Page 7 - Oremor EE Guide 01-18_FINAL1
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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
         Lifetime Maximum Benefit                   Unlimited
                                                                            medical plan and you can be added to their
         Deductible (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                                                 stipulations.
          - 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
         Hospitalization                                                    medical  plan  and  elect  the  HRA  Supplemental
          - Inpatient                           $500 Copay per Day          Medical Plan. The maximum reimbursement for
                                                                            medical  expenses is up to $2,000 per calendar
          - Outpatient                         $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
         Preventive Care                            No Charge
                                                                            be  forfeited  and  you  will  have  up  to  90  days
         Physical Therapy / Physical                $20 Copay               after  your  ineligibility  date  to  submit  for  reim‐
         Medicine & Occupational                                            bursement. Please complete the benefits enroll‐

         Therapy / Speech Therapy                                           ment form and the HRA Supplemental Medical
                                                                            Plan notice 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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