A BETTER WAY to take care of business OREGON 2016 For Oregon groups with 101 or more employees Product portfolio 50LBG-15/9-15 All plans offered and underwritten by Kaiser Foundation Health Plan of the Northwest. 500 NE Multnomah St., Suite 100, Portland, OR 97232.
OVERVIEWS TRADITIONAL S Our sensible approach to health care has benefited individuals and families in the Northwest for more than 65 years. Employees will pay simple s for most services when they come in for care. Most preventive services are provided at no additional charge. There are no claim forms or s to worry about. S To help balance the needs of businesses and their employees, we offer multiple plans with various s, coinsurance levels, s, and out-of-pocket maximums. Employees will pay simple s for most outpatient visits, and preventive services are provided at no additional charge. Employers can choose the plans that best meet their needs, whether the overall goal is to keep employee costs down or reduce premiums. These plans may also be paired with a Kaiser Permanente health reimbursement arrangement (HRA) or flexible spending account (FSA). ADDED CHOICE S Would you like to give your employees the opportunity to keep their current doctor or the option of seeing any licensed provider for covered services at any time? Do you have employees who travel for extended periods and need access to routine care? Only Kaiser Permanente offers the option to see any licensed provider across the nation for covered services along with exclusive access to our Select Providers and Select Facilities. Go to a Select Provider or Select Facility and receive quality integrated care at an affordable price. Go to a Select Provider or Select Facility and receive preventive care at no additional charge.* Go to a PPO provider or facility anywhere in the nation and receive covered services with higher s and coinsurance. Kaiser Permanente has partnered with First Choice Health to provide an extensive PPO network for our members. Go to any other non-participating provider or facility nationwide for covered services. Since these providers are not contracted with us, they may require payment in advance of or at the time services are rendered. They may also be unwilling to bill us on the member s behalf. We ll reimburse for covered services paid by members at the allowed amount (less applicable coinsurance) once they ve satisfied their. Added Choice may also be paired with a Kaiser Permanente HRA or FSA. With Added Choice, employees choose their own best balance among cost, choice, and coverage! KAISER PERMANENTE'S INTEGRATED CONSUMER- DIRECTED CARE OFFERINGS Consumer engagement meets Kaiser Permanente's high-quality care HSA-QUALIFIED HIGH S We combine the cost savings of a high health plan with a collaborative approach to care that helps keep employees healthier and more productive at work and at home. Helping prevent issues before they start, most preventive services are provided at no additional charge and are not subject to the. HSA-qualified plans may be paired with a Kaiser Permanente HSA, HRA, or FSA. KAISER PERMANENTE HEALTH PAYMENT SERVICES With consumer-directed health care HRAs, HSAs, and FSAs you can have workers who are more fully engaged in maintaining their health. Our integrated offering blends one of the nation s most experienced consumer-directed health care administrators with the high-quality integrated care that sets Kaiser Permanente apart. You pick the plan design from a wide range of s, copays, and coinsurance. Your employees will be encouraged to participate in managing their personal and financial health. With Kaiser Permanente s integrated solution, your employees can access their plan information and their health information right from their desktop or mobile device. You get: Comprehensive administrative support. Multiple account-funding options. Easy transition to a Kaiser Permanente consumerdirected plan. Online enrollment and eligibility management. A customizable employee portal. Reports and notifications delivered to you automatically. Your employees get: A single Kaiser Permanente health payment card that works for HRAs, individual HSAs, and FSAs as well as stacked FSA/HRA accounts. Ability to access all accounts, manage their personal health information, and file financial account claims just by signing on to kp.org. Real-time transaction information. Live phone support. * Members who live and work outside our service area may be eligible to receive preventive care at no additional cost through the PPO network. Allowed amount: See your Evidence of Coverage (EOC) for complete details. 2
Kaiser Permanente Health Payment Services Financial Account Pairing Options Take advantage of Kaiser Permanente s integrated consumer-directed health care offerings by choosing the health plan and financial arrangement that works for you. All Kaiser Permanente plans may be paired with HRAs, FSAs, and stacked FSA/HRA accounts. Kaiser Permanente s HSA-qualified high health plans may be paired with any of the above, in addition to HSAs. MEDICAL FINANCIAL ACCOUNT 1 HRA HSA FSA Stacked FSA/HRA Limited Purpose HRA 3 NA 2 HSA-QUALIFIED HIGH HEALTH (HDHP) ADDED CHOICE NA 2 HSA-QUALIFIED ADDED CHOICE TRADITIONAL NA NA 2 NA NA 1 All financial account options above are subject to IRS 213d rules for reimbursement and are supported by a Kaiser Permanente Health Payment Card. 2 HSA may only be paired with an HSA-qualified plan per U.S. Treasury guidelines. Additional financial accounts may affect HSA tax-exempt status. 3 Limited purpose HRA is available for dental, vision hardware, or pharmacy services. Additional financial account options are available. Please contact your broker or sales associate for more information on Kaiser Permanente s plan designs for groups with 101 or more employees. 3
