Page 9 - Covered 6 Employee Benefits 2021-2022
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Kaiser Medical Plans
HSA HDHP 2000 HMO*
Deductible:
Individual $2,000
Family $4,000
Individual within a family $2,800
Annual Out of Pocket
Maximum:
Individual $3,500
Family $7,000
Individual within a family $3,500
Hospital Services:
Inpatient $250 per admission**
Outpatient Surgery $150 per procedure**
Emergency Room $100 per visit**
Physician Services:
Office Visit
(PCP/Specialist) $30** / $30**
Urgent Care $30**
Preventive Care: No charge
Prescription Drugs:
Generic $10 for a 30-day supply**
Brand Name $30 for a 30-day supply**
Specialty 20% 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
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