Page 7 - 2021 Sample Benefit Booklet
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MEDICAL COVERAGE

         Kaiser Permanente


         ABC Group offers three comprehensive health plans, a Bronze and a Gold plan, through Kaiser Per- manente,
         and a Bronze plan through Sutter Health Plus. ABC Group will contribute 100% of the em- ployee cost
         towards the Bronze plans through Kaiser or Sutter Health Plus. Employees are responsible for paying the cost
         of their dependents. We will fund up to $4,000 of your out of pocket expenses incurred under the Kaiser or
         Sutter Health Plus Bronze plans for employees. Another $1,000 will be added for those covering dependents
         ($5,000 total). The funding for these out of pocket expenses will be provided through a Visa debit card
         administered by Administrative Solutions Inc (ASi). Please refer to the Bronze benefit summaries for more
         details.

                                                 Kaiser Permanente—Bronze 60 HDHP HMO 6900/0 Plan (BasePlan)

                  Plan Features               Bronze 60 HDHP HMO6900/0                   ABC Group Funding

         Annualdeductible                 $6,900 per individual/$13,800 per family  $2,000 per individual/$4,000 perfamily

         Annual Out‐of‐Pocket maximum     $6,900 per individual/$13,800 per family  $2,000 per individual/$4,000 perfamily

         Lifetimemaximum                                                 Unlimited
         Medical Benefits                                              What you pay

         Doctor’s Office Visits                             After $2,000 individual/$4,000 family BB Funds
                                                         0% after $4,900 individual/$9,800 family maximum
                                                          After $2,000 individual/$4,000 family BB Funds
         Specialists Office Visits
                                                        0% after $4,900 individual/$9,800 family maximum

         Preventive Care
         (includes x‐ray &lab)                                        Covered at 100%

         X‐Ray and LaboratoryServices                     After $2,000 individual/$4,000 family BB Funds
                                                         0% after $4,900 individual/$9,800 family maximum

         Prescription DrugBenefits


         Retail (30‐day supply)                           After $2,000 individual/$4,000 family BB Funds
         Generic & FormularyBrands                      0% after $4,900 individual/$9,800 family maximum

         HospitalBenefits
                                                          After $2,000 individual/$4,000 family BB Funds
         InpatientHospitalization                        0% after $4,900 individual/$9,800 family maximum

         Mental Health/Substance Abuse

                                                          After $2,000 individual/$4,000 family BB Funds
         Inpatient/Outpatient Services                   0% after $4,900 individual/$9,800 family maximum



                                                          After $2,000 individual/$4,000 family BB Funds
         Emergency Room Copay                           0% after $4,900 individual/$9,800 family maximum




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