Page 9 - BOC 2021 Benefits Booklet

MEDICAL INSURANCE

Kaiser HMO
Group Number: 602290
Plan: $30 HMO Traditional Plan

Benefits Member Pays

Individual/Family Deductible None
Individual/Family Out of Pocket Max $3,000/$6,000
Primary Care Physician Office Visits $30 copay
Specialists Office Visits $30 copay
Lab & X-ray – Basic $10 copay
(per encounter)
Lab & X-ray – Complex $50 copay
(i.e. MRI, MRA, PET, CT) (per procedure)
Emergency Room: $150 copay (waived if admitted)
Inpatient Hospital – Room/Board $500 per day
Inpatient Professional Services $500 per day
Outpatient Surgery: $250 copay per procedure
(Freestanding Surgical Facility)
Maternity – Office Visit copay: $30 copay
Maternity – Hospital: See Hospitalization

Well Baby Care: No Charge
$10 copay
Chiropractic Care: (30 visits per calendar year)

Prescription Drugs Participating Pharmacy

Generic: $10 copay
Brand Name $30 copay

Questions?

Member Services: 800-464-4000
Website: www.kp.org

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