Plan Details
Plan Name HMO
Description All Employees
Carrier Kaiser Permanente Insurance Company
Effective Dates January 1, 2020 to January 1, 2021
In-Network Benefits
General Plan Information
Annual Deductible/Individual $0
Annual Deductible/Family $0
Coinsurance 100%
Office Visit/Exam $30 copay per visit
Outpatient Specialist Visit $30 copay per visit
Annual Out-of-Pocket Limit/Individual $1,500
Annual Out-of-Pocket Limit/Family $3,000
Preventive Services
Well-Child Care 100%
Well Woman Exams 100%
Adult Periodic Exams with Preventive Tests 100%
Inpatient Hospital Services
Inpatient Hospitalization 100%
Semi-Private Room & Board; Including Services and Supplies 100%
Surgical Services
Outpatient Facility Charge $30 copay per procedure
Emergency Services
Emergency Room $100 copay per visit
Urgent Care
Urgent Care Facility $30 copay per visit
Mental Health Benefits
Inpatient Care 100%
Outpatient Care $30 copay per individual visit; $15 per group visit
Prescription Drug Benefits
Prescription Drug Deductible N/A
Generic $10 copay
Brand (Formulary/Preferred) $25 copay
Brand (Non-Formulary/Non-preferred) $25 copay
Number of Days Supply 30 days
Mail Order
Generic $20 copay
Brand (Formulary/Preferred) $50 copay
Brand (Non-Formulary/Non-preferred) $50 copay
Number of Days Supply for Mail Order 100 days
Other Services and Supplies
Durable Medical Equipment & Prosthetic Devices 80%
Chiropractic Services $15 copay; limited to 30 visits per year
Acupuncture $30 copay
Outpatient Rehabilitative Therapy Services
Physical $30 copay per visit