Page 7 - Oremor EE Guide 01-17_Updated 11.17.16

Benefits

Medical Insurance

Kaiser Permanente Summary of Benefits and
Plan Name HMO Coverage (SBC)
Network Name Network Health insurance issuers and group health plans
are required to provide you with an easy‐to‐
Health Benefits understand summary about your health plan’s
Life me Maximum Benefit Unlimited benefits and coverage, referred to as a
Summary of Benefits and Coverage (SBC). This
Deduc ble (Annual)
guide is designed to help you understand the
‐ Individual none medical plan op ons offered to you by OREMOR
‐ Family Limit none Automo ve Group. Please refer to the SBC and
Co‐Insurance (Plan Pays) 100% carrier contracts provided by Anthem Blue Cross
and Kaiser Permanente for addi onal plan
Office Visit Copay
details.
‐ Primary Care Physician $20 Copay
‐ Specialist Office Visit $20 Copay
HRA Supplemental Medical Plan
Out‐of‐Pocket Maximum
‐ Individual $3,000 ELIGIBILITY
‐ Family Limit $6,000 In order to qualify for the HRA Supplemental
Medical Plan, the Employee will need to be en‐
Hospitaliza on rolled on Oremor’s medical plan for 12 months.
‐ Inpa ent $500 Copay per Day
He or She must elect to waive the Oremor’s
‐ Outpa ent $250 Copay/Procedure medical plan and elect the HRA Supplemental
Medical Plan. The maximum reimbursement for

medical expenses is up to $2,000 per calendar
Emergency Services $150 Copay year. You may roll over your unused balance to
the next plan year, however, the dollars will
Urgent Care $20 Copay
stop accruing at the end of the second year. The
Preven ve Care No Charge max amount of accrual for the HRA Supple‐
mental Medical Plan is $4,000. In the event you
Physical Therapy / Physical $20 Copay leave the company, the remaining balance will
Medicine & Occupa onal
be forfeited. Please complete the benefits en‐
Therapy / Speech Therapy
rollment form and the HRA Supplemental Medi‐
cal Plan no ce for plan enrollment.
Pharmacy Benefits
Specialty Out‐of‐Pocket Maximum HOW TO SUBMIT A CLAIM
‐ Individual N/A Once you have incurred a qualified medical expense
‐ Family N/A under your Spouse’s employer medical plan:
 Provide an itemized statement with provider
Retail Pharmacy
name, date of service, descrip on of service and
‐ Generic Formulary $15 Copay
‐ Brand Name Formulary $30 Copay pa ent por on of charges. NOTE: you will find
‐ Non‐Formulary N/A this on an Explana on of Benefits (EOB) state-
‐ Specialty 30% Max $200  ment or copay receipts from the physician office.
‐ Supply Limit 30 Days Unacceptable Forms of Documenta on: credit/
cash statements, cancelled checks, balance for‐
Mail Order Pharmacy ward statements (i.e. super bills, etc.)
‐ Generic Formulary $30 Copay  Submit documenta on and claim form to EBAM.
‐ Brand Name Formulary $60 Copay You can request a claim form from the Benefits
‐ Non‐Formulary N/A
Department.
‐ Specialty N/A 
‐ Supply Limit 90 Days EBAM will send a reimbursement check to the
mailing address provided.

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