Page 7 - Oremor EE Benefits Guide 01-19.pub

Benefits

Kaiser Permanente HRA Supplemental Medical Plan
Plan Name HMO
A Health Reimbursement Arrangement (HRA) is
Network Name Network a health benefit plan that reimburses employees
Health Benefits for out of pocket medical expenses. This may
save you money if your Spouse has an employer
Life me Maximum Benefit Unlimited
medical plan and you can be added to their
Deduc ble (Annual) plan. The reimbursed medical expenses may be
‐ Individual none incurred by you, your spouse, or your eligi‐
‐ Family Limit none ble dependents as long you are enrolled in the
HRA plan. A qualified medical expense is subject
Co‐Insurance (Plan Pays) 100%
to the medical plan provisions as well as IRS
Office Visit Copay s pula ons.
‐ Primary Care Physician $20 Copay
‐ Specialist Office Visit $20 Copay ELIGIBILITY
In order to qualify for the HRA Supplemental
Out‐of‐Pocket Maximum Medical Plan, the Employee will need to be en‐
‐ Individual $3,000 rolled on Oremor’s medical plan for 12 months.
‐ Family Limit $6,000
He or She must elect to waive the Oremor’s
Hospitaliza on medical plan and elect the HRA Supplemental
‐ Inpa ent $500 Copay per Day Medical Plan. The maximum reimbursement for
medical expenses is up to $2,000 per calendar
‐ Outpa ent $250 Copay/Procedure year. You may roll over your unused balance to
the next plan year, however, the dollars will
stop accruing at the end of the second year. The
Emergency Services $150 Copay
max amount of accrual for the HRA Supple‐
Urgent Care $20 Copay mental Medical Plan is $4,000. In the event you
leave the company, the remaining balance will
Preven ve Care No Charge
be forfeited and you will have up to 90 days
Physical Therapy / Physical $20 Copay a er your ineligibility date to submit for reim‐
Medicine & Occupa onal bursement. Please complete the benefits enroll‐

Therapy / Speech Therapy ment form and the HRA Supplemental Medical
Plan no ce for plan enrollment.
Pharmacy Benefits
HOW TO SUBMIT A CLAIM
Specialty Out‐of‐Pocket Maximum
‐ Individual N/A
‐ Family N/A
Retail Pharmacy
‐ Generic Formulary $15 Copay
‐ Brand Name Formulary $30 Copay
‐ Non‐Formulary N/A
‐ Specialty 30% Max $200
‐ Supply Limit 30 Days
Mail Order Pharmacy
‐ Generic Formulary $30 Copay
‐ Brand Name Formulary $60 Copay
‐ Non‐Formulary N/A
‐ Specialty N/A 
‐ Supply Limit 90 Days

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