Page 10 - Covered 6 Employee Benefits 2021-2022
P. 10
Kaiser Medical Plans
Deductible 1500 HMO*
Deductible:
Individual $1,500
Family $3,000
Annual Out of Pocket
Maximum:
Individual $4,000
Family $8,000
Hospital Services:
Inpatient 30% coinsurance**
Outpatient Surgery 30% coinsurance**
Emergency Room 30% coinsurance**
Physician Services:
Office Visit
(PCP/Specialist) $40 / $40
Urgent Care $40
Preventive Care: No charge
Prescription Drugs:
$10 for a 30-day supply
Generic
Brand Name $30 for a 30-day supply
20% coinsurance not to exceed $200
Specialty
*Please refer to carrier benefit summaries for more detailed information. Should there be a
discrepancy between this booklet and the provisions of the insurance contracts or plan documents,
the provisions of the insurance contracts or plan documents will govern
**Deductible must be satisfied first
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