Page 7 - 2022 US Benefits Guide FINAL

KAISER MEDICAL AND

PHARMACY COVERAGE

Please Note: This plan is available for California employees only .

Platinum HMO Plan Gold HMO Plan

Medical Plan Provisions In-Network In-Network
Annual Deductible
(Individual/Family) None $250 / $500
Out-of-Pocket Maximum $1,500 / $3,000 $3,000 / $6,000
(Includes Deductible)
Preventive Care Covered at 100% Covered at 100%
Primary Care Provider $10 Copay $10 Copay
Office Visit
Specialist Office Visit $10 Copay $10 Copay

X-Ray and Lab No charge for most services $10 Copay
Inpatient Hospital Services No charge 90%*

Outpatient Hospital Services $10 Copay 90%*

Urgent Care $10 Copay $10 Copay

Emergency Room $100 Copay 90%*
Pharmacy Provisions In-Network In-Network

Retail pharmacy (up to a 30-day supply)

Generic $10 Copay $10 Copay
Brand Preferred $20 Copay $30 Copay

Specialty 20% coinsurance up to $250 20% coinsurance up to $200

Mail Order Pharmacy (100-day supply)
Generic $20 Copay $20 Copay

Brand Preferred $40 Copay $60 Copay
*After Deductible

How the Kaiser Plans Work
• You choose a primary care physician (PCP) from Kaiser’s network.
• The PCP coordinates your care and refers you to specialists.
• The plan covers the cost of services only when authorized by your primary care physician.
• You can only use doctors, hospitals and pharmacies that participate in the Kaiser HMO
network. There is no coverage if you go to out-of-network providers, except for
emergency services.

7