Page 14 - ABM 2021 Benefit Guide AMPCO
P. 14
KAISER PERMANENTE
If you select a Kaiser Permanente plan, you California, Colorado, Georgia, Mid-Atlantic States
must use Kaiser Permanente providers to (Maryland, Virginia, Washington, DC), Northwest
Standard HMO
receive coverage. Under these plans, you Calendar Year Deductible
will pay the full cost if you go to a non-Kaiser Individual $0
provider; there is no out-of-network coverage Family $0
Out-of-Pocket Maximum
unless your event qualiies as an emergency or Individual $3,000
urgent care. If you are visiting another Kaiser Family $6,000
region, however, you can receive the same or Physician Oice Visits
similar beneits as your current location. Please Primary Care $25
$50
Specialist
go to kp.org/travel for more information. The Urgent Care $25
coinsurance percentage shown in the chart Wellness/Preventive No charge
below represents the amount the team member Chiropractic Care Not covered
Lab Services
will pay toward the cost. Physician Oice $10 per encounter
X-Ray/Radiology Services
Physician Oice $10 per encounter
MRI/PET/CAT Scans $50 per encounter
Hospital Services
Emergency Room $150 (waived if admitted)
Mental Health
Inpatient $500 per day
Outpatient $25 private sessions
$12 group sessions
Substance Abuse
Inpatient $500 per day
Outpatient $25 private sessions
$5 group sessions
Prescription Drugs
Retail—Supply Limit 30 days
Generic $10
Preferred Brand Drugs $30
Specialty Drugs $30
Mail Order—Supply Up to 100 days
Limit
Generic $20
Preferred Brand Drugs $60
Specialty Drugs $60
14 2021 Benefits Enrollment
If you select a Kaiser Permanente plan, you California, Colorado, Georgia, Mid-Atlantic States
must use Kaiser Permanente providers to (Maryland, Virginia, Washington, DC), Northwest
Standard HMO
receive coverage. Under these plans, you Calendar Year Deductible
will pay the full cost if you go to a non-Kaiser Individual $0
provider; there is no out-of-network coverage Family $0
Out-of-Pocket Maximum
unless your event qualiies as an emergency or Individual $3,000
urgent care. If you are visiting another Kaiser Family $6,000
region, however, you can receive the same or Physician Oice Visits
similar beneits as your current location. Please Primary Care $25
$50
Specialist
go to kp.org/travel for more information. The Urgent Care $25
coinsurance percentage shown in the chart Wellness/Preventive No charge
below represents the amount the team member Chiropractic Care Not covered
Lab Services
will pay toward the cost. Physician Oice $10 per encounter
X-Ray/Radiology Services
Physician Oice $10 per encounter
MRI/PET/CAT Scans $50 per encounter
Hospital Services
Emergency Room $150 (waived if admitted)
Mental Health
Inpatient $500 per day
Outpatient $25 private sessions
$12 group sessions
Substance Abuse
Inpatient $500 per day
Outpatient $25 private sessions
$5 group sessions
Prescription Drugs
Retail—Supply Limit 30 days
Generic $10
Preferred Brand Drugs $30
Specialty Drugs $30
Mail Order—Supply Up to 100 days
Limit
Generic $20
Preferred Brand Drugs $60
Specialty Drugs $60
14 2021 Benefits Enrollment