HIGHLIGHTS FOR TRADITIONAL COPAYMENT S OPTIONS Plan B Plan C Plan D Plan E Plan F Plan G Plan H Plan J Plan K BENEFIT/ FEATURE* (PER CALENDAR YEAR) OFFICE VISITS PRIMARY SPECIALTY CARE OFFICE VISITS URGENT CARE PREVENTIVE AND WELL- CHILD CARE AND PREVENTIVE SERVICES INPATIENT HOSPITAL CARE EMERGENCY CARE OUTPATIENT SURGERY LABS, X-RAYS, AND SPECIAL DIAGNOSTIC PROCEDURES CT, MRI, AND PET SCANS OUT-OF- POCKET MAXIMUM Member pays Member pays Member pays Member pays Member pays Member pays Member pays Member pays $0 $0 $0 $0 $0 $0 $0 $0 $0 $10 $20 $30 $10 $20 $30 $15 $25 $35 $15 $25 $35 $20 $30 $40 $20 $30 $40 $25 $35 $45 $30 $40 $0 $0 $0 $0 $0 $0 $0 $0 $0 per day, up to $250 per admission $200 $20 $10 per visit $600 individual, $1,200 per day, up to 0 per admission $200 $10 per visit $600 individual, $1,200 per day, up to $250 per admission $200 $20 $15 per visit $600 individual, $1,200 $200 per day, up to $1,000 per admission $200 $15 per visit individual, per day, up to 0 per admission $200 $20 per visit $1,000 individual, $2,000 $200 per day, up to $1,000 per admission $200 $20 per visit individual, 0 per admission $200 $75 $25 per visit individual, $750 per admission $200 $30 per visit $2,000 individual, $4,000 Member pays $35 $45 $60 $800 per admission $200 $150 $35 per visit individual, $6,000 These plans are subject to exclusions and limitations. A complete list of the exclusions and limitations is included In the Evidence of Coverage (EOC). To obtain a copy of the EOC, call the Client Services Unit at 1-866-246-3613 (toll free). * These plans include limited coverage for dependent children outside the Kaiser Foundation Health Plan of the Northwest service area. For covered services, the member pays 20 percent of the actual fee. Services are limited to 10 office visits, 10 diagnostic labs or X-rays, and 10 prescription drug fills. For specific plan information, see the following form: EOLGTRAD0116 4
SUPPLEMENTAL BENEFIT OPTIONS FOR TRADITIONAL AND S SUPPLEMENTAL BENEFITS Below are just a few of many options available with a medical plan. Contact your sales executive or account manager for more information. Outpatient prescription drugs The Kaiser Permanente formulary applies to all plans. Members get up to a 30-day supply for each (up to a 90-day supply of maintenance drugs for two s when our Mail-Delivery Pharmacy is used). 1 All of these plans, except the $15/50%, are Medicare Part D creditable. View our formulary at kp.org/formulary. Options Member pays $10/$20/$40/$150 $10 for generic, $20 for preferred brand-name drug, $40 for non-preferred brand-name drug, $150 for specialty drugs $10/$20/$40 $10 for generic, $20 for preferred brand-name drug, $40 for non-preferred brand-name drug $10/$30/50% /50% $150 $10 for generic, $30 for preferred brand-name drug, 50% up to for non-preferred brand-name drug, 50% up to $150 for specialty drugs $10/$30/50% $10 for generic, $30 for preferred brand-name drug, 50% up to for non-preferred brand-name drug $10/$30/$45 $10 for generic, $30 for preferred brand-name drug, $45 for non-preferred brand-name drug $15/$30/50% $200 $15 for generic, $30 for preferred brand-name drug, 50% up to $200 for non-preferred brand-name drug $15/$30//$150 $15 for generic, $30 for preferred brand-name drug, for non-preferred brand-name drug, $150 for specialty drugs $15/$30/ $15 for generic, $30 for preferred brand-name drug, for non-preferred brand-name drug $20/$40/$60/$150 $20 for generic, $40 for preferred brand-name drug, $60 for non-preferred brand-name drug, $150 for specialty drugs $20/$40/$60 $20 for generic, $40 for preferred brand-name drug, $60 for non-preferred brand-name drug Note: Prescription drug cost shares apply to the medical out-of-pocket maximum. 1 Specialty drugs are provided at one copay (or one maximum) for a 30-day supply. Chiropractic care* Self-referred chiropractic care is available through The CHP Group approved network providers in the Kaiser Foundation Health Plan of the Northwest service area. Visit chpgroup.com for a list of providers. Alternative care (includes chiropractic care)* Self-referred alternative care without prior authorization is available for chiropractic, naturopathic, acupuncture, and mesage therapy from The CHP Group network providers in our service area. Annual benefit maximums of 0, $1,000, or. Visit chpgroup.com for a list of providers. Options Member pays $10 $10 per chiropractic, acupuncture, or naturopathic visit; $25 per massage therapy visit for up to 12 visits per year $15 $15 per chiropractic, acupuncture, or naturopathic visit; $25 massage therapy visit for up to 12 visits per year. $20 $20 per chiropractic, acupuncture, or naturopathic visit; $25 per massage therapy visit for up to 12 visits per year $25 $25 per chiropractic, acupuncture, or naturopathic visit; $25 massage therapy visit for up to 12 visits per year. Vision hardware* Eye exams are covered