Page 6 - PLM Benefit Guide 4-2018 Final

Medical Benefits

Kaiser Permanente Kaiser Permanente Blue Shield
Gold 80 HMO 0/25 GF $30/$1500 Silver Access+ HMO
Deductible HMO 1750/55 OffEx
Kaiser Only Kaiser Only Access+ Network

Health Benefits

Lifetime Maximum Benefit Unlimited Unlimited Unlimited
Deductible (Annual)
 Individual None $1,500 $1,750
 Family None $3,000 $3,500
Coinsurance (You Pay) N/A N/A 40%
Office Visit Copay
 Primary Care Physician $25 Copay $30 Copay $55 Copay
 Specialist Office Visit $55 Copay $30 Copay $85 Copay

Out-of-Pocket Maximum
 Individual $6,000 $3,500 $7,000
 Family $12,000 $7,000 $14,000
Hospitalization
 Inpatient $600 Copay/Day (5 Day Max) Ded, $500 Copay/Day Ded, 40%
 Outpatient $340 Copay Ded, $250 Copay Ded, 40%

Lab and X-Ray (Complex) $35/$55 Copay ($275 Copay) Ded, $10 Copay ($50 Copay) $55/$75 Copay ($75 Copay)
- Outpatient Hospital $350 Copay
Emergency Services $325 Copay Ded, $100 Copay Ded, 40%

Urgent Care $25 Copay $30 Copay $55 Copay
Preventive Care No Charge No Charge No Charge
Chiropractic Not Covered Not Covered $15 Copay
(15 Visits/Year)
Pharmacy Benefits

Pharmacy Deductible
 Individual None None None
 Family None None None
Retail Pharmacy
 Tier 1 $15 Copay $10 Copay $15 Copay
 Tier 2 $55 Copay $30 Copay $55 Copay
 Tier 3 $55 Copay $30 Copay $75 Copay
 Supply Limit 30 Days 30 Days 30 Days

Mail Order Pharmacy
 Tier 1 $30 Copay $20 Copay $30 Copay
 Tier 2 $110 Copay $60 Copay $110 Copay
 Tier 3 $110 Copay $60 Copay $150 Copay
 Supply Limit 100 Days 100 Days 90 Days

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