Page 9 - Eden Housing 2022 Benefit Guide

Kaiser Medical Plan Comparison

Kaiser Traditional HMO Kaiser HDHP HMO
Plan Features In-Network
In-Network
Only

1
Calendar Year Deductible None $1,400 / $2,800
Individual/Family

Calendar Year
2
Out-of-Pocket Maximum $1,500 / $3,000 $3,000 / $6,000
Individual/Family
You pay: You pay:
Preventive Care Visit Covered in full Covered in full
Primary Care Visit $20 copay $20 after deductible
Specialist Visit $20 copay $20 after deductible
Lab & X-ray $10 copay $10 after deductible
Emergency Room $100 copay $100 after deductible
(copay waived if admitted)
Urgent Care $20 copay $20 after deductible
Outpatient Services $20 copay $150 after deductible
Inpatient Services No Charge $250 after deductible
Chiropractic
& Acupuncture $10 copay Not Covered
(30 visits per year combined)
Prescription Drugs
$10 copay
Generic (30-day) $10 after deductible
$0 for Preventative
Brand-name (30-day) $25 copay $30 after deductible
20% (not exceed $250) after
Specialty (30-day) 20% (not exceed $150) deductible

Generic (100-day) $20 copay $20 after deductible

Brand-name (100 -day) $50 copay $60 after deductible

This chart provides a brief overview of benefits and coverage. Refer to the detailed summary plan documents for
questions about a specific procedure, service, or provider. In the event of a conflict, the official plan documents prevail.

Save Time and Money with the Mail Order Program
Using the mail order program to fill your maintenance medication saves you both time and
money. You’ll receive a 100-day supply delivered right to your door (with free shipping).

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