as a medical benefit at the applicable office visit charge. Vision hardware must be prescribed and purchased at Vision Essentials by Kaiser Permanente. Visit kp2020.org. Hardware options 12-month allowance 24-month allowance Hearing aids * Member pays For members 19 and older: Balance after allowance applied toward the purchase of frames and lenses or contacts every 12 months. Allowance options: $150, $200, $250, $300, $400, or 0 For members 18 and younger: No charge for one pair of frames from a select list and lenses or contacts every 12 months. Eyeglasses or contacts outside of the select list are available for purchase with an allowance toward the purchase price, as a buy-up option. (Members cannot use both the standard/free benefit and the allowance benefit within the same calendar year.) For members 19 and older: Balance after allowance applied toward the purchase of frames and lenses or contacts every 24 months. Allowance options:, $150, $200, $250, $300, $400, or 0 For members 18 and younger: No charge for one pair of frames from a select list and lenses or contacts every 12 months One hearing aid per ear per 48 months up to: $250, 0, $1,000, allowance. *Member payments for supplemental benefits do not apply to the medical out-of-pocket maximum. Note: These supplemental benefits are not available with Senior Advantage plans. 5
HIGHLIGHTS FOR S Most of our plans can be paired with an Added Choice plan, and many are included in our multi-plan bundles on page 8. Deductible plans with "TR" in the name are tailored to provide additional pairing combinations within the product pairing guidelines for Added Choice. (PER CALENDAR YEAR) OUT-OF-POCKET MAXIMUM (INCLUDES ) BENEFITS* OFFICE VISITS PRIMARY CARE OFFICE VISITS URGENT CARE OFFICE VISITS FOR PREVENTIVE AND WELL-CHILD CARE AND PREVENTIVE SERVICES OFFICE VISITS PRENATAL CARE OFFICE VISITS SPECIALTY CARE ROUTINE EYE EXAMS OUTPATIENT SURGERY LABS, X-RAYS, AND SPECIAL DIAGNOSTIC PROCEDURES CT, MRI, AND PET SCANS EMERGENCY CARE INPATIENT HOSPITAL CARE $150 10% TR $150 per $450 per $1,150 per $3,450 per 150 10% $150 per $450 per $1,650 per $4,950 per 150-20% $150 per $450 per $1,650 per $4,950 per 250 10% TR $250 per $750 per $1,250 per $3,750 per 250 10% $250 per $750 per $2,250 per $6,750 per $250 20% TR $250 per $750 per $1,750 per $5,250 per Member pays $250 20% $250 per $750 per $2,250 per $6,750 per 0 10% TR 0 per per $2,000 per $6,000 per 500 10% 0 per per per $9,000 per $10 $10 $15 $15 $15 $15 $15 $20 $20 $20 $30 $30 $35 $35 $35 $35 $35 $40 $40 $40 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $20 $20 $25 $25 $25 $25 $25 $30 $30 $30 $10 $10 $15 $15 $15 $15 $15 $20 $20 $20 $10 $10 $15 $15 $15 $15 $15 $20 per visit per visit per visit per visit per visit per visit per visit per visit $20 per visit 0 20% 0 per per per $9,000 per $20 per visit *These plans include limited coverage for dependent children outside the Kaiser Foundation Health Plan of the Northwest service area. For covered services, the member pays 20 percent of the actual fee. Services are limited to 10 office visits, 10 diagnostic labs or X-rays, and 10 prescription drug fills. Deductible does not apply. Visit our website kp.org/plans for more information on how our plans work. 6
750 20% TR 750 20% 1000 20% 1500 20% 2000 20% TR 2000 30% 2500 20% 3000 20% TR 3000 20% 3500 20% 4000 20% TR 5000 20% $750 per $2,250 per $750 per $2,250 per $1,000 per per per $4,500 per $2,000 per $6,000 per $2,000 per $6,000 per $2,500 per $7,500 per per $9,000 per per $9,000 per $3,500 per $10,500 per $4,000 per per $5,000 per $12,700 per $2,250 per $6,750 per $3,250 per $9,750 per $4,000 per per $5,000 per per $5,000 per per $6,850 per $13,700 per $5,000 per per $5,000 per per $6,850 per $13,700 per $6,850 per $13,700 per $5,000 per per $6,850 per $13,700 per Member pays $20 $20 $25 $25 $25 $30 $25 $30 $30 $30 $30 $30 $40 $40 $45 $45 $45 $45 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $30 $30 $35 $35 $35 $40 $35 $40 $40 $40 $40 $40 $20 $20 $25 $25 $25 $30 $25 $30 $30 $30 $30 $30 30% of $20 per visit $20 per visit $25 per $25 $25 visit per visit per visit $30 per $25 visit per visit $30 per visit $30 per visit $30 per visit $30 per visit $30 per visit 30% of 30% of *These plans include limited coverage for dependent children outside the Kaiser Foundation Health Plan of the Northwest service area For covered services, the member pays 20 percent of the actual fee. Services are limited to 10 office visits, 10 diagnostic labs or x-rays, and 10 prescription drug fills. Deductible does not apply. For standard plans, the following services are not subject to : most outpatient office visits; labs, X-rays, and special diagnostic procedures; urgent care; and supplemental options such as alternative care, adult hearing aids, prescription drugs, physical, speech, and occupational therapies and vision hardware (if purchased). The and most s and coinsurance apply to the medical out-of-pocket maximum. For specific plan information, see the following form: EOLGDED0116 7
BUNDLED AND ADDED CHOICE S 250 DD 500 DE 250-20% TR ADDED CHOICE DD 500-20% ADDED CHOICE DE INDIVIDUAL/FAMILY INDIVIDUAL/FAMILY (PER CALENDAR YEAR) $250 per $750 per Tier 1 1 $250 / $750 Tier 2 2 0 / 0 per per Tier 1 1 0 / Tier 2 2 $1,000 / Tier 3 3 $750 / $2,250 Tier 3 3 / $4,500 OUT-OF-POCKET MAXIMUM (INCLUDES ) $1,750 per $5,250 per Tier 1 1 $1,750 / $5,250 Tier 2 2 / $9,000 Tier 3 3 $4,000 / per $9,000 per Unlimited Tier 1 1 / $6,000 Tier 2 2 $4,750 / $9,500 Tier 3 3 $6,000 / NA LIFETIME BENEFIT MAXIMUM Unlimited NA OFFICE VISITS PRIMARY CARE OFFICE VISITS URGENT CARE OFFICE VISITS FOR PREVENTIVE AND WELL- CHILD CARE AND PREVENTIVE SERVICES OFFICE VISITS PRENATAL CARE OFFICE VISITS SPECIALTY CARE $15* $35* Tier 1 1 $20 Tier 2 2 $30 Tier 1 1 $40 Tier 2 2 $0* NA $0* NA $25* Tier 1 1 $30 Tier 2 2 $40 ROUTINE EYE EXAMS $15* NA OUTPATIENT SURGERY NA LABS, X-RAYS, AND SPECIAL DIAGNOSTIC PROCEDURES $15 per visit* Tier 1 1 $20 / Tier 2 2 $30 / 30% CT, MRI, AND PET SCANS * NA EMERGENCY CARE All $200 INPATIENT HOSPITAL CARE INPATIENT COPAY PER ADMISSION Tier 1 1 20% Tier 2 2 30% $20* $40* Tier 1 1 $20 Tier 2 2 $30 Tier 1 1 $40 Tier 2 2 $0* NA $0* NA $30* Tier 1 1 $30 Tier 2 2 $40 $20* NA NA $20 per visit* Tier 1 1 $20 / Tier 2 2 $30 / 30% * NA All $200 INPATIENT COPAY PER ADMISSION Tier 1 1 20% Tier 2 2 30% *Deductible does not apply. Deductible applies. See footnotes in the plans and Added Choice plans sections of this booklet for restrictions and more information. 8
750 DP 1000 DN 1500DX 750-20% TR ADDED CHOICE DP 1000-20% ADDED CHOICE DN 1500-20% ADDED CHOICE DX INDIVIDUAL/FAMILY INDIVIDUAL/FAMILY INDIVIDUAL/FAMILY $750 per $2,250 per $2,250 per $6,750 per Unlimited $20* $40* Tier 1 1 $750 / $2,250 Tier 2 2 / $4,500 Tier 3 3 $2,250 / $6,750 Tier 1 1 $2,250 / $4,500 Tier 2 2 $4,500 / $9,000 Tier 3 3 $6,000 / NA Tier 1 1 $25 Tier 2 2 $35 Tier 1 1 $45 Tier 2 2 $55 $1,000 per per $4,000 per per Unlimited $25* $45* Tier 1 1 $1,000 / Tier 2 2 $2,000 / $6,000 Tier 3 3 / $9,000 Tier 1 1 $4,000 / $8,000 Tier 2 2 $6,000 / Tier 3 3 $7,500 / $15,000 NA Tier 1 1 $25 Tier 2 2 $35 Tier 1 1 $45 Tier 2 2 $55 per $4,500 per $5,000 per per Unlimited $25* $45* Tier 1 1 / $4,500 Tier 2 2 / $9,000 Tier 3 3 $4,500 / $13,500 Tier 1 1 $5,000 / Tier 2 2 $6,850 / $13,700 Tier 3 3 $8,400 / $16,800 NA Tier 1 1 $25 Tier 2 2 $35 Tier 1 1 $45 Tier 2 2 $55 $0* NA $0* NA $0* NA $30* Tier 1 1 $35 Tier 2 2 $45 $20* NA NA $20 per visit* Tier 1 1 $25 / Tier 2 2 $35 / 30% * NA All $200 INPATIENT COPAY PER ADMISSION Tier 1 1 20% Tier 2 2 30% $0* NA $0* NA $35* Tier 1 1 $35 Tier 2 2 $45 $25* NA NA $25 per visit* Tier 1 1 $25 / Tier 2 2 $35 / 30% * NA All $200 INPATIENT COPAY PER ADMISSION Tier 1 1 20% Tier 2 2 30% $0* NA $35* Tier 1 1 $35 Tier 2 2 $45 $25* NA NA $25 per visit* Tier 1 1 $25 / Tier 2 2 $35 / 30% * NA All $200 INPATIENT COPAY PER ADMISSION Tier 1 1 20% Tier 2 2 30% 9
BUNDLED AND ADDED CHOICE S 250/500 DD 250-20% TR 500-20% ADDED CHOICE DD INDIVIDUAL/FAMILY (PER CALENDAR YEAR) $250 per $750 per 0 per per Tier 1 1 $250 / $750 Tier 2 2 0 / Tier 3 3 $750 / $2,250 OUT-OF-POCKET MAXIMUM (INCLUDES ) $1,750 per $5,250 per per $9,000 per Tier 1 1 $1,750 / $5,250 Tier 2 2 / $9,000 Tier 3 3 $4,000 / LIFETIME BENEFIT MAXIMUM Unlimited Unlimited NA OFFICE VISITS PRIMARY CARE $15* $20* OFFICE VISITS URGENT CARE $35* $40* Tier 1 1 $20 Tier 2 2 $30 Tier 1 1 $40 Tier 2 2 OFFICE VISITS FOR PREVENTIVE AND WELL- CHILD CARE AND PREVENTIVE SERVICES $0* $0* NA OFFICE VISITS PRENATAL CARE $0* $0* NA OFFICE VISITS SPECIALTY CARE $25* $30* Tier 1 1 $30 Tier 2 2 $40 ROUTINE EYE EXAMS $15* $20* NA OUTPATIENT SURGERY NA LABS, X-RAYS, AND SPECIAL DIAGNOSTIC PROCEDURES $15 per visit* $20 per visit* Tier 1 1 $20 / Tier 2 2 $30 / 30% CT, MRI, AND PET SCANS * * NA EMERGENCY CARE All $200 INPATIENT COPAY PER ADMISSION INPATIENT HOSPITAL CARE Tier 1 1 20% Tier 2 2 30% *Deductible does not apply. Deductible applies. See footnotes in the plans and Added Choice plans sections of this booklet for restrictions and more information. 10
500/1000 DE 750/1500 DP 500-20% 1000-20% ADDED CHOICE DE 750-20% TR 1500-20% ADDED CHOICE DP INDIVIDUAL/FAMILY INDIVIDUAL/FAMILY 0 per per $1,000 per per Tier 1 1 0 / Tier 2 2 $1,000 / $750 per $2,250 per per $4,500 per Tier 1 1 $750 / $2,250 Tier 2 2 / $4,500 Tier 3 3 / $4,500 Tier 3 3 $2,250 / $6,750 per $9,000 per $4,000 per per Tier 1 1 / $6,000 Tier 2 2 $4,750 / $9,500 Tier 3 3 $6,000 / $2,250 per $6,750 per $5,000 per per Tier 1 1 $2,250 / $4,500 Tier 2 2 $4,500 / $9,000 Tier 3 3 $6,000 / Unlimited Unlimited NA Unlimited Unlimited NA Tier 1 1 $20 Tier 1 1 $25 $20* $25* Tier 2 2 $30 $20* $25* Tier 2 2 $35 Tier 1 1 $40 Tier 1 1 $45 $40* $45* Tier 2 2 $40* $45* Tier 2 2 $55 $0* $0* NA $0* $0* NA $0* $0* NA $0* $0* NA Tier 1 1 $30 Tier 1 1 $35 $30* $35* Tier 2 2 $40 $30* $35* Tier 2 2 $45 $20* $25* NA NA $20* $25* NA NA Tier 1 1 $20 / Tier 1 1 $25 / $20 per visit* $25 per visit* Tier 2 2 $30 / 30% $20 per visit* $25 per visit* Tier 2 2 $35 / 30% * * NA All $200 INPATIENT COPAY PER ADMISSION * * NA All $200 INPATIENT COPAY PER ADMISSION Tier 1 1 20% Tier 1 1 20% Tier 2 2 30% Tier 2 2 30% 11
BUNDLED AND ADDED CHOICE S 1000/2000 DN 1000-20% 2000-20% TR ADDED CHOICE DN INDIVIDUAL/FAMILY (PER CALENDAR YEAR) $1,000 per per $2,000 per $6,000 per Tier 1 1 $1,000 / Tier 2 2 $2,000 / $6,000 Tier 3 3 / $9,000 OUT-OF-POCKET MAXIMUM (INCLUDES ) $4,000 per per $5,000 per per Tier 1 1 $4,000 / $8,000 Tier 2 2 $6,000 / Tier 3 3 $7,500 / $15,000 LIFETIME BENEFIT MAXIMUM Unlimited Unlimited NA OFFICE VISITS PRIMARY CARE $25* $25* OFFICE VISITS URGENT CARE $45* $45* Tier 1 1 $25 Tier 2 2 $35 Tier 1 1 $45 Tier 2 2 $55 OFFICE VISITS FOR PREVENTIVE AND WELL- CHILD CARE AND PREVENTIVE SERVICES $0* $0* NA OFFICE VISITS PRENATAL CARE $0* $0* NA OFFICE VISITS SPECIALTY CARE $35* $35* Tier 1 1 $35 Tier 2 2 $45 ROUTINE EYE EXAMS $25* $25* NA OUTPATIENT SURGERY NA LABS, X-RAYS, AND SPECIAL DIAGNOSTIC PROCEDURES $25 per visit* $25 per visit* Tier 1 1 $25 / Tier 2 2 $35 / 30% CT, MRI, AND PET SCANS * * NA EMERGENCY CARE All $200 INPATIENT COPAY PER ADMISSION INPATIENT HOSPITAL CARE Tier 1 1 20% Tier 2 2 30% *Deductible does not apply. Deductible applies. See footnotes in the plans and Added Choice plans sections of this booklet for restrictions and more information. 12
1500/3000 DX 1500-20% per $4,500 per $5,000 per per 3000-20% per $9,000 per $6,850 per $13,700 per ADDED CHOICE DX INDIVIDUAL/FAMILY Tier 1 1 / $4,500 Tier 2 2 / $9,000 Tier 3 3 $4,500 / $13,500 Tier 1 1 $5,000 / Tier 2 2 $6,850 / $13,700 Tier 3 3 $8,400 / $16,800 Unlimited Unlimited NA $25* $30* $45* * Tier 1 1 $25 Tier 2 2 $35 Tier 1 1 $45 Tier 2 2 $55 $0* $0* NA $0* $0* NA $35* $40* Tier 1 1 $35 Tier 2 2 $45 $25* $30* NA NA Tier 1 1 $25 / $25 per visit* $30 per visit* Tier 2 2 $35 / 30% * * NA All $200 INPATIENT COPAY PER ADMISSION Tier 1 1 20% Tier 2 2 30% 13
HIGHLIGHTS FOR ADDED CHOICE POINT-OF-SERVICE S COMPARISON OPTIONS 83 86 70 71 72 74 75 89E 91 DA DB : INDIVIDUAL/ FAMILY OUT OF-POCKET MAXIMUM: INDIVIDUAL/ FAMILY (INCLUDES ) PRIMARY CARE VISIT Tier 1 1 N/A N/A N/A N/A N/A N/A N/A N/A N/A Tier 2 2 $200 / $600 Tier 3 3 $400 / $1,200 Tier 1 1 $600 / $1,200 Tier 2 2 $1,200 / $3,600 Tier 3 3 $2,150 / $6,450 $250 / $750 0 / $750 / $1,750 / $5,250 $3,125 / $9,375 $250 / $750 0 / $750 / $1,750 / $5,250 $3,500 / $10,500 $300 / $900 $600 / $1,800 $1,000 / $2,000 $1,800 / $5,400 $5,100 / $15,300 $300 / $900 $600 / $1,800 $1,000 / $2,000 $3,300 / $9,900 $6,600 / $19,800 0 / $1,000 / / $2,500 / $7,500 $4,000 / 0 / $1,000 / $2,000 / $4,000 $3,500 / $10,500 $6,500 / $19,500 $1,000 / $2,000 / $6,000 $1,000 / $2,000 $5,000 / $8,000 / $16,000 / $4,500 / $9,000 / $6,000 $5,500 / $11,000 $9,000 / $18,000 $150 / $450 $300 / $900 $450 / $1,350 $1,150 / $3,450 $2,300 / $6,900 $3,450 / $9,900 Tier 1 1 $10 $10 $15 $10 $15 $15 $20 $20 $35 $10 $20 Tier 2 2 $20 $20 $25 $20 $25 $25 $30 $30 $20 $30 $250 / $750 0 / $750 / $2,250 $1,250 / $3,750 $2,500 / $7,500 $3,500 / $10,500 Tier 3 3 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%* SPECIALTY CARE VISIT Tier 1 1 $20 $20 $25 $20 $25 $25 $30 $30 $45 $20 $30 Tier 2 2 $30 $30 $35 $30 $35 $35 $40 $40 $60 $30 $40 Tier 3 3 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%* LAB/X-RAY/ SPECIAL DIAGNOSTIC PROCEDURES Tier 1 1 $10 / $10 / $15 / $10 / $15 / $15 / Tier 2 2 $20 / 20%* $25 / 20%* $25 / 20%* $10 / 10%* $20 / 20%* $25 / 10%* $20 / $25 / 20%* $20 / $30 / 20%* $35 / / 30%* $10 / $20 / 20%* $20 / $30 / 20%* Tier 3 3 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%* URGENT CARE VISIT Tier 1 1 $30 $30 $35 $30 $35 $35 $40 $40 $60 $30 $40 Tier 2 2 $40 $40 $45 $40 $45 $45 $75 $40 Tier 3 3 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%* EMERGENCY CARE INPATIENT COPAY PER ADMISSION All $200 $200 $200 $200 $200 $200 $200 $200 $200 $200 $200 Tier 1 1 /day max $250/ admit /day max 0/ admit $200/ admit $200/ admit /day max 0/ admit $200/day max 0/ max $200/day max $1,000/ admit $200/day max $1,000/ admit $800/ admit 10%* 10%* Tier 2 2 20%* 20%* 20%* 10%* 20%* 10%* 20%* 20%* 30%* 20%* 20%* Tier 3 3 35%* 35%* 40%* 30%* 40%* 30%* 40%* 40%* 50%* 35%* 35%* We recognize that each client has specific needs with regard to their product pairings. Please contact your account manager or sales executive for guidance on which of our traditional and plans best suit your needs when offered alongside an Added Choice plan. 1 In most cases, Tier 1 services are provided by Select Providers and Select Facilities. The Evidence of Coverage (EOC) provides a complete definition of Select Provider, Select Facility, and Select Pharmacy. The EOC also explains when Tier 1 services are provided by other providers and facilities. 2 Tier 2 services are provided by PPO Providers and PPO Facilities. Refer to the Evidence of Coverage (EOC) for a complete definition of PPO Provider and PPO Facilities. We provide coverage for certain Tier 2 preventive services with no cost share for out-of-area subscribers and their dependents. See the Preventive Care Services section of your 2016 Evidence of Coverage (EOC) for details. 3 Tier 3 services are provided by Non-Participating Providers and Non-Participating Facilities. Refer to the Evidence of Coverage (EOC) for a complete definition of Non-Participating Provider and Non-Participating Facility. *Deductible applies. 14
OPTIONS DD DC DE DF DP DN DX DR DS DK : INDIVIDUAL/ FAMILY OUT OF-POCKET MAXIMUM: INDIVIDUAL/ FAMILY (INCLUDES ) PRIMARY CARE VISIT Tier 1 1 $250 / $750 Tier 2 2 0 / Tier 3 3 $750 / $2,250 Tier 1 1 $1,750 / $5,250 Tier 2 2 / $9,000 Tier 3 3 $4,000 / 0 / $1,000 / / $4,500 $2,000 / $6,000 $4,000 / $5,500 / $16,500 0 / $1,000 / / $4,500 / $6,000 $4,750 / $9,500 $6,000 / 0 / $1,000 / / $4,500 / $6,000 $5,500 / $11,000 $7,500 / $15,000 $750 / $2,250 / $4,500 $2,250 / $6,750 $2,250 / $4,500 $4,500 / $9,000 $6,000 / $1,000 / $2,000 / $6,000 / $9,000 $4,000 / $8,000 $6,000 / $7,500 / $15,000 / $4,500 / $9,000 $4,500 / $13,500 $5,000 / $6,850 / $13,700 $8,400 / $16,800 $2,000 / $6,000 $4,000 / $6,000 / $16,800 $5,000 / $6,850 / $13,700 $8,400 / $16,800 / $9,000 $6,000 / $12,700 $8,400 / $16,800 $5,000 / $6,850 / $13,700 $8,400 / $16,800 Tier 1 1 $20 $20 $20 $30 $25 $25 $25 $25 $30 $30 Tier 2 2 $30 $30 $30 $40 $35 $35 $35 $35 $40 $40 $4,000 / $6,350 / $12,700 $8,400 / $16,800 $5,000 / $6,850 / $13,700 $8,400 / $16,800 Tier 3 3 45%* 35%* 45%* 50%* 40%* 40%* 40%* 40%* 40%* 45%* SPECIALTY CARE VISIT Tier 1 1 $30 $30 $30 $40 $35 $35 $35 $35 $40 $40 Tier 2 2 $40 $40 $40 $45 $45 $45 $45 Tier 3 3 45%* 35%* 45%* 50%* 40%* 40%* 40%* 40%* 40%* 45%* LAB/X-RAY/ SPECIAL DIAGNOSTIC PROCEDURES Tier 1 1 $20 / Tier 2 2 $30 / 30%* $20 / $30 / 20%* $20 / $30 / 30%* $25 / $35 / 35%* $25 / $35 / 30%* $25 / $35 / 30%* $25 / $35 / 30%* $25 / $35 / 30%* $30 / $40 / 30%* $30 / $40 / 35%* Tier 3 3 45%* 35%* 45%* 50%* 40%* 40%* 40%* 40%* 40%* 45%* URGENT CARE VISIT Tier 1 1 $40 $40 $40 $45 $45 $45 $45 Tier 2 2 $60 $55 $55 $55 $55 $60 $60 EMERGENCY CARE Tier 3 3 45%* 35%* 45%* 50%* 40%* 40%* 40%* 40%* 40%* 45%* All $200 $200 $200 $200 $200 $200 $200 20% 20% 20%* INPATIENT COPAY PER ADMISSION Tier 1 1 20%* 10%* 20%* 25%* 20%* 20%* 20%* 20%* 20%* 20%* Tier 2 2 30%* 20%* 30%* 35%* 30%* 30%* 30%* 30%* 30%* 35%* Tier 3 3 45%* 35%* 45%* 50%* 40%* 40%* 40%* 40%* 40%* 45%* 1 In most cases, Tier 1 services are provided by Select Providers and Select Facilities. The Evidence of Coverage (EOC) provides a complete definition of Select Provider, Select Facility, and Select Pharmacy. The EOC also explains when Tier 1 services are provided by other providers and facilities. 2 Tier 2 services are provided by PPO Providers and PPO Facilities. Refer to the Evidence of Coverage (EOC) for a complete definition of PPO Provider and PPO Facilities. We provide coverage for certain Tier 2 preventive services with no cost share for out-of-area subscribers and their dependents. See the Preventive Care Services section of your 2016 Evidence of Coverage (EOC) for details. 3 Tier 3 services are provided by Non-Participating Providers and Non-Participating Facilities. Refer to the Evidence of Coverage (EOC) for a complete definition of Non-Participating Provider and Non-Participating Facility. *Deductible applies. This brochure provides summaries of various plans and is not a contract. These plans are subject to exclusions and limitations. Plan details, including all benefits, exclusions, and limitations, are provided in the Evidence of Coverage (EOC). For specific plan information about the plans referred to in this brochure, see the following forms: EOLGPOSDED3T0116 EOLGPOSDED2T0116 15 All of the following are non-grandfathered plans: EOLGPOSDED3T0116 EOLGPOSDED2T0116
SUPPLEMENTAL BENEFIT OPTIONS FOR ADDED CHOICE S OUTPATIENT PRESCRIPTION DRUGS Select Pharmacies MedImpact pharmacies GENERIC COPAYMENT BRAND COPAYMENT GENERIC COPAYMENT 16 PREFERRED BRAND COPAYMENT* NON-PREFERRED BRAND COPAYMENT* $10 $20 $15 $30 $15 $30 $20 $40 $60 $20 $40 $25 $70 SUPPLEMENTAL BENEFIT OPTIONS FOR ADDED CHOICE S Select Pharmacies GENERIC COPAYMENT PREFERRED BRAND- NAME DRUG COPAYMENT NON- PREFERRED BRAND-NAME DRUG MedImpact Pharmacies GENERIC COPAYMENT PREFERRED BRAND COPAYMENT* NON- PREFERRED BRAND COPAYMENT* $10 $20 $40 $15 $30 $10 $20 $40 $20 $30 SPECIALTY COPAYMENT $10 $20 $40 $20 $40 $60 $300 $15 $30 $20 $40 $60 $15 $30 $25 $70 $300 $20 $40 $60 $30 $60 $80 $20 $40 $60 $20 or 50%, whichever is greater $300 * If a brand drug with an equivalent generic is prescribed and the member or the prescriber requests the brand drug, the will be the plus the difference in retail price between generic and brand drug. ALTERNATIVE CARE Self-referred chiropractic care OFFICE VISIT COPAYMENT NUMBER OF VISITS PER CALENDAR YEAR UP TO Self-referred chiropractic, massage, acupuncture, and naturopathic care OFFICE VISIT COPAYMENT CALENDAR YEAR BENEFIT MAXIMUM UP TO $10 15, 20, 30 $10 0, $1,000, $15 $15 $20 $20 $25 $25 $30 Massage office is always $25 with a 12-visit limit per calendar year. To be covered by your benefit, you must receive care from a provider in our service area who is part of The CHP Group network. If you are on an Added Choice plan with an alternative care benefit, you may use your benefits at The CHP Group (located in our service area), First Choice, or any licensed non participating providers and facilities. The amount an Added Choice member pays is based on the provider. For a list of participating providers, visit chpgroup.com. VISION HARDWARE COVERAGE 12-month allowance 24-month allowance HEARING AIDS MEMBER PAYS One hearing aid per ear per 48 months up to: $250, 0, $1,000, allowance For members 19 and older: Balance after allowance applied toward the purchase of frames and lenses or contacts every 12 months., 150, $200, $250, $300, $400, or 0 For members 18 and younger: No charge for one pair of frames from a select list and lenses or contacts every 12 months. Eyeglasses or contacts outside of the select list are available for purchase with an allowance toward the purchase price, as a buy-up option. (Members cannot use both the standard/free benefit and the allowance benefit within the same calendar year.) For members 19 and older: Balance after allowance applied toward the purchase of frames and lenses or contacts every 24 months., $150, $200, $250, $300, $400, or 0 For members 18 and younger: No charge for one pair of frames from a select list and lenses or contacts every 12 months.
HIGHLIGHTS FOR HSA-QUALIFIED HIGH HEALTH S Kaiser Permanente combines the cost savings of a high health plan with a collaborative approach to care that helps keep employees healthier and more productive at work and at home. Our primary care providers, specialists, pharmacists, and other caregivers all work together with one mission: keeping employees healthy. Choose from plans with a variety of, coinsurance, and out-of-pocket maximum options. CHOOSE FROM THE FOLLOWING AND OUT-OF-POCKET MAXIMUM COMBINATIONS THEN CHOOSE A COINSURANCE Deductible (Individual/Family) Out-of-Pocket Maximum (Individual/Family) Accumulation Type * Available Coinsurance per combination $1,300/$2,600 $2,600/$5,200 Aggregate 10%, 20% / $2,500/$5,000 Aggregate 10%, 20%, 30% $2,000/$4,000 $4,000/$6,550 Aggregate 10%, 20%, 30%, 50% $2,500/$5,000 $5,000/$6,550 Aggregate 10%, 20%, 30%, 50% $2,600/$5,200 $5,200/$10,400 Embedded 20%, 30%, 40%, 50% /$6,000 $6,000/ Embedded 20%, 30%, 40%, 50% $3,500/$7,000 $6,550/$13,100 Embedded 20%, 30%, 40%, 50% $4,000/$8,000 $6,550/$13,100 Embedded 20%, 30%, 40%, 50% $5,000/ $6,550/$13,100 Embedded 20%, 30%, 40%, 50% $6,550/$13,100 $6,550/$13,100 Embedded 0% BENEFIT/FEATURE OFFICE VISITS PREVENTIVE AND WELL- CHILD CARE AND PREVENTIVE SERVICES* 10% 20% 30% 40% 50% 0% Member pays $0 $0 $0 $0 $0 $0 OFFICE VISITS PRENATAL CARE* $0 $0 $0 $0 $0 $0 OFFICE VISITS PRIMARY AND URGENT CARE 10% after 20% after 30% after 40% after 50% after 0% after OFFICE VISITS SPECIALTY CARE 10% after 20% after 30% after 40% after 50% after 0% after ROUTINE EYE EXAMS 10% after 20% after 30% after 40% after 50% after 0% after OUTPATIENT SURGERY 10% after 20% after 30% after 40% after 50% after 0% after LABS, X-RAYS, AND SPECIAL DIAGNOSTIC PROCEDURES 10% after 20% after 30% after 40% after 50% after 0% after EMERGENCY CARE 10% after 20% after 30% after 40% after 50% after 0% after HOSPITAL INPATIENT CARE 10% after 20% after 30% after 40% after 50% after 0% after * Aggregate Accumulation: For Services that are subject to the Deductible and Out-of-Pocket Maximum, you must pay Charges for the Services when you receive them, until you meet your Deductible or Out-of-Pocket Maximum. If you are the only Member in your Family, then you must meet the Member Deductible/Out-of-Pocket Maximum. If you are a Member in a Family of two or more Members, you meet the Deductible/Out-of- Pocket Maximum when your entire Family meets the Family Deductible amount. Every Member in your Family must pay during the Year until the entire Family meets the Family Deductible or Out-of-Pocket Maximum. Embedded Accumulation: For Services that are subject to the Deductible and Out-of-Pocket Maximum, you must pay Charges for the Services when you receive them, until you meet your Deductible or Out-of-Pocket Maximum. If you are the only Member in your Family, then you must meet the Member Deductible/Out-of-Pocket Maximum. If there is at least one other Member in your Family, then you must each meet the Member Deductible/Out-of-Pocket Maximum, or your Family must meet the Family Deductible/Out-of-Pocket Maximum, whichever is less. Each Member Deductible amount counts toward the Family Deductible amount. Once the Family Deductible is satisfied, no further Member Deductible will be due for the remainder of the Year. 17
HIGHLIGHTS FOR HSA-QUALIFIED HIGH HEALTH S KAISER PERMANENTE VALUE S We have developed a new portfolio of plans designed to meet the needs of employers interested in offering coverage that falls within the requirements of a Minimum Value plan under the Affordable Care Act. These plans cover medical essential health benefits and exclude those services above and beyond essential health benefits that are typically covered under Kaiser Permanente's standard large group plans. Excluded non-essential health benefits: routine vision exams for adults (medically necessary eye care is still covered), infertility diagnosis, physician referred alternative care, and dependent child out of area coverage. (See EOC for complete list of exclusions and limitations.) 50% VALUE 40% VALUE 30% VALUE BENEFIT/FEATURE Member pays Member pays Member pays (PER CALENDAR YEAR, EMBEDDED ACCUMULATION) OUT-OF-POCKET MAXIMUM (INCLUDES, EMBEDDED ACCUMULATION) OFFICE VISITS PREVENTIVE AND WELL-CHILD CARE AND PREVENTIVE SERVICES* $3,500 per member / $7,000 per $6,550 per member / $13,100 per $4,500 per member / $9,000 per $6,550 per member / $13,100 per $0 $0 $0 OFFICE VISITS PRENATAL CARE* $0 $0 $0 $5,500 per member / $11,000 per $6,550 per member / $13,100 per OFFICE VISITS PRIMARY AND URGENT CARE 50% after 40% after 30% after OFFICE VISITS SPECIALTY CARE 50% after 40% after 30% after ROUTINE EYE EXAMS 50% after 40% after 30% after OUTPATIENT SURGERY 50% after 40% after 30% after LABS, X-RAYS, AND SPECIAL DIAGNOSTIC PROCEDURES 50% after 40% after 30% after EMERGENCY CARE 50% after 40% after 30% after HOSPITAL INPATIENT CARE 50% after 40% after 30% after In order to meet minimum value requirements, prescription drug coverage must match plan coinsurance and be subject to the. 18
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SUPPLEMENTAL BENEFIT OPTIONS FOR HSA-QUALIFIED HIGH HEALTH S SUPPLEMENTAL BENEFITS Below are the options available with our high health plans. Contact your sales executive or account manager for more information. Outpatient prescription drugs The Kaiser Permanente formulary applies to all plans. Members get up to a 30-day supply for each (up to a 90-day supply of maintenance drugs for two s when our Mail-Delivery Pharmacy is used). 1 View our formulary at kp.org/formulary. Options Member pays (after is met) * 10% 10% coinsurance (after ) 20% 20% coinsurance (after ) 30% 30% coinsurance (after ) 40% 40% coinsurance (after ) 50% 50% coinsurance (after ) $10/$20 $10 generic/$20 brand (after ) $10/$20/$40/$150 $10 generic/$20 brand/$40 non-formulary brand /$150 specialty (after ) $10/$20/$40 $10 generic/$20 brand/$40 non-formulary brand (after ) $10/$30/50%/50% $10 generic/$30 brand/50% non-formulary brand/50% specialty (after ) $10/$30/25%/25% $10 generic/$30 brand/25% non-formulary brand/25% specialty (after ) $10/$30/$45 $10 generic/$30 brand/$45 non-formulary brand (after ) $15/$30 $15 generic/$30 brand (after ) $15/$30/50%/50% $15 generic/$30 brand/50% non-formulary brand/50% specialty (after ) $15/$30/ $15 generic/$30 brand/ non-formulary brand (after ) $15/$30//$150 $15 generic/$30 brand/ non-formulary brand/$150 specialty (after ) $20/$40 $20 generic/$40 brand (after ) $20/$40/$60 $20 generic/$40 brand/$60 non-formulary brand (after ) $20/$40/$60/$150 $20 generic/$40 brand/$60 non-formulary brand/$150 specialty (after ) *The prescription drug rider may also be purchased with preventive drugs not subject to the. Contact your account manager for details. 20
Chiropractic care Self-referred chiropractic care is available through The CHP Group approved network providers in the Kaiser Permanante service area. Visit chpgroup.com for a list of providers. Alternative care (includes chiropractic care) Self-referred alternative care is available from The CHP Group network providers in our service area. Annual benefit maximums of $1,000, or. Visit chpgroup.com for a list of providers. Options Member pays $10 $10 per chiropractic, acupuncture, or naturopathic visit; $25 per massage therapy visit for up to 12 visits per year all after. $15 $15 per chiropractic, acupuncture, or naturopathic visit; $25 per massage therapy visit for up to 12 visits per year all after. $20 $20 per chiropractic, acupuncture, or naturopathic visit; $25 per massage therapy visit for up to 12 visits per year all after. 20% coinsurance 20% coinsurance after per chiropractic, acupuncture, naturopathic or massage therapy visit for up to 12 visits per year. Vision hardware 2 Eye exams are covered as a medical benefit at the applicable office visit charge. Vision hardware must be prescribed and purchased at Vision Essentials by Kaiser Permanente. Visit kp2020.org. Options 12-month allowance 24-month allowance Hearing aids Member pays For members 19 and older: Balance after allowance applied toward the purchase of frames and lenses or contacts every 12 months. Allowance options: $150, $200, $250, $300, $400, or 0 For members 18 and younger: No charge for one pair of frames from a select list and lenses or contacts every 12 months. Eyeglasses or contacts outside of the select list are available for purchase with an allowance toward the purchase price, as a buy-up option. (Members cannot use both the standard/free benefit and the allowance benefit within the same calendar year.) For members 19 and older: Balance after allowance applied toward the purchase of frames and lenses or contacts every 24 months. Allowance options:, $150, $200, $250, $300, $400, or 0 For members 18 and younger: No charge for one pair of frames from a select list and lenses or contacts every 12 months. One hearing aid per ear per 48 months up to: $250, 0, $1,000, allowance 2 Member payments for this benefit do not apply to the medical out-of-pocket maximum or. 21
HIGHLIGHTS FOR HSA-QUALIFIED ADDED CHOICE S HSA-Qualified Added Choice Plans give your employees the opportunity to combine the cost savings of a high health plan with their desire to keep their current doctor or the option to see any licensed provider for covered services. Only Kaiser Permanente offers the option to see any licensed provider across the nation along with exclusive access to Select Providers and Select Facilities. AA 1 EE 1 EE 3 EE 4 ACCUMULATION TYPE AGGREGATE EMBEDDED EMBEDDED EMBEDDED TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 TIER 1 TIER 2 TIER 3 / $2,500 / $5,000 $3,500 / $7,000 $2,600 / $5,200 $3,600 / $7,200 $4,600 / $9,200 $2,600 / $5,200 $3,600 / $7,200 $4,600 / $9,200 $2,600 / $5,200 $3,600 / $7,200 $4,600 / $9,200 OUT-OF-POCKET MAXIMUM $2,500 / $5,000 $4,000 / $6,550 $5,000 / $4,000 / $8,000 $5,000 / $6,000 / $5,200 / $10,400 $6,200 / $12,400 $9,200 / $18,400 $5,200 / $10,400 $6,200 / $12,400 $9,200 / $18,400 OFFICE VISITS PREVENTIVE OFFICE VISITS PRENATAL CARE OFFICE VISITS PRIMARY CARE & URGENT CARE OFFICE VISITS SPECIALTY CARE $0 20% 30% $0 20% 30% $0 20% 30% $0 30% 40% $0 20% 30% $0 20% 30% $0 20% 30% $0 30% 40% 10% 20% 30% 10% 20% 30% 10% 20% 30% 20% 30% 40% 10% 20% 30% 10% 20% 30% 10% 20% 30% 20% 30% 40% ROUTINE EYE EXAMS 10% 20% 30% 10% 20% 30% 10% 20% 30% 20% 30% 40% OUTPATIENT SURGERY 10% 20% 30% 10% 20% 30% 10% 20% 30% 20% 30% 40% LABS, X-RAYS, AND SPECIAL DIAGNOSTIC PROCEDURES 10% 20% 30% 10% 20% 30% 10% 20% 30% 20% 30% 40% EMERGENCY CARE 10% 10% 10% 20% HOSPITAL INPATIENT CARE 10% 20% 30% 10% 20% 30% 10% 20% 30% 20% 30% 40% 22
SUPPLEMENTAL BENEFIT OPTIONS FOR HSA-QUALIFIED ADDED CHOICE S SUPPLEMENTAL BENEFITS Below are the options available with our HSA-Qualified Added Choice Plans Contact your sales executive or account manager for more information. Outpatient prescription drugs The Kaiser Permanente formulary applies to all plans. Members get up to a 30-day supply for each (up to a 90-day supply of maintenance drugs for two s when our Mail-Delivery Pharmacy is used). 1 View our formulary at kp.org/formulary. Note: Prescription drug cost shares apply to the medical out-of-pocket maximum. 1 Specialty drugs are provided at one copay (or one maximum) for a 30-day supply. Select Pharmacies GENERIC COPAYMENT FORMULARY BRAND COPAYMENT MedImpact pharmacies GENERIC COPAYMENT FORMULARY BRAND COPAYMENT 2 NON-FORMULARY BRAND COPAYMENT 2 $10 $20 $15 $30 $15 $30 $20 $40 $60 Select Pharmacies GENERIC COPAYMENT 20% coinsurance 30% coinsurance FORMULARY BRAND COPAYMENT NON-FORMULARY BRAND COPAYMENT MedImpact pharmacies GENERIC COPAYMENT FORMULARY BRAND COPAYMENT 2 NON-FORMULARY BRAND COPAYMENT 2 $10 $20 $40 $15 $30 $15 $30 $20 $40 $60 $20 $40 $60 $30 $60 $80 2 If a brand drug with an equivalent generic is prescribed and the member requests the brand drug, the will be the plus the difference in retail price between the generic and the brand drug. If the prescriber indicates brand is medically necessary, the member will pay the applicable. Alternative care Self-referred alternative care, without prior authorization, is available through The CHP Group approved network providers. If you are on an Added Choice plan with an alternative care benefit, you may use your benefits at The CHP Group (located in our service area), First Choice, or any licensed nonparticipating providers and facilities. The amount an Added Choice member pays is based on the provider. For a list of participating providers, visit www.chpgroup.com. ALTERNATIVE CARE Self-referred chiropractic care OFFICE VISIT COPAYMENT NUMBER OF VISITS PER CALENDAR YEAR UP TO Self-referred chiropractic, massage, 3 acupuncture, and naturopathic care OFFICE VISIT COPAYMENT CALENDAR YEAR BENEFIT MAXIMUM UP TO $10 15, 20, 30 $10 0, $1,000, $15 $15 $20 $20 $25 $25 $30 3 Massage office is always $25 with a 12-visit limit per calendar year. VISION HARDWARE COVERAGE 12-month allowance 24-month allowance Hearing aids Member pays For members 19 and above: Balance after allowance applied toward the purchase of frames and lenses or contacts every 12 months. Allowance options: $150, $200, $250, $300, $400, or 0 For members 18 and under: No charge for one pair of frames and lenses or contacts every 12 months. Eyeglasses or contacts outside of the select list are available for purchase with an allowance toward the purchase price, as a buy-up option. (Members cannot use both the standard/free benefit and the allowance benefit within the same calendar year.) For members 19 and above: Balance after allowance applied toward the purchase of frames and lenses or contacts every 24 months. Allowance options:, $150, $200, $250, $300, $400, or 0 For members 18 and under: No charge for one pair of frames and lenses or contacts every 24 months One hearing aid per ear per 48 months up to: $250, 0, $1,000, allowance. 23
kp.org 50LBG-15/9-15 2015 Kaiser Foundation Health Plan of the Northwest