pay 20% | $250 copay (waived if admitted), then DED then you pay 20% |
| Outpatient Surgery | DED then you pay 20% | DED then you pay 20% |
| Inpatient Hospitalization | DED then you pay 20% | DED then you pay 20% |