Page 4 - First Bank- Open Enrollment Guide 2015
P. 4
Open
Enrollment
Kaiser Permanente Traditional Plan
In lieu of the PPO Plan options, First Bank employees in the State of
California may choose medical coverage through Kaiser Permanente
(a leading HMO). All services must be received in-network from
plan physicians and providers. In the Kaiser HMO Plan, copayments
of plan provider ofice visits are $20, while specialist visits are $30.
Outpatient services are $20, emergency department visits are $100, and
ambulance services are $50 per trip. Hospitalization is covered at 100%
. For services subject to coinsurance (after the copayments above), the
maximum out-of-pocket cost per individual is $1,500 and for an entire
family is $3,000 per calendar year. Prescription drugs are covered only
if purchased through a plan pharmacy at the following rates.
X Generic—$15 for up to 30-day supply, $30 for up to a 60-day
supply, $45 for 61-100 day supply
X Preferred name brand—$35 for up to a 30-day supply, $70 for up
to a 100-day supply
X Non-preferred brand drugs—same as preferred brand drugs
X Specialty drugs—same as preferred brand drugs
Benefit Summary
Covered Beneits HMO
Deductible $0
Out-of-Pocket Maximum (Individual/Family) $1,500/$3,000
Outpatient Surgery/Procedures $20 per procedure
Primary Care Visits $20 per visit
Specialty Care Visits $30 per visit
Emergency Room Visit $100 per visit
Prescription Drug Coverage 30-Day Retail 100-Day Mail
Supply Order Supply
Generic $15 $30
Brand-name $35 $70
4
Enrollment
Kaiser Permanente Traditional Plan
In lieu of the PPO Plan options, First Bank employees in the State of
California may choose medical coverage through Kaiser Permanente
(a leading HMO). All services must be received in-network from
plan physicians and providers. In the Kaiser HMO Plan, copayments
of plan provider ofice visits are $20, while specialist visits are $30.
Outpatient services are $20, emergency department visits are $100, and
ambulance services are $50 per trip. Hospitalization is covered at 100%
. For services subject to coinsurance (after the copayments above), the
maximum out-of-pocket cost per individual is $1,500 and for an entire
family is $3,000 per calendar year. Prescription drugs are covered only
if purchased through a plan pharmacy at the following rates.
X Generic—$15 for up to 30-day supply, $30 for up to a 60-day
supply, $45 for 61-100 day supply
X Preferred name brand—$35 for up to a 30-day supply, $70 for up
to a 100-day supply
X Non-preferred brand drugs—same as preferred brand drugs
X Specialty drugs—same as preferred brand drugs
Benefit Summary
Covered Beneits HMO
Deductible $0
Out-of-Pocket Maximum (Individual/Family) $1,500/$3,000
Outpatient Surgery/Procedures $20 per procedure
Primary Care Visits $20 per visit
Specialty Care Visits $30 per visit
Emergency Room Visit $100 per visit
Prescription Drug Coverage 30-Day Retail 100-Day Mail
Supply Order Supply
Generic $15 $30
Brand-name $35 $70
4
