Page 4 - CFA 2020 Benefits Guide

Your Medical Plan At-A-Glance

Deductible HMO
Kaiser Medical Plan
In-Network Out-of-Network
Deductible
Individual $250 Not Covered
Family $750 Not Covered
Out-of-Pocket Max
Individual $1,500 Not Covered
Family $3,000 Not Covered
Maximums
Lifetime Unlimited Not covered
Copays
Primary Care $20 Copay 1 Not covered
Specialist $20 Copay 2 Not covered
Preventive Care $0 Copay 3 Not covered
ER 10% Coinsurance 10% Coinsurance
Urgent Care $40 Copay 4 Not covered
Hospital Care 10% Coinsurance Not covered
RX—Retail
Formulary - Generic (60 days) $15 Copay Not covered
Formulary - Brand Name (60 days) $40 Copay Not covered
Non Formulary (60 days) Not covered Not covered
20% Of coinsurance up to $250 per drug
dispensed retail and mail order prescriptions.
Specialty Not subject to ‘overall’ deductible. Subject to Not covered
formulary guidelines. Member cost share for
all prescription drugs is limited to $3,500
RX- Mail Order
Formulary - Generic (60 days) $15 Copay Not covered
Formulary - Brand Name (60 days) $40 Copay Not covered
Non Formulary (60 days) Not covered Not covered
20% Of coinsurance up to $250 per drug
dispensed retail and mail order prescriptions.
Specialty Not subject to ‘overall’ deductible. Subject to Not covered
formulary guidelines. Member cost share for
all prescription drugs is limited to $3,500

1 10% coinsurance for covered services received during a visit
2 10% coinsurance for covered services received during a visit
3 Not subject to the overall deductible. $70 per visit for colorectal cancer screenings (not subject to the overall deductible).
4 10% coinsurance for covered services received during a visit. Urgent care is deined as after-hours care. Copay not subject to the overall deductible.
5 30% coinsurance for covered services received during a visit

For additional information, visit www.kp.org.

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