Page 11 - ABM 2021 Benefit Guide SVC HI
P. 11
Kaiser Permanente HMO
As part of your healthcare beneits, all of our medical plan
choices provide 100% coverage for qualiied wellness/
preventive care services.
If you select the Kaiser Permanente plan, you
must use Kaiser Permanente providers to
receive coverage. Under this plan, you will pay
the full cost if you go to a non-Kaiser provider;
there is no out-of-network coverage unless
your event qualiies as an emergency or urgent
care. If you are visiting another Kaiser region,
however, you can receive the same beneits as
your current location. Please go to kp.org/travel
for more information.
Kaiser Permanente
Hawaii
Standard HMO
Calendar Year Deductible
Individual $0
Family $0
Out-of-Pocket Maximum
Individual $2,500
Family $7,500
Physician Oice Visits
Primary Care $20 copay
Specialist $20 copay
Urgent Care $20 per copay
Wellness/Preventive No charge
X-Ray/radiology services
Physician Oice $10 copay or 20% of applicable
charges for specialty labs/imaging
Hospital Services
Emergency Room $100 per copay
Mental Health
Inpatient 10% coinsurance
Outpatient $20/copay
Substance Abuse
Inpatient 10% coinsurance
Outpatient $20/copay
Chiropractic Care
Not covered
Prescription Drugs
Retail—Supply Limit 30-days
Generic $10
Preferred Brand Drugs $35
Mail Order—Supply Limit 90-days
Generic $20
Preferred Brand Drugs $70
ABM 11
As part of your healthcare beneits, all of our medical plan
choices provide 100% coverage for qualiied wellness/
preventive care services.
If you select the Kaiser Permanente plan, you
must use Kaiser Permanente providers to
receive coverage. Under this plan, you will pay
the full cost if you go to a non-Kaiser provider;
there is no out-of-network coverage unless
your event qualiies as an emergency or urgent
care. If you are visiting another Kaiser region,
however, you can receive the same beneits as
your current location. Please go to kp.org/travel
for more information.
Kaiser Permanente
Hawaii
Standard HMO
Calendar Year Deductible
Individual $0
Family $0
Out-of-Pocket Maximum
Individual $2,500
Family $7,500
Physician Oice Visits
Primary Care $20 copay
Specialist $20 copay
Urgent Care $20 per copay
Wellness/Preventive No charge
X-Ray/radiology services
Physician Oice $10 copay or 20% of applicable
charges for specialty labs/imaging
Hospital Services
Emergency Room $100 per copay
Mental Health
Inpatient 10% coinsurance
Outpatient $20/copay
Substance Abuse
Inpatient 10% coinsurance
Outpatient $20/copay
Chiropractic Care
Not covered
Prescription Drugs
Retail—Supply Limit 30-days
Generic $10
Preferred Brand Drugs $35
Mail Order—Supply Limit 90-days
Generic $20
Preferred Brand Drugs $70
ABM 11
