Page 6 - Column Five EE Guide 12-19 -California

BENEFITS

Medical Insurance

Kaiser Permanente Kaiser Permanente
Plan Name Silver 70 HMO 1000/55 Gold 80 HMO 0/30
Network Name Kaiser Facilities Only Kaiser Facilities Only

Health Benefits
Virtual Visits
When you don’t feel well, or Lifetime Maximum Unlimited Unlimited
your child is sick, the last thing Deductible (Annual)
you want to do is leave the - Individual $1,000 $0
comfort of home to sit in a - Family $2,000 $0
waiting room. Now you don’t
have to. Out-of-Pocket Maximum
- Individual $7,550 $7,200
- Family $15,100 $14,400
Virtual Visits allow you see and
talk to a doctor from your Co-Insurance (Plan Pays) 100% 100%
mobile device or computer
without an appointment. Most Office Visit Copay
visits take about 10-15 minutes - Preventive Care No Charge No Charge
- Primary Care Physician $55 Copay $30 Copay
and doctors can write a
- Specialist Office Visit $75 Copay $55 Copay
prescription, if needed, that you
can pick up at your local - Urgent Care $55 Copay $30 Copay
pharmacy. Use this service for - Virtual Visits $0 Copay $0 Copay
minor issues such as colds, Hospitalization
fever, flu, allergies, soar throats, - Inpatient Deductible, 35% $600/Day Max 5 days
headache, stomach ache and - Outpatient Surgery Deductible, 35% $340 Copay
more. This service is part of
your health benefits offered Lab and X-Ray
through Kaiser Permanente and - Diagnostic $50-$70 Copay $35-$55 Copay
- Complex Deductible, $350 Copay $275 Copay
Anthem Blue Cross.
Emergency Services Deductible, 35% $325 Copay
Kaiser Permanente
Quickly and easily make your Chiropractic $15 Copay Not covered
video visits online or via the 20 Visits/Year
Kaiser Permanente mobile app. Pharmacy Benefits
You must be registered on
Kaiser’s website to take Pharmacy Deductible Waived for generics
advantage of this service. - Individual $250 $0
www.kaiserpermanente.org - Family $500 $0

Retail (30 Day Supply)
Anthem Blue Cross - Generic Formulary $30 Copay $15 Copay
Signing up is quick, easy, and - Brand Name Formulary $75 Copay $55 Copay
- Non-Formulary $75 Copay $55 Copay
free to do. Be sure to enter
- Specialty 20% Max $250 Copay 20% Max $250 Copay
your insurance information
since LiveHealth Online is a Mail Order (100 Day Supply)
covered benefit under our - Generic Formulary $60 Copay $30 Copay
Anthem plans. - Brand Name Formulary $150 Copay $110 Copay
www.livehealthonline.com - Non-Formulary $150 Copay $110 Copay
- Specialty 20% Max $250 Copay 20% Max $250 Copay

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