Page 9 - 2021 Dreyer's Benefits Guide

KAISER HMO KAISER HMO
NORTHERN CALIFORNIA (NCA) SOUTHERN CALIFORNIA (SCA)

Available in California ONLY
IN-NETWORK ONLY IN-NETWORK ONLY
CALENDAR YEAR DEDUCTIBLE
Individual $0 $0
Family $0 $0
CALENDAR YEAR OUT-OF-POCKET MAXIMUM (INCLUDES DEDUCTIBLE)
Individual $2,000 $2,000
Family $4,000 $4,000
YOU PAY YOU PAY
COINSURANCE / COPAYS
Office Visits $20/$30 copay $20/$30 copay
(PCP/SPC)
Lab Work $10 copay $10 copay
X-rays $10 copay $10 copay
Advanced Radiology $50 copay $50 copay
Hospital Services $500 copay per admit $500 copay per admit
(Inpatient)
Urgent Care $20 copay $20 copay
Emergency Room $250 copay per visit $250 copay per visit
Acupuncture Not covered Not covered
Chiropractic Not covered Not covered
PHARMACY
FORMULARY NAME Essential Drug List
(
RETAIL UP TO 30-DAY SUPPLY )
IN-NETWORK ONLY IN-NETWORK ONLY
Generic $15 $15
Brand $40 $40
Specialty 20% up to $150 20% up to $150
(
MAIL ORDER UP TO 100-DAY SUPPLY )
IN-NETWORK ONLY IN-NETWORK ONLY
Generic $30 $30
Brand $80 $80
Specialty Not covered Not covered

KAISER HMO NORTHERN CALIFORNIA (NCA)
MONTHLY RATES EMPLOYER MONTHLY COST EMPLOYEE MONTHLY COST EMPLOYEE PER-PAY-PERIOD COST*
Employee Only $550.74 $411.49 $139.25 $69.63
* Employee contributions to insurance are deducted from the first two paychecks of each month. For those months with a third paycheck, no
insurance premiums will be deducted from the third paycheck.
Click here to view the complete Employee Contributions schedule for this plan.

KAISER HMO SOUTHERN CALIFORNIA (SCA)
MONTHLY RATES EMPLOYER MONTHLY COST EMPLOYEE MONTHLY COST EMPLOYEE PER-PAY-PERIOD COST*
Employee Only $550.74 $444.74 $106.00 $53.00
* Employee contributions to insurance are deducted from the first two paychecks of each month. For those months with a third paycheck, no
insurance premiums will be deducted from the third paycheck.
Click here to view the complete Employee Contributions schedule for this plan.

9

MEDICAL PLANS