Page 22 - ABM 2021 Benefit Guide MGT
P. 22
Kaiser Permanente. If you select a Kaiser Permanente plan, you must use Kaiser Permanente
providers to receive coverage. Under these plans, you will pay the full cost if you go to a non-
Kaiser provider; there is no out-of-network coverage unless your event qualiies as an emergency
or urgent care. If you are visiting another Kaiser region, however, you can receive the same or
similar beneits as your current location. Please go to kp.org/travel for more information. The
coinsurance percentage shown in the chart below represents the amount the team member will
pay toward the cost. See separate lyer for the Washington plan design.
California, Colorado, Georgia, Mid-Atlantic States
(Maryland, Virginia, Washington, DC), Northwest
Standard HMO Value Plan
Calendar Year Deductible
Individual $500 $2,000
Family $1,000 $4,000
Out-of-Pocket Maximum
Individual $5,000 $6,850
Family $10,000 $13,700
Physician Oice Visits
Primary Care $30 First 3 visits —$30 copay
1
Subsequent visits—$30 copay after deductible
Specialist $60 $60 after deductible
Urgent Care CA—$30 CO, GA—$60 copay after deductible
GA—$50 CA—First 3 visits —$30 copay
1
All other states—$60 Subsequent visits—$30 copay after deductible
CA—$60 copay (irst 3 visits)
1
All other states—mirror PCP copay
Wellness/Preventive No charge No charge
Chiropractic Care Beneit varies by state Not covered
Lab Services
Physician Oice Beneit varies by state CA—$10 per encounter
All other states—$30 per encounter
X-Ray/Radiology Services
Physician Oice Beneit varies by state CA—$10 per encounter
All other states—$50 per encounter
MRI/PET/CAT Scans Beneit varies by state 30% after deductible
Hospital Services
Emergency Room 20% after deductible 30% after deductible
Mental Health
Inpatient 20% after deductible 30% after deductible
Outpatient $30 private sessions First 3 visits —$30 copay
1
$15 group sessions Subsequent visits—$30 copay after deductible
Substance Abuse
Inpatient 20% after deductible 30% after deductible
Outpatient $30 private sessions First 3 visits —$30 copay
1
Group Sessions: beneit varies by state Subsequent visits—$30 copay after deductible
Prescription Drugs
Retail—Supply Limit 30 days 30 days
Generic $15 $15
Preferred Brand Drugs $40 $50
Specialty Drugs CO—20% coinsurance up to $250 Mid-Atlantic States—30% up to $150
All other states— applicable Brand or Generic All other states—30% up to 200
copay
Mail Order—Supply Limit CA up to 100 days 90 days available through retail only
All other states—90 days CA—up to 100 days
Generic Beneit varies by state $30
Preferred Brand Drugs Beneit varies by state $100
Specialty Drugs Beneit varies by state Retail only
my.kp.org/ABM for more beneit information.
* Visit
1 Beneits subject to the irst 3 visits are cumulative in CA, CO, and MAS.
22 2021 Benefits Enrollment
providers to receive coverage. Under these plans, you will pay the full cost if you go to a non-
Kaiser provider; there is no out-of-network coverage unless your event qualiies as an emergency
or urgent care. If you are visiting another Kaiser region, however, you can receive the same or
similar beneits as your current location. Please go to kp.org/travel for more information. The
coinsurance percentage shown in the chart below represents the amount the team member will
pay toward the cost. See separate lyer for the Washington plan design.
California, Colorado, Georgia, Mid-Atlantic States
(Maryland, Virginia, Washington, DC), Northwest
Standard HMO Value Plan
Calendar Year Deductible
Individual $500 $2,000
Family $1,000 $4,000
Out-of-Pocket Maximum
Individual $5,000 $6,850
Family $10,000 $13,700
Physician Oice Visits
Primary Care $30 First 3 visits —$30 copay
1
Subsequent visits—$30 copay after deductible
Specialist $60 $60 after deductible
Urgent Care CA—$30 CO, GA—$60 copay after deductible
GA—$50 CA—First 3 visits —$30 copay
1
All other states—$60 Subsequent visits—$30 copay after deductible
CA—$60 copay (irst 3 visits)
1
All other states—mirror PCP copay
Wellness/Preventive No charge No charge
Chiropractic Care Beneit varies by state Not covered
Lab Services
Physician Oice Beneit varies by state CA—$10 per encounter
All other states—$30 per encounter
X-Ray/Radiology Services
Physician Oice Beneit varies by state CA—$10 per encounter
All other states—$50 per encounter
MRI/PET/CAT Scans Beneit varies by state 30% after deductible
Hospital Services
Emergency Room 20% after deductible 30% after deductible
Mental Health
Inpatient 20% after deductible 30% after deductible
Outpatient $30 private sessions First 3 visits —$30 copay
1
$15 group sessions Subsequent visits—$30 copay after deductible
Substance Abuse
Inpatient 20% after deductible 30% after deductible
Outpatient $30 private sessions First 3 visits —$30 copay
1
Group Sessions: beneit varies by state Subsequent visits—$30 copay after deductible
Prescription Drugs
Retail—Supply Limit 30 days 30 days
Generic $15 $15
Preferred Brand Drugs $40 $50
Specialty Drugs CO—20% coinsurance up to $250 Mid-Atlantic States—30% up to $150
All other states— applicable Brand or Generic All other states—30% up to 200
copay
Mail Order—Supply Limit CA up to 100 days 90 days available through retail only
All other states—90 days CA—up to 100 days
Generic Beneit varies by state $30
Preferred Brand Drugs Beneit varies by state $100
Specialty Drugs Beneit varies by state Retail only
my.kp.org/ABM for more beneit information.
* Visit
1 Beneits subject to the irst 3 visits are cumulative in CA, CO, and MAS.
22 2021 Benefits Enrollment
