Page 8 - Covered 6 Employee Benefits 2021-2022
P. 8
Kaiser Medical Plans
Deductible 5500 HMO (BASE PLAN)*
Deductible:
Individual $5,500
Family $11,000
Annual Out of Pocket
Maximum:
Individual $6,850
Family $13,700
Hospital Services:
Inpatient 40% coinsurance**
Outpatient Surgery 40% coinsurance**
Emergency Room 40% coinsurance**
Physician Services***:
Office Visit
(PCP/Specialist) $50 / $50
Urgent Care $50
Preventive Care: No charge
Prescription Drugs:
Generic $15 for a 30-day supply**
Brand Name 40% coinsurance not to exceed $100**
Specialty 40% coinsurance not to exceed $200**
*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
***Deductible waived for first three visits combined for non-preventive primary care, urgent care,
mental/behavioral health and substance use disorder outpatient services.
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