2013 small busiess CALIFORNIA Pla highlights For effective dates Jauary 1 Jue 1, 2013 Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie
Notes for all plas The copaymet plas, HSA-qualified deductible HMO plas, deductible HMO plas, deductible HMO plas with HRA, ad the i-etwork portio of the poit-of-service (POS) pla are uderwritte by Kaiser Foudatio Health Pla, Ic. (KFHP). Kaiser Permaete Isurace Compay (KPIC), a subsidiary of KFHP, uderwrites the PPO plas ad the out-of-etwork portio of the POS pla as well as the Delta Detal of Califoria detal plas. The chiropractic/acupucture pla is admiistered by America Specialty Health Plas of Califoria, Ic. The PPO chiropractic/acupucture pla is admiistered by Private Healthcare Systems. This booklet is a summary oly. The KFHP Evidece of Coverage ad the KPIC Certificate of Isurace cotai a complete explaatio of beefits, exclusios, ad limitatios. The iformatio provided i this brochure is ot iteded for use as a beefit summary, or is it desiged to serve as the Evidece of Coverage or Certificate of Isurace. Summary of Beefits ad Coverage (SBC) documets for all of our plas are available at kp.org/smallbusiess-sbc/ca to help you make a iformed choice about your health pla(s). These documets summarize importat iformatio about your health coverage optios, so you ca easily compare Kaiser Permaete beefits ad coverage with those of other carriers. Kaiser Permaete plas do ot iclude a pre-existig coditio clause. Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie
Cotets 2 3 4 5 6 8 10 13 19 Copaymet plas HMO plas with predictable out-of-pocket costs ad o aual deductible to meet for medical services Deductible HMO plas Lower mothly premiums, ad doctor visits are ot subject to the deductible HSA-qualified deductible HMO plas Lower mothly premiums, plus optioal employee-owed savigs accouts provide a iovative way to pay for qualified medical expeses Deductible HMO plas with health reimbursemet arragemet (HRA) A IRS-regulated, employer-sposored program that allows your employees to receive tax-free dollars from you to pay for qualified medical expeses $35 POS Pla A poit-of-service pla that gives employees access to Kaiser Permaete medical care with the added flexibility of choosig physicias ad services from a exteral provider etwork or ay licesed provider $40/$1,000 PPO Isurace Pla Choose a physicia from a cotracted etwork or ay licesed oparticipatig provider. $40/$2,500 PPO Isurace Pla with HSA Optio Our HSA-optio PPO offers the flexibility of a PPO alog with lower mothly premiums ad optioal employee-owed savigs accouts. Detal plas A variety of detal pla optios, icludig Delta Detal Premier, Delta Detal PPO, ad DeltaCare HMO Chiropractic ad acupucture plas Chiropractic/acupucture plas provide members up to 20 visits aually for a copaymet of oly $15 per visit. Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie
KAISER PERMANENTE Copaymet plas PLAN HIGHLIGHTS Features Steve@SteveShorr.com 310.519.1335 $5 Pla Member Pays $15 Pla Member Pays $20 Pla Member Pays Most Popular Copaymet pla $30 Pla Member Pays Caledar-Year Deductible Pharmacy Caledar-Year Deductible N/A N/A N/A $250 for brad prescriptio $50 Pla Member Pays $250 for brad prescriptio Aual Out-of-Pocket Maximum 1 Idividual/Family $1,500/$3,000 $2,500/$5,000 $2,500/$5,000 $3,000/$6,000 $3,500/$7,000 I the Medical Office Office visits Prevetive exams Materity/Preatal care 2 Well-child prevetive care visits 3 Vaccies (immuizatios) Allergy ijectios Ifertility services Occupatioal, physical, ad speech therapy Most labs ad imagig MRI/CT/PET Outpatiet surgery Emergecy Services Emergecy Departmet visits (waived if admitted directly to hospital) Ambulace Prescriptios 4 Geeric 5 Brad-ame Hospital Care Physicias services, room ad board, tests, medicatios, supplies, therapies Skilled ursig facility care (up to 100 days per beefit period) Metal Health Services I the medical office I the hospital Chemical Depedecy Services I the medical office I the hospital (detoxificatio oly) Other Certai durable medical equipmet (DME) Certai prosthetics, orthotics, ad devices Optical (eyewear) Visio exam Home health care (up to 100 two-hour visits per caledar year) Hospice care $5 50% $5 $50 $5 per procedure 0 $75 (up to a 100-day supply) $5 $15 5 $5 idividual $2 group $5 idividual 20% 6 8 $150 allowace 9 $15 $5 50% $15 $50 0 per procedure 0 $75 (up to a 30-day supply) $25 5 $200 per day $15 idividual $7 group $200 per day $15 idividual $200 per day 20% 6 8 $150 allowace 9 $20 $5 $20 $50 $150 per procedure 0 $75 (up to a 30-day supply) $30 5 $300 per day $20 idividual group $300 per day $20 idividual $300 per day 20% 6 8 10 $30 $5 $30 $50 $200 per procedure 0 $75 (up to a 100-day supply) $35 (after pharmacy deductible) $400 per day $30 idividual $15 group $400 per day $30 idividual $400 per day 7 7 10 For effective dates 1/1/13 6/1/13 $50 $5 $50 $50 $250 per procedure $150 $300 (up to a 100-day supply) $35 (after pharmacy deductible) $500 per day $50 idividual $25 group $500 per day $50 idividual $500 per day 7 7 10 Kaiser Permaete plas do ot iclude a pre-existig coditio clause. Prevetive services o this pla are available at o cost share. For a complete list of prevetive services please refer to the Evidece of Coverage or busiesset.kp.org. 1 Out-of-pocket maximum is the maximum amout a idividual or family will pay for certai services i a caledar year. 2 Scheduled preatal visits ad the first postpartum visit 3 Well-child visits through age 23 moths 4 Prescriptio drugs are covered i accordace with our formulary whe prescribed by a Pla physicia ad obtaied at Pla pharmacies. A few drugs have differet copaymets; please refer to the Evidece of Coverage for detailed iformatio about prescriptio drug copaymets. 5 The deductible does ot apply to this service. 6 The maximum allowable amout for DME is $2,000. 7 Please refer to the Evidece of Coverage for more iformatio o DME, prosthetics, orthotics, ad devices. Most DME for home use, prosthetics, orthotics, ad devices are ot covered. 8 There is o maximum amout for prosthetics, orthotics, ad devices. 9 Allowace toward the cost of eyeglass leses, frames, ad cotact leses fittig ad dispesig every 24 moths 10 Kaiser Permaete members are etitled to a 20 percet discout o eyeglasses ad cotact leses purchased at Kaiser Permaete optical ceters. These discouts may ot be coordiated with ay other Health Pla visio beefit. The discouts will ot apply to ay sale, promotio, or packaged eyewear program, for ay cotact les exteded purchase agreemet, or to low-visio aids or devices. Visit kp2020.org for Kaiser Permaete optical locatios. 2 Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie
KAISER PERMANENTE DEDUCTIBLE HMO plas Pla Highlights Features $30/$1,000 PLAN Member Pays Most Popular Deductible pla $30/$1,500 PLAN Member Pays $40/$2,000 PLAN Member Pays $40/$3,000 PLAN Member Pays Caledar-Year Deductible 1 Idividual/Family $1,000/$2,000 $1,500/$3,000 $2,000/$4,000 $3,000/$6,000 Pharmacy Caledar-Year Deductible N/A N/A N/A N/A Aual Out-of-Pocket Maximum 1,2 Idividual/Family $3,500/$7,000 $3,500/$7,000 $4,500/$9,000 $6,000/$12,000 I the Medical Office Office visits 3 Prevetive exams 3 Materity/Preatal care 3,4 Well-child prevetive care visits 3,5 Vaccies (immuizatios) 3 Allergy ijectios Ifertility services Occupatioal, physical, ad speech therapy Most labs ad imagig MRI/CT/PET Outpatiet surgery Emergecy Services Emergecy Departmet visits (waived if admitted directly to hospital) Ambulace Prescriptios 3,6 Geeric Brad-ame Hospital Care Physicias services, room ad board, tests, medicatios, supplies, therapies Skilled ursig facility care (up to 60 days per beefit period) Metal Health Services I the medical office 3 I the hospital Chemical Depedecy Services I the medical office 3 I the hospital (detoxificatio oly) Other Certai durable medical equipmet (DME) 7 Certai prosthetics, orthotics, ad devices 7 Optical (eyewear) 8 Visio exam 3 Home health care 3 (up to 100 two-hour visits per caledar year) Hospice care 3 $30 $5 $30 $50 $250 per procedure 0 $75 (up to a 30-day supply) $30 $500 per day $50 per day $30 (for idividual therapy) $15 (for group therapy) $500 per day $30 (for idividual therapy) $500 per day $30 $5 $30 $50 $250 per procedure 0 $75 (up to a 30-day supply) $30 $500 per day $50 per day $30 (for idividual therapy) $15 (for group therapy) $500 per day $30 (for idividual therapy) $500 per day $40 $5 $40 $50 0 (up to a 30-day supply) $35 30% per admissio 30% per admissio $40 (for idividual therapy) $20 (for group therapy) 30% per admissio $40 (for idividual therapy) 30% per admissio For effective dates 1/1/13 6/1/13 $40 $5 $40 3 $50 0 (up to a 30-day supply) $35 30% per admissio 30% per admissio $40 (for idividual therapy) $20 (for group therapy) 30% per admissio $40 (for idividual therapy) 30% per admissio Kaiser Permaete plas do ot iclude a pre-existig coditio clause. Prevetive services o this pla are available at o cost share. For a complete list of prevetive services please refer to the Evidece of Coverage or busiesset.kp.org. 1 This is a embedded pla. For a family of two or more, a idividual deductible is part of the family deductible. Each family member becomes eligible for copaymets or coisurace either after meetig his or her idividual deductible or after the family collectively meets the family deductible. The same methodology applies to the out-of-pocket maximum. 2 Out-of-pocket maximum is the maximum amout a idividual or family will pay for certai services i a caledar year. 3 For this service the deductible does t apply. 4 Scheduled preatal visits ad the first postpartum visit 5 Well-child visits through age 23 moths 6 Prescriptio drugs are covered i accordace with our formulary whe prescribed by a Pla physicia ad obtaied at Pla pharmacies. A few drugs have differet copaymets; please refer to the Evidece of Coverage for detailed iformatio about prescriptio drug copaymets. 7 Please refer to the Evidece of Coverage for more iformatio o DME, prosthetics, orthotics, ad devices. Most DME for home use, prosthetics, orthotics, ad devices are ot covered. 8 Kaiser Permaete members are etitled to a 20 percet discout o eyeglasses ad cotact leses purchased at Kaiser Permaete optical ceters. These discouts Ay may aotatios ot be coordiated are persoal with commets ay other for Health research, Pla visio iformatioal beefit. The ad discouts educatio will purposes ot apply ONLY. to ay Sales sale, promotio, Proposals or ONLY packaged allow eyewear the additio program, of Aget for ay Cotact Ifo! cotact les exteded purchase agreemet, or to low-visio aids or devices. Visit kp2020.org for Kaiser Permaete optical locatios. Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie 3
KAISER PERMANENTE HSA-Qualified Deductible HMO plas PLAN HIGHLIGHTS Features /$2,000 PLAN w/hsa Member Pays Most Popular DEDUCTIBLE pla W/HSA /$2,700 Pla w/hsa Member Pays Caledar-Year Deductible Idividual/Family $2,000/$4,000 1 $2,700/$5,450 2 $3,000/$6,000 2 Pharmacy Caledar-Year Deductible N/A N/A N/A Aual Out-of-Pocket Maximum 3 Idividual/Family $3,500/$7,000 1 $4,500/$9,000 2 $5,950/$11,900 2 I the Medical Office Office visits Prevetive exams 4 Materity/Preatal care 4,5 Well-child prevetive care visits 4,6 Vaccies (immuizatios) 4 Allergy ijectios Ifertility services Occupatioal, physical, ad speech therapy Most labs ad imagig MRI/CT/PET Outpatiet surgery Emergecy Services Emergecy Departmet visits (waived if admitted directly to hospital) Ambulace Prescriptios 7 Geeric Brad-ame Hospital Care Physicias services, room ad board, tests, medicatios, supplies, therapies Skilled ursig facility care (up to 100 days per beefit period) Metal Health Services I the medical office I the hospital Chemical Depedecy Services I the medical office I the hospital (detoxificatio oly) Other Certai durable medical equipmet (DME) 8 Certai prosthetics, orthotics, ad devices 8 Optical (eyewear) 9 Visio exam Home health care (up to 100 two-hour visits per caledar year) Hospice care $50 $150 per procedure 0 0 (up to a 30-day supply) $30 $300 per day per admissio (after deductible for idividual therapy) (after deductible for group therapy) $300 per day (after deductible for idividual therapy) $300 per day $50 $250 per procedure 0 0 (up to a 30-day supply) $30 $450 per day per admissio (after deductible for idividual therapy) (after deductible for group therapy) $450 per day (after deductible for idividual therapy) $450 per day For effective dates 1/1/13 6/1/13 $30/$3,000 Pla w/hsa Member Pays $30 $5 $30 $50 0 (up to a 30-day supply) $30 30% per admissio 30% per admissio $30 (after deductible for idividual therapy) $15 (after deductible for group therapy) 30% per admissio $30 (after deductible for idividual therapy) 30% per admissio $30 Kaiser Permaete plas do ot iclude a pre-existig coditio clause. Prevetive services o this pla are available at o cost share. For a complete list of prevetive services please refer to the Evidece of Coverage or busiesset.kp.org. 1 This is a aggregate pla. For a family of two or more, the family deductible applies to the whole family. Oce the family deductible is met (by oe family member or combiatio of family members), the family becomes eligible for copaymets or coisurace. The same methodology applies to the out-of-pocket maximum. 2 This is a embedded pla. For a family of two or more, a idividual deductible is part of the family deductible. Each family member becomes eligible for copaymets or coisurace either after meetig his or her idividual deductible or after the family collectively meets the family deductible. The same methodology applies to the out-of-pocket maximum. 3 Out-of-pocket maximum is the maximum amout a idividual or family will pay for certai services i a caledar year 4 The deductible does ot apply to this service. 5 Scheduled preatal visits 6 Well-child visits through age 23 moths 7 Prescriptio drugs are covered i accordace with our formulary whe prescribed by a Pla physicia ad obtaied at Pla pharmacies. A few drugs have differet copaymets; please refer to the Evidece of Coverage for detailed iformatio about prescriptio drug copaymets. 8 Please refer to the Evidece of Coverage for more iformatio o DME, prosthetics, orthotics, ad devices. Most DME for home use, prosthetics, orthotics, ad devices are ot covered. 9 Kaiser Permaete members are etitled to a 20 percet discout o eyeglasses ad cotact leses purchased at Kaiser Permaete optical ceters. These discouts may ot be coordiated with ay other Health Pla visio beefit. The discouts will ot apply to ay sale, promotio, or packaged eyewear program, for ay cotact les exteded purchase agreemet, or to low-visio aids or devices. Visit kp2020.org for Kaiser Permaete optical locatios. 4 Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie
KAISER PERMANENTE Deductible HMO plas with HRA PLAN HIGHLIGHTS For effective dates 1/1/13 6/1/13 Features $30/$1,500 PLAN WITH HRA Member Pays $30/$2,500 PLAN WITH HRA Member Pays Caledar-Year Deductible 1 Idividual/Family $1,500/$3,000 $2,500/$5,000 Pharmacy Caledar-Year Deductible N/A N/A Aual Out-of-Pocket Maximum 1,2 Idividual/Family $3,500/$7,000 $5,000/,000 I the Medical Office Office visits Prevetive exams 3 Materity/Preatal care 3,4 Well-child prevetive care visits 3,5 Vaccies (immuizatios) 3 Allergy ijectios Ifertility services Occupatioal, physical, ad speech therapy Most labs ad imagig MRI/CT/PET Outpatiet surgery Emergecy Services Emergecy Departmet visits (waived if admitted directly to hospital) Ambulace Prescriptios 3,6 Geeric Brad-ame Hospital Care Physicias services, room ad board, tests, medicatios, supplies, therapies Skilled ursig facility care Metal Health Services I the medical office I the hospital Chemical Depedecy Services I the medical office I the hospital (detoxificatio oly) Other Certai durable medical equipmet (DME) 7 Certai prosthetics, orthotics, ad devices 7 Optical (eyewear) 8 Visio exam 3 Home health care 3 (up to 100 two-hour visits per caledar year) Hospice care 3 $30 $30 $50 20% 20% $150 (up to a 30-day supply) $30 20% per admissio 20% per admissio (up to 100 days per beefit period) $30 (after deductible for idividual therapy) $15 (after deductible for group therapy) 20% per admissio $30 (after deductible for idividual therapy) 20% per admissio $30 $30 $50 20% 20% $150 (up to a 30-day supply) $30 20% per admissio 20% per admissio (up to 100 days per beefit period) $30 (after deductible for idividual therapy) $15 (after deductible for group therapy) 20% per admissio $30 (after deductible for idividual therapy) 20% per admissio Kaiser Permaete plas do ot iclude a pre-existig coditio clause. Prevetive services o this pla are available at o cost share. For a complete list of prevetive services please refer to the Evidece of Coverage or busiesset.kp.org. Employer is required to establish ad fud a HRA accout. However, there is o miimum fudig requiremet. 1 This is a embedded pla. For a family of two or more, a idividual deductible is part of the family deductible. Each family member becomes eligible for copaymets or coisurace either after meetig his or her idividual deductible or after the family collectively meets the family deductible. The same methodology applies to the out-of-pocket maximum. 2 Out-of-pocket maximum is the maximum amout that a idividual or family will pay for certai services i a caledar year. 3 The deductible does ot apply to this service. 4 Scheduled preatal visits ad the first postpartum visit 5 Well-child visits through age 23 moths 6 Prescriptio drugs are covered i accordace with our formulary whe prescribed by a Pla physicia ad obtaied at Pla pharmacies. A few drugs have differet copaymets; please refer to the Evidece of Coverage for detailed iformatio about prescriptio drug copaymets. 7 Please refer to the Evidece of Coverage for more iformatio o DME, prosthetics, orthotics, ad devices. Most DME for home use, prosthetics, orthotics, ad devices are ot covered. 8 Kaiser Permaete members are etitled to a 20 percet discout o eyeglasses ad cotact leses purchased at Kaiser Permaete optical ceters. These discouts may ot be coordiated with ay other Health Pla visio beefit. The discouts will ot apply to ay sale, promotio, or packaged eyewear program, for ay cotact les exteded purchase agreemet, or to low-visio aids or devices. Visit kp2020.org for Kaiser Permaete optical locatios. Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie 5
KAISER PERMANENTE $35 POS PLAN PLAN HIGHLIGHTS Kaiser Permaete Pla providers (HMO) (i-etwork) PHCS providers (PPO)* For effective dates 1/1/13 6/1/13 Noparticipatig providers (out-of-etwork)* Features Member Pays Member Pays Member Pays Caledar-Year Deductible 1 $500 (idividual)/$1,000 (family of 2)/$1,500 (family of 3+) Pharmacy Caledar-Year Deductible N/A N/A Aual Out-of-Pocket Maximum 2,3 I the Medical Office Office visits Routie adult physical exams Prevetive exams Scheduled preatal care 6 Well-child prevetive care visits Vaccies (immuizatios) Allergy ijectios Ifertility services 9 Occupatioal, physical, ad speech therapy Most labs ad imagig MRI/CT/PET Outpatiet surgery Emergecy Services Emergecy Departmet visits (copay waived if admitted directly to hospital) Emergecy Ambulace Services Medically ecessary oemergecy ambulace service Prescriptios 13 (up to a 100-day supply) Geeric Brad-ame Noformulary Hospital Care Physicias services, room ad board, tests, medicatios, supplies, therapies Skilled ursig facility care (up to 100 days per beefit period) Metal Health Services I the medical office I the hospital Chemical Depedecy Services I the medical office I the hospital Other Certai durable medical equipmet (DME) 16 Certai prosthetics, orthotics, ad special footwear 16 Optical (eyewear) Visio exam Home health care $3,000 (idividual)/ $6,000 (family of 2+) $35 7 $5 $35 $50 0 $3,000 (idividual)/$6,000 (family of 2)/$9,000 (family of 3+) 4 $45 (deductible waived) $45 (deductible waived) 5 $45 (deductible waived) $25 (deductible waived) $25 (deductible waived) 8 $25 (deductible waived) $45 (deductible waived) 10 30% 30% 30% $6,000 (idividual)/$12,000 (family of 2)/$18,000 (family of 3+) 4 50% 50% (deductible waived) 50% 50% 8 50% 50% 10 50% 50% 50% 11 Covered as a HMO beefit, subject to a 0 copay, regardless of facility/hospital accessed Covered as a HMO beefit, subject to a $75 charge $75 50% 12 50% 12 Obtaied at Kaiser Permaete Pla pharmacies (icludig affiliated pharmacies) $35 $50 $200 per day $35 idividual therapy $17 group therapy $200 per day $35 idividual therapy $5 group therapy $200 per day Obtaied at participatig MedImpact pharmacies 14 Ay aotatios See foototes are persoal ad other commets importat for research, iformatio iformatioal o pages ad 7 ad educatio 12. purposes ONLY. Sales Proposals ONLY allow the additio of Aget Cotact Ifo! 6 Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie $15 $40 $60 30% 30% $45 per idividual therapy visit (deductible waived) $45 group therapy (deductible waived) 30% $45 per idividual therapy visit (deductible waived) $45 group therapy (deductible waived) 30% 30% 17 18 20% 19 (up to 100 two-hour visits per caledar year) Hospice care 30% 20 50% 20 Maximum beefit while isured Noe $2 millio 21 50% 15 50% 15 50% per idividual therapy visit 50% group therapy 50% 15 50% per idividual therapy visit 50% group therapy 50% 15 50% 17 20% 19 For your group to be eligible for the $35 POS Pla, the $40/$1,000 PPO Pla, or the $40/$2,500 PPO Pla with HSA Optio, you must have Kaiser Permaete as your sole carrier, ad the pla must be offered with at least oe copaymet or deductible HMO pla as part of a multiple pla offerig. If you iclude a PPO or POS pla i your multiple pla offerig, at least 70 percet of all employees erolled i the Health Pla must be erolled i a copaymet or deductible HMO pla, ad combied erollmet i Kaiser Permaete Isurace Compay (KPIC) medical plas must ot exceed 30 percet.
Notes for the Kaiser Permaete $35 POS Pla Kaiser Permaete plas do ot iclude a pre-existig coditio clause. * Based o maximum allowable charge for covered services Paymets are based upo the maximum allowable charge for covered services. Maximum allowable charge meas the lesser of: the usual, customary, ad reasoable charges; the egotiated rate; or the actual billed charges. The maximum allowable charge may be less tha the amout actually billed by the provider. Covered persos may be resposible for paymet of ay amouts i excess of the maximum allowable charge for a covered service. 1 Deductible amouts are combied for services provided by PHCS etwork ad oparticipatig providers. Deductibles do ot cout toward satisfyig the out-of-pocket maximum. This pla carries a embedded deductible. Each family member becomes eligible for beefits after meetig the idividual deductible, or whe the family deductible is satisfied. 2 The aual out-of-pocket maximum is the limit to the total amout that a idividual (self-oly) or family must pay for certai services i a caledar year (as discussed i the Evidece of Coverage ad the Certificate of Isurace). A family member ca meet the idividual aual out-of-pocket maximum before the family out-of-pocket maximum is satisfied. 3 Covered charges icurred to satisfy the out-of-pocket maximum at the PHCS etwork level will ot be applicable toward satisfactio of the out-ofpocket maximum at the oparticipatig providers level. Likewise, covered charges applied to satisfy the out-of-pocket maximum at the oparticipatig providers level will ot be applicable toward satisfactio of the out-of-pocket maximum at the PHCS etwork level. 4 The family out-of-pocket maximum equals three times the idividual out-of-pocket maximum for family cotracts of three or more members. Family cotracts with two members will require each member to satisfy the idividual out-of-pocket maximum. 5 Routie adult physical exams are limited to oe exam every 12 moths. Prevetive lab tests, X-ray, ad immuizatios are covered as part of the prevetive exam. 6 Scheduled preatal visits ad the first postpartum visit. 7 Well-child care is covered by Kaiser Permaete Pla providers (HMO) through age 23 moths. 8 Well-child care (ages 0 to 21) is exempt from deductibles from PHCS etwork providers ad icludes immuizatios. 9 I accordace with Califoria law, health care plas ad isurers are required to offer cotract holders ad policyholders the optio to purchase coverage of ifertility treatmet (excludig i vitro fertilizatio). For details regardig this optioal coverage, icludig how you may elect this coverage ad the amout of additioal rates, please cotact your broker or the Accout Maagemet Team at 1-800-790-4661. 10 All outpatiet therapies, except those associated with Autism Spectrum Disorders, are limited to 60 days per caledar year for services from PHCS etwork ad oparticipatig providers combied. 11 KPIC pays a maximum of $400 per procedure for outpatiet surgery services from oparticipatig providers. 12 The PHCS Provider Network does ot cotract for ambulace coverage. Therefore, ambulace coverage is payable at the oparticipatig providers level. Noemergecy ambulace coverage is limited to a maximum of $2,000 per caledar year for all KPIC-covered services. 13 Please refer to the Evidece of Coverage ad KPIC Certificate of Isurace for detailed iformatio about prescriptio drug copaymets. Regardless of your provider, prescriptios ca be filled at either a Kaiser Permaete or MedImpact participatig pharmacy. 14 Participatig MedImpact pharmacy copaymets ad deductibles are ot subject to, or do they cotribute toward satisfactio of, the caledar-year deductible or the out-of-pocket maximum. Select prescriptio medicatios are excluded from coverage. Please cosult your participatig pharmacy directory for a curret list of participatig pharmacies. 15 KPIC pays a maximum of $600 per day combied for all hospital care received from oparticipatig providers, excludig physicia, surgeo, ad surgical services. 16 Please refer to the Evidece of Coverage ad the Certificate of Isurace for more iformatio. 17 DME beefit is limited to $2,000 maximum per caledar year for services from PHCS etwork ad oparticipatig providers combied, excludig diabetic testig supplies ad equipmet. 18 Kaiser Permaete members are etitled to a 20 percet discout o eyeglasses ad cotact leses purchased at Kaiser Permaete optical ceters. These discouts may ot be coordiated with ay other Health Pla visio beefit. The discouts will ot apply to ay sale, promotio, or packaged eyewear program, for ay cotact les exteded purchase agreemet, or to low-visio aids or devices. Visit kp2020.org for Kaiser Permaete optical locatios. 19 Home health care is limited to a maximum of 100 visits per caledar year combied for services provided by PHCS etwork ad oparticipatig providers. Deductible amout is limited to a maximum of $50 per caledar year. 20 Hospice care is limited to a 180-day maximum beefit while isured for services from PHCS etwork ad oparticipatig providers combied. 21 Maximum beefit while isured is $2 millio combied for services provided by PHCS etwork ad oparticipatig providers. Exclusios ad limitatios Exclusios ad limitatios are listed i the Evidece of Coverage cotaied i the Group Agreemet. Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie 7
KAISER PERMANENTE $40/$1,000 PPO isurace pla Pla Highlights PHCS etwork (PPO)* For effective dates 1/1/13 6/1/13 Noparticipatig providers (out-of-etwork)* Features Member Pays Member Pays Caledar-Year Deductible 1 $1,000 (idividual)/$2,000 (family of 2+) Aual Out-of-Pocket Maximum 1,2 $5,000 (idividual)/,000 (family of 2+),000 (idividual)/$20,000 (family of 2+) outpatiet care Office visits Routie adult physical exams Prevetive exams Well-child prevetive care visits (through age 21) 7 Allergy ijectio visits Scheduled preatal care 9 Birth services 10 Diagostic imagig, icludig X-rays Diagostic lab tests Eye exams for eyeglass prescriptios Hearig screeigs Occupatioal, physical, respiratory, ad speech therapy visits 11 Health educatio Outpatiet surgery emergecy services Emergecy Departmet visits Emergecy ambulace service Medically ecessary oemergecy ambulace service 12 Prescriptios 13 Brad-ame deductible (pharmacy ad mail order) Geeric drugs Brad-ame drugs Self-admiistered ijectable drugs 15 Mail-order geeric drugs Mail-order brad-ame drugs hospital care Room, board, ad critical care uits Imagig, icludig X-rays ad lab tests Trasplats Physicia, surgeo, ad surgical services Nursig care, aesthesia, ad ipatiet prescribed drugs metal health care Ipatiet hospitalizatio Outpatiet visits Alcohol ad chemical depedecy Ipatiet hospitalizatio Outpatiet visits Additioal beefits Care i a skilled ursig facility (60-day combied limit per Beefit period) Home health care (100 visits per caledar year) 16 Hospice care (180-day combied maximum beefit while isured) Ifertility services 17 Certai durable medical equipmet (DME) 18 Certai prosthetics, orthotics, ad special footwear Diabetic equipmet ad supplies 19 $40 copay 4,5 5,6 5 5 5 5 5 0 copay, the 30% (copay waived if admitted) 50% 5 50% 5 8 MedImpact pharmacy 14 $200 deductible 4 $15 copay (maximum 30-day supply) 4 $35 copay (maximum 30-day supply) 4 (after brad-ame drug deductible) 30% 4 $30 copay (maximum 100-day supply) 4 $70 copay (maximum 100-day supply) 4 0 copay, the 30% (copay waived if admitted) 3 3 3 3 3 $40 copay 4,5 $40 copay 4,5 3 20% Maximum beefit while isured 20 Noe $5 milllio 3 20% For your group to be eligible for the $35 POS Pla, the $40/$1,000 PPO Pla, or the $40/$2,500 PPO Pla with HSA Optio, you must have Kaiser Permaete as your sole carrier, ad the pla must be offered with at least oe copaymet or deductible HMO pla as part of a multiple pla offerig. If you iclude a PPO or POS pla i your multiple pla offerig, at least 70 percet of all employees erolled i the Health Pla must be erolled i a copaymet or deductible HMO pla, ad combied erollmet i Kaiser Permaete Isurace Compay (KPIC) medical plas must ot exceed 30 percet. See foototes ad other importat iformatio o pages 9 ad 12. 8 Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie
Notes for the Kaiser Permaete $40/$1,000 PPO Isurace Pla Kaiser Permaete plas do ot iclude a pre-existig coditio clause. * Based o maximum allowable charge for covered services Paymets are based upo the maximum allowable charge for covered services. Maximum allowable charge meas the lesser of: the usual, customary, ad reasoable charges; the egotiated rate; or the actual billed charges. The maximum allowable charge may be less tha the amout actually billed by the provider. Covered persos may be resposible for paymet of ay amouts i excess of the maximum allowable charge for a covered service. 1 Caledar-year deductible amouts are combied for services provided by PHCS etwork ad oparticipatig providers. Deductibles do ot cout toward satisfyig the out-of-pocket maximum. This pla carries a embedded deductible. Each family member becomes eligible for beefits after meetig the idividual deductible, or whe the family deductible is satisfied. A family member ca meet the idividual aual out-of-pocket maximum before the family outof-pocket maximum is satisfied. 2 Covered charges icurred toward satisfactio of the out-of-pocket maximum at the oparticipatig providers tier will ot accumulate toward satisfactio of the out-of-pocket maximum o the PHCS etwork tier. Likewise, covered charges icurred toward satisfactio of the out-of-pocket maximum at the PHCS etwork tier will ot accumulate toward satisfactio of the out-of-pocket maximum o the oparticipatig providers tier. 3 KPIC pays a maximum of $600 per day combied for all hospital care received from oparticipatig providers, excludig physicia, surgeo, ad surgical services. 4 Brad-ame drug deductible, copaymets, ad coisurace paid for physicia office visit or paid for prescriptios filled at participatig pharmacies are ot subject to, or do they cotribute toward, satisfactio of either the caledar-year deductible or the out-of-pocket maximum. 5 For this service a deductible does ot apply. 6 Routie adult physical exams are limited to oe exam every 12 moths. Prevetive lab tests, X-ray, ad immuizatios are covered as part of the prevetive exam. 7 Well-child prevetive care is exempt from deductibles ad icludes immuizatios. 8 KPIC pays a maximum of $400 per procedure for outpatiet surgery services from oparticipatig providers. 9 Routie preatal care office visits are covered as required uder the Patiet Protectio ad Affordable Care Act (PPACA). This icludes the iitial ad subsequet histories, physical examiatios, recordig of weight, blood pressures, fetal heart toes, ad routie chemical urialysis. 10 Birth services, icludig delivery ad ipatiet care for mother ad baby, are covered uder your ipatiet services beefit. For a complete uderstadig of birth services, please see your Certificate of Isurace. 11 All outpatiet therapies, except those associated with Autism Spectrum Disorders, are limited to 60 visits per caledar year combied for both PHCS etwork ad oparticipatig providers. 12 The PHCS etwork does ot cotract for ambulace service. Therefore, medically ecessary oemergecy ambulace service is payable at the oparticipatig providers level. Noemergecy ambulace coverage is limited to a maximum of $2,000 per caledar year for all services. 13 Member is resposible for payig the brad-ame copay plus the differece i cost betwee the geeric drug ad the brad-ame drug whe the patiet requests a brad-ame drug ad a geeric versio is available. 14 MedImpact pharmacy copaymets are ot subject to, or do they cotribute toward satisfactio of, the caledar-year deductible or the out-of-pocket maximum. Select prescriptio drugs are excluded from coverage. 15 Self-admiistered ijectable medicatios are limited to a 30-day maximum supply ad are ot available uder the mail-order service. Prescriptios for isuli are covered at the brad-ame or geeric copaymet level. 16 Combied maximum deductible of $50 per caledar year 17 Beefits payable for treatmet of ifertility are limited to $1,000 per caledar year combied for services provided by PHCS etwork or oparticipatig providers. I vitro fertilizatio is ot covered. Beefits payable for diagosis of ifertility will be covered o the same basis as ay other illess. 18 Certai DME ad supplies are limited to a combied maximum beefit of $2,000 per caledar year for services from PHCS etwork ad oparticipatig providers, excludig diabetic testig supplies ad equipmet. 19 Diabetic equipmet ad supplies are limited to ifusio set ad syrige with eedle for exteral isuli pumps, testig strips, lacets, ski barrier, adhesive remover wipes, ad trasparet film. Coisurace amouts are based o actual billed charges ad are ot subject to the DME aual maximum limit of $2,000 per caledar year. 20 Maximum beefit while isured applies to covered charges from oparticipatig providers oly. Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie 9
KAISER PERMANENTE $40/$2,500 PPO INSURANCE PLAN WITH HSA OPTIO PLAN HIGHLIGHTS PHCS etwork (PPO)* For effective dates 1/1/13 6/1/13 Noparticipatig providers (out-of-etwork)* Features Member Pays Member Pays Caledar-Year Deductible 1 $2,500 (idividual)/$5,000 (family of 2+) $3,500 (idividual)/$7,000 (family of 2+) Aual Out-of-Pocket Maximum 2 $5,000 (idividual)/,000 (family of 2+),000 (idividual)/$20,000 (family of 2+) outpatiet care Office visits Routie adult physical exams Prevetive exams Well-child prevetive care visits (through age 21) 6 Allergy ijectio visits Scheduled preatal care 8 Birth services 9 Diagostic imagig, icludig X-rays Diagostic lab tests Eye exams for eyeglass prescriptios Hearig screeigs Occupatioal, physical, respiratory, ad speech therapy visits 10 Health educatio Outpatiet surgery emergecy services Emergecy Departmet visits Emergecy ambulace service Medically ecessary oemergecy ambulace service 11 Noemergecy urget care Prescriptios 12 Geeric drugs Brad-ame drugs Self-admiistered ijectable medicatios 14 Mail-order geeric drugs Mail-order brad-ame drugs hospital CAre Room, board, ad critical care uits Imagig, icludig X-rays ad lab tests Trasplats Physicia, surgeo, ad surgical services Nursig care, aesthesia, ad ipatiet prescribed drugs metal health care Ipatiet hospitalizatio Outpatiet visits Alcohol ad chemical depedecy Ipatiet hospitalizatio Outpatiet visits Additioal beefits Care i a skilled ursig facility (60-day combied limit per Beefit period) Home health care (100 visits per caledar year) Hospice care (180-day combied maximum beefit while isured) Ifertility services 15 Certai durable medical equipmet (DME) 16 Certai prosthetics, orthotics, ad special footwear Diabetic equipmet ad supplies 17 $40 copay 4,5 4 4 4 4 4 0 copay, the 30% (copay waived if admitted) 50% 4 50% 4 7 MedImpact pharmacy 13 $15 copay (maximum 30-day supply) $35 copay (maximum 30-day supply) 30% $30 copay (maximum 100-day supply) $70 copay (maximum 100-day supply) $40 copay $40 copay 20% 0 copay, the 30% (copay waived if admitted 3 3 3 3 3 3 3 20% Maximum beefit while isured 18 Noe $5 milllio For your group to be eligible for the $35 POS Pla, the $40/$1,000 PPO Pla, or the $40/$2,500 PPO Pla with HSA Optio, you must have Kaiser Permaete as your sole carrier, ad the pla must be offered with at least oe copaymet or deductible HMO pla as part of a multiple pla offerig. If you iclude a PPO or POS pla i your multiple pla offerig, at least 70 percet of all employees erolled i the Health Pla must be erolled i a copaymet or deductible HMO pla, ad combied erollmet i Kaiser Permaete Isurace Compay (KPIC) medical plas must ot exceed 30 percet. See foototes ad other importat iformatio o pages 11 ad 12. 10 Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie
Notes for the Kaiser Permaete $40/$2,500 PPO Isurace Pla with HSA Optio Kaiser Permaete plas do ot iclude a pre-existig coditio clause. * Based o maximum allowable charge for covered services Paymets are based upo the maximum allowable charge for covered services. Maximum allowable charge meas the lesser of: the usual, customary, ad reasoable charges; the egotiated rate; or the actual billed charges. The maximum allowable charge may be less tha the amout actually billed by the provider. Covered persos may be resposible for paymet of ay amouts i excess of the maximum allowable charge for a covered service. 1 Caledar-year deductible amouts are separate for services provided by PHCS etwork ad oparticipatig providers. Covered charges applied toward the satisfactio of the caledar-year deductible may also be applied toward the satisfactio of the out-of-pocket maximum. 2 Out-of-pocket maximums are separate for services provided by PHCS etwork ad oparticipatig providers. 3 KPIC pays a maximum of $600 per day combied for all hospital care received from oparticipatig providers, excludig physicia, surgeo, ad surgical services. 4 For this service a deductible does ot apply. 5 Routie adult physical exams are limited to oe exam every 12 moths. Prevetive lab tests, X-ray, ad immuizatios are covered as part of the prevetive exam. 6 Well-child prevetive care is exempt from deductibles ad icludes immuizatios. 7 KPIC pays a maximum of $400 per procedure for outpatiet surgery services from oparticipatig providers. 8 Routie preatal care office visits are covered as required uder the Patiet Protectio ad Affordable Care Act (PPACA). This icludes the iitial ad subsequet histories, physical examiatios, recordig of weight, blood pressures, fetal heart toes, ad routie chemical urialysis. 9 Birth services, icludig delivery ad ipatiet care for mother ad baby, are covered uder your ipatiet services beefit. For a complete uderstadig of birth services, please see your Certificate of Isurace. 10 All outpatiet therapies, except those associated with Autism Spectrum Disorders, are limited to 60 visits per caledar year combied for both PHCS etwork ad oparticipatig providers. 11 The PHCS etwork does ot cotract for ambulace service. Therefore, medically ecessary oemergecy ambulace service is payable at the oparticipatig providers level. Noemergecy ambulace coverage is limited to a maximum of $2,000 per caledar year for all services. 12 Member is resposible for payig the brad-ame copay plus the differece i cost betwee the geeric drug ad the brad-ame drug whe the patiet requests a brad-ame drug ad a geeric versio is available. 13 MedImpact pharmacy copaymets are subject to the satisfactio of the caledar-year deductible ad out-of-pocket maximum. Drugs prescribed for family plaig are subject to the caledar-year deductible. Select prescriptio drugs are excluded from coverage. 14 Self-admiistered ijectable medicatios are limited to a 30-day maximum supply ad are ot available uder the mail-order service. Prescriptios for isuli are covered at the brad-ame or geeric copaymet level. 15 Beefits payable for treatmet of ifertility are limited to $1,500 per lifetime combied for services provided by PHCS etwork or oparticipatig providers. I vitro fertilizatio is ot covered. Beefits payable for diagosis of ifertility will be covered o the same basis as ay other illess. 16 Certai DME ad supplies are limited to a combied maximum beefit of $2,000 per caledar year for services from PHCS etwork ad oparticipatig providers, excludig diabetic testig supplies ad equipmet. 17 Diabetic equipmet ad supplies are limited to ifusio set ad syrige with eedle for exteral isuli pumps, testig strips, lacets, ski barrier, adhesive remover wipes, ad trasparet film. Coisurace amouts are based o actual billed charges ad are ot subject to the DME aual maximum limit of $2,000 per caledar year. 18 Maximum beefit while isured applies to covered charges from oparticipatig providers oly. Importat otice regardig the $40/$2,500 PPO Isurace Pla with HSA Optio This chart is a summary of the beefits for a federally qualified High Deductible Health Pla (HDHP) compatible with Health Savigs Accouts (HSAs) i accordace with the Medicare Prescriptio Drug, Improvemet ad Moderizatio Act of 2003, as the costituted or later ameded. Erollmet i a HDHP that is HSA-compatible is oly oe of the eligibility requiremets for establishig ad cotributig to a HSA. Please cosult with your employer about other eligibility requiremets for establishig a HSA-qualified pla. Please ote: If you have other health coverage, icludig coverage uder Medicare, i additio to the coverage uder this Group Policy, you may ot be eligible to establish or cotribute to a HSA uless both coverages qualify as High Deductible Health Plas. KPIC does ot provide tax advice. The Califoria Departmet of Isurace does ot i ay way warrat that this pla meets the federal requiremets. Cosult with your fiacial or tax adviser for tax advice or more iformatio about your eligibility for a HSA. Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie 11
Notes for Kaiser Permaete POS ad PPO plas Precertificatio of services provided by PHCS etwork ad oparticipatig providers Precertificatio is required for all hospital cofiemets, icludig preadmissio testig; ipatiet care at a skilled ursig facility or other licesed, freestadig facilities, such as hospice care, home health care, or care at a rehabilitatio facility; ad select outpatiet procedures. Failure to obtai precertificatio will result i a additioal deductible of $500 per occurrece for covered charges icurred i coectio with these services. This additioal deductible will ot cout toward the satisfactio of ay caledar-year deductibles or out-of-pocket maximums. PHCS etwork ad oparticipatig providers Uless specifically covered uder the group policy, expeses icurred i coectio with the followig services are excluded: charges, services, or care that are provided or reimbursed by Kaiser Foudatio Health Pla; ot medically ecessary; i excess of the maximum allowable charge; ot available i the Uited States; for persoal comfort. Emergecy Departmet facility fees or charges for oemergecy weeked (Friday through Suday) hospital admissios. Charges arisig from work or that ca be covered uder workers compesatio or ay similar law, or for which the group policyholder or member is required by law to maitai alterative isurace or coverage. Charges for military service-related coditios or where care is provided at govermet expese. Services or care provided i a member s home, by a family member, or by a residet of the household. Detal care, appliaces, or orthodotia, uless due to ijury to atural teeth. Cosmetic services; plastic surgery; sex trasformatio; sexual dysfuctio; surrogacy arragemets; biotechology drugs or diagostics; oprescriptio drugs or medicies; treatmet, procedures, or drugs Kaiser Permaete Isurace Compay determies to be experimetal or ivestigatioal. Educatio, couselig, therapy, or care for learig deficiecies or behavioral problems, except as otherwise provided for the treatmet of Serious Metal Illess of a perso of ay age ad/or Serious Emotioal Disturbaces of a Child. Services, care, or treatmet of or i coectio with obesity or weight maagemet. Services, care, or treatmet of or i coectio with craiomadibular or temporomadibular joit disorders, uless for medically ecessary surgical treatmet of the disorder. Services, care, or treatmet of or i coectio with musculoskeletal therapy; health educatio; biofeedback; hypotherapy; routie adult physical exams; immuizatios; medical social services; hearig exams, aids, or therapy; radial keratotomy or similar procedures; reversal of sterilizatio; or routie foot care. Services or care required by a court of law or for isurace, travel, employmet, school, camp, govermet licesig, or similar purposes. Trasplats, icludig door costs. Custodial care; care i a itermediate care facility; maiteace therapy for rehabilitatio; or livig or trasportatio expeses. Treatmet of metal illess; substace abuse. Services or supplies ecessary to treat a ijury to which a cotributig cause was a member s: commissio of or attempt to commit a feloy; egagemet i a illegal occupatio; itoxicatio; or uder the ifluece of a arcotic, uless admiistered by a physicia. Services of a private-duty urse. Visio care, icludig routie exams, eye refractios, orthoptics, glasses, cotact leses, or fittigs; drugs ad medicie for smokig cessatio; well-child care ad immuizatios. Exteded well-child care. Services for which o charge is ormally made i the absece of isurace. Importat iformatio Writte iformatio o topics related to coverage offered to employer groups i the small group market is available ad ca be obtaied by cotactig your broker or your sales represetative. Topics iclude: 1. Factors that affect rate settig ad rate adjustmets 2. Provisios related to reewig coverage 3. Geographic areas covered by the Health Pla 12 Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie
Detal plas 2013 Small Busiess For effective dates Jauary 1 Jue 1, 2013 Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie 13
Delta Detal Premier Plas For effective dates 1/1/13 6/1/13 Pla C Pla D Pla E Pla E with Ortho 1 Limitatios Service Pla pays 2 Pla pays 2 Pla pays 2 Pla pays 2 No deductible applies to these procedures. Exam 100% 100% 100% 100% Twice i a caledar year Bitewig X-rays X-rays of the top ad bottom molars ad premolars to show decay betwee teeth or uder filligs 100% 100% 100% 100% Twice i a caledar year for childre through age 18, or oce i a caledar year for adults ages 19 ad over Other X-rays 80% 80% 80% 80% Full-mouth X-rays, sigle X-rays, ad paographic X-rays oce i ay five-year period Prophylaxis A professioal cleaig to remove plaque, calculus (mieralized plaque), ad stais to help prevet detal disease Fluoride treatmets A treatmet with a chemical compoud that prevets cavities ad makes the tooth surface stroger so the teeth ca resist decay 100% 100% 100% 100% Twice i a caledar year 100% 100% 100% 100% Oly for childre through age 18, twice i a caledar year Deductibles apply to procedures uder plas D, E, ad E with Orthodotics. Caledar-year deductible No deductible $25 $25 $25 Per perso per caledar year up to a family maximum of $75 per caledar year Aual beefit maximum $500 $1,000 $1,000 $1,000 Aual beefit maximum represets the total aual amout paid by the pla per perso, per caledar year Palliative care Ay form of medical care or treatmet that cocetrates o reducig the severity of disease symptoms; the goal is to prevet ad relieve sufferig ad improve quality of life 80% 80% 80% 80% Usual, customary, ad reasoable Deture relies 80% 80% 80% Twice i a caledar year (limited to two upper, two lower, or ay combiatio) 3 Space maitaiers 100% 100% 100% 100% Usual, customary, ad reasoable Filligs 80% 80% 80% 80% Usual, customary, ad reasoable Stailess steel crows 80% 80% 80% 80% Primary teeth oly Edodotics A detal specialty cocered with treatmet of the root ad erve of the tooth Periodotics A detal specialty cocered with the treatmet of gums, tissue, ad boe that supports the teeth 80% 80% 80% Usual, customary, ad reasoable 80% 80% 80% Usual, customary, ad reasoable Oral surgery 80% 80% 80% Usual, customary, ad reasoable Crows ad cast restoratios The artificial coverig of a tooth with metal porcelai or porcelai fused to metal; covers teeth that are weakeed by decay or severely damaged or chipped Prosthodotics A detal specialty cocered with restoratio ad/or replacemet of missig teeth with artificial materials Orthodotics A detal specialty cocered with straighteig or movig misaliged teeth ad/or jaws with braces ad/or surgery 50% 50% Icludes replacemets after five years, but oly if origially covered by KPIC detal pla 50% 50% Stadard removable prosthetic appliace (icludes replacemets after five years, but oly if origially covered by KPIC detal pla) 50% For eligible depedet childre through age 18, $1,500 lifetime maximum per isured (Replacemet or repair of a orthodotic appliace paid for i part or i full by this pla is ot covered.) 1 Pla E with Orthodotics requires at least 10 subscribers. 2 Beefits payable will be based o the lesser of the usual, customary, ad reasoable fees or the fees actually charged. 3 Limitatio applies oly to Pla D. 14 Email us at Steve@SteveShorr.com to get a OFFICIAL clea umarked