Page 12 - National General 2021 Annual Benefits Enrollment

Kaiser Permanente Plan and Rates

An HMO medical coverage option

California-based Employees Only

With Kaiser Permanente you must select a primary care physician to coordinate all your care within the Kaiser HMO
network. Care received outside of the Kaiser HMO network is not covered.

Benefit In-Network Out-of-Network
Benefit Period Calendar year Not covered
Deductible (Individual/Family)* $1,000/$2,000 Not covered
Coinsurance 20% after deductible Not covered
Out-of-Pocket Maximum $3,000/$6,000 Not covered
Lifetime Maximum Unlimited Not covered
Physician Office Visits $20 copay Not covered
Preventive Care No cost Not covered
Specialist Office Visits $20 copay Not covered
Virtual Visits $20 copay Not covered
Emergency Room 20% after deductible Not covered
Urgent Care $20 copay Not covered
Therapy (Physical, Speech, Occupational) $20 copay after deductible Not covered
Diagnostic Services $10 copay after deductible Not covered
Inpatient Hospital Services 20% after deductible Not covered
Outpatient Services 20% after deductible Not covered

* For family coverage, a single family member can satisfy the individual deductible amount and the plan will begin to pay coinsurance for that individual.

Prescription Drugs
Plan Pharmacy (up to a 30-day supply) Most generic items—$10
Most brand items —$30
Most specialty items—20% to a $200 maximum
(Medical deductible doesn’t apply)
Mail Order Service (up to 100-day supply) Most generic items —$20
Most brand items—$60
Specialty items—N/A
Rates shown are before any Be Well credits are applied. Please note the Spousal Surcharge (page 5) is in addition to the rates below.

Bi-Weekly Rates Employee Only Employee and Spouse Employee and Child(ren) Employee and Family
(per pay period)
Kaiser HMO $97.21 $191.62 $171.39 $252.32

12