Page 10 - Volcom Benefit Summary 2019 Hawaii

MEDICAL

KAISER PERMANENTE
Plan Features HMO
Network Kaiser Network
Lifetime Maximum Unlimited
Annual Deductible
Individual None
Family None
Coinsurance (You Pay) 20%
Physician Office Visit
PCP $20 Copay
Specialist $20 Copay
Out-of-Pocket Maximum
Individual $2,500
Family $7,500
Hospitalization
Inpatient 20%
Outpatient Surgery 20%
Laboratory, Imaging and Testing Services
Inpatient $10 Copay
Outpatient 20%
Emergency Services Within and Outside of the Hawaii Service Area 20%
Urgent Care
At a Kaiser Facility Within the Hawaii Service Area $20 Copay
At a Non-Kaiser Facility Outside of the Hawaii Service Area 20%
Preventive Care No Charge
Prescription Drugs
Retail Pharmacy
- Tier 1: Generic Maintenance Medications $3 Copay
- Tier 2: Other Generic Medications $10 Copay
- Tier 3: Brand Name Medications $45 Copay
- Tier 4: Specialty Medications $200 Copay
- Supply Limit 30 Days
Mail Order Pharmacy
- Tier 1: Generic Maintenance Medications $3 Copay
- Tier 2: Other Generic Medications $20 Copay
- Tier 3: Brand Name Medications $90 Copay
- Tier 4: Specialty Medications Not Covered
- Supply Limit 90 Days

H FINDING A MEDICAL PROVIDER:

Login to www.kaiserpermanente.org/hawaii or call (800) 966-5955.

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