Page 6 - Volcom Benefit Summary 2017 Hawaii

MEDICAL OPTIONS

KAISER
Plan Features HMO
Network Kaiser Network
Lifetime Maximum Unlimited
Annual Deductible
Individual None
Family None
Coinsurance (You Pay) N/A
Physician Office Visit
PCP $25 Copay
Specialist $25 Copay
Out-of-Pocket Maximum
Individual $2,500
Family $7,500
Hospitalization
Inpatient $150 Copay per Day
Outpatient Surgery $25 Copay
Laboratory, Imaging and Testing Services
Inpatient No Charge
Outpatient 20%
Emergency Services 20%
Urgent Care
At a Kaiser Facility within the Hawaii Service Area $25 Copay
At a Non-Kaiser Facility Outside of the Hawaii Service Area 20%
Preventive Care No Charge
Prescription Drugs
Retail Pharmacy
- Tier 1: Generic Maintenance Medications $3 Copay
- Tier 2: Other Generic Medications $10 Copay
- Tier 3: Brand Name Medications $45 Copay
- Tier 4: Specialty Medications $200 Copay
- Supply Limit 30 Days
Mail Order Pharmacy
- Tier 1: Generic Maintenance Medications $6 Copay
- Tier 2: Other Generic Medications $20 Copay
- Tier 3: Brand Name Medications $90 Copay
- Tier 4: Specialty Medications $400 Copay
- Supply Limit 90 Days

H FINDING A MEDICAL PROVIDER:
Login to www.kaiserpermanente.org or call (808) 432-5955 (Oahu) or (800) 966-5955 (Neighboring
Islands).

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