Page 7 - Ria Benefits Guide 2020 FINAL CO
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Medical Plan Choices (HMO)
Kaiser Permanente
Plan Name HMO
Health Benefits
Lifetime Maximum Unlimited
Deductible (Annual)
- Individual $0
- Family $0
Out-of-Pocket Maximum
- Individual $3,000
- Family $6,000
Co-Insurance (Plan Pays) 100%
Office Visit Copay
- Preventive Care No Charge
- Primary Care Physician $30 Copay
- Specialist Office Visit $40 Copay
- Urgent Care $40 Copay
- Telemedicine $0 Copay
Hospitalization
- Inpatient $500 per admission
- Outpatient $400 Copay
Lab and X-Ray
- Diagnostic No Charge
- Complex $50 Copay
Emergency Services $150 Copay
Chiropractic none
Pharmacy Benefits
Pharmacy Deductible
- Individual / Family None
(waived for generics)
Retail Pharmacy
- Generic Formulary $15 Copay
- Brand Name Formulary $30 Copay
- Non-Formulary $30 Copay
- Supply Limit 30 Days
Mail Order Pharmacy
- Generic Formulary $30 Copay
- Brand Name Formulary $60 Copay
- Non-Formulary $60 Copay
- Supply Limit 90 Days
Employee contribution per pay date Kaiser Permanente
HMO
- Employee $60.00
- Employee + spouse $315.00
- Employee + child(ren) $305.00
- Employee + family $445.00
RIA EMPLOYEE BENEFITS 2020 7
