Page 7 - Ria Benefits Guide 2020 FINAL Mid-Atlantic
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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 $2,000
- Family $4,000
Co-Insurance (Plan Pays) 100%
Office Visit Copay
- Preventive Care No Charge
- Primary Care Physician $20 Copay
- Specialist Office Visit $20 Copay
- Urgent Care $20 Copay
- Telemedicine $0 Copay
Hospitalization
- Inpatient No Charge
- Outpatient $50 Copay
Lab and X-Ray
- Diagnostic No Charge
- Complex $50 Copay
Emergency Services $75 Copay
Chiropractic $20 (20 visits)
Pharmacy Benefits
Pharmacy Deductible
- Individual / Family None
(waived for generics)
Retail Pharmacy
- Generic Formulary $15 Copay
- Brand Name Formulary $25 Copay
- Non-Formulary $40 Copay
- Supply Limit 30 Days
Mail Order Pharmacy
- Generic Formulary $30 Copay
- Brand Name Formulary $50 Copay
- Non-Formulary $80 Copay
- Supply Limit 90 Days
Employee contribution per pay date Kaiser Permanente
HMO
- Employee $55.00
- Employee + spouse $275.00
- Employee + child(ren) $225.00
- Employee + family $385.00
RIA EMPLOYEE BENEFITS 2020 7
