Page 26 - Skechers 2022 Benefits Guide

HAWAII KAISER PERMANENTE MEDICAL PLAN
OVERVIEW — HAWAII ONLY
WHO CAN JOIN?
Full-time or Part-time Hawaii employees and their eligible dependents may join the plan on the first of the month following 28 days from date of hire. Eligible dependents include spouses, domestic partners, and children under the age of 26. Coverage is only available for dependent children through and including age 25.
In the Kaiser Medical Plan, all care must be received from providers within Kaiser’s Network (except in an emergency). Members must select a Primary Care Physician. To find participating providers near you, please visit Kaiser’s website at kp.org or call member services at 808-432-5955.
For open enrollment, you will receive an open enrollment letter (via email or regular mail) with enrollment instructions. Failure to follow the waiver instructions will result in your auto enrollment in employee only Kaiser Coverage. Auto enrollment will be effective on January 1 of the following year.
For new hires, you will receive an eligibility letter (via email or regular mail) with enrollment instructions. Failure to follow the waiver instructions will result in your auto enrollment in employee only Kaiser Coverage. Auto enrollment will be effective on the first the month following 28 days from your date of hire.
Member Services: 808-432-5955 Website: kp.org
Employee
Employee + Family
Out-of-Pocket Maximum
Employee
Employee + Family
Services
Physician Office Visits
Specialist Office Visits
Preventative
Emergency Services
Hospitalization
Outpatient Services
X-ray and Laboratory Services
Mental health and Substance Abuse – Outpatient Visit
Mental health and Substance Abuse – Inpatient Visit
None
None
$2,500
$7,500
$15 Copay
$15 Copay
No Copay
$75 Copay
$75 Copay
$15 Copay
Contributions**
Employee
Employee + 1 Dependent
Employee + 2 or more Dependents
$0
$210.49
$420.98
KAISER HAWAII MEDICAL HIGHLIGHTS
Your Cost Share Shown Below
Generic
Preferred
$15 Copay
$15 Copay
per day
KAISER HAWAII MEDICAL, DENTAL, AND VISION CONTRIBUTIONS*
*Contributions include Medical, Dental, and Vision
**Your cost per paycheck (pre-tax). For the Kaiser Hawaii plan your benefits become effective on the first of the month following 28 days from your date of hire and you will be responsible for all per paycheck costs for the month. If you become ineligible for the plan, your benefits terminate on the last day of the month in which you become ineligible, and you will be responsible for all per paycheck costs for the month. Benefit costs are NOT prorated.
IF YOU WOULD LIKE TO ENROLL IN THE PLAN, YOU MUST LOG IN TO skechersbenefits.com
10% of applicable charges
$15 Copay
$75 Copay per day
Prescription Drugs (30-Day Supply)
Mail Order Prescription Drugs ( 90-Day Supply)
Generic $30 Copay
Preferred $30 Copay
26 SKECHERS