Page 4 - 2016 Open Enrollment
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4
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 $30, emergency department visits are $100, and ambulance
services are $50 per trip. Hospitalization is covered at 100 percent.
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.
New for 2016– we will be adding a specialty drug tier where you will
be responsible for 30 percent of the prescription cost, with a $150 per
specialty prescription maximum.
Generic—$15 for up to 30-day supply, $30 for up to a 60-day supply,
$45 for 61–100 day supply
Preferred name brand—$35 for up to a 30-day supply, $70 for up to a
100-day supply
Non-preferred brand drugs—same as preferred brand drugs
Specialty drugs—30 percent member responsibility for specialty
prescriptions, $150 per script maximum
Benefit Summary
Covered Beneits HMO
Deductible $0
Out-of-pocket maximum (individual/family) $1,500/$3,000
Outpatient surgery/procedures $30 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
Specialty drugs 30% of cost,
$150 maximum per specialty
prescription
First Bank
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 $30, emergency department visits are $100, and ambulance
services are $50 per trip. Hospitalization is covered at 100 percent.
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.
New for 2016– we will be adding a specialty drug tier where you will
be responsible for 30 percent of the prescription cost, with a $150 per
specialty prescription maximum.
Generic—$15 for up to 30-day supply, $30 for up to a 60-day supply,
$45 for 61–100 day supply
Preferred name brand—$35 for up to a 30-day supply, $70 for up to a
100-day supply
Non-preferred brand drugs—same as preferred brand drugs
Specialty drugs—30 percent member responsibility for specialty
prescriptions, $150 per script maximum
Benefit Summary
Covered Beneits HMO
Deductible $0
Out-of-pocket maximum (individual/family) $1,500/$3,000
Outpatient surgery/procedures $30 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
Specialty drugs 30% of cost,
$150 maximum per specialty
prescription
First Bank
