Page 7 - 2016 Enrollment
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7
Kaiser Permanente Health Plan
Let’s take a look at the key features of each plan.
Kaiser HMO
Network
Calendar Year Deductible
None
Out-of-Pocket Maximum
Individual $1,500
Family $3,000
Physician Ofice Visits
Primary care $20 copay
Specialist $35 copay
Preventive Care
Coverage level 100% covered
Hospital Services
Inpatient $250 per admittance
Outpatient $35 per procedure
Emergency room $100 per visit
Urgent care $20 copay
Prescription Drugs
Retail supply limit 30 days
Generic $10 copay
Brand $35 copay
Self-injectables Varies by drug
Mail order supply limit 90 days
Generic $20 copay
Brand $70 copay
Self-injectables Not covered
Please refer to your Summary Plan Description (SPD) for complete details of plan beneits,
limitations, and exclusions. In the event of a conlict between the SPD and this description, the
terms of the SPD will prevail.
2016 New Hire Enrollment
Kaiser Permanente Health Plan
Let’s take a look at the key features of each plan.
Kaiser HMO
Network
Calendar Year Deductible
None
Out-of-Pocket Maximum
Individual $1,500
Family $3,000
Physician Ofice Visits
Primary care $20 copay
Specialist $35 copay
Preventive Care
Coverage level 100% covered
Hospital Services
Inpatient $250 per admittance
Outpatient $35 per procedure
Emergency room $100 per visit
Urgent care $20 copay
Prescription Drugs
Retail supply limit 30 days
Generic $10 copay
Brand $35 copay
Self-injectables Varies by drug
Mail order supply limit 90 days
Generic $20 copay
Brand $70 copay
Self-injectables Not covered
Please refer to your Summary Plan Description (SPD) for complete details of plan beneits,
limitations, and exclusions. In the event of a conlict between the SPD and this description, the
terms of the SPD will prevail.
2016 New Hire Enrollment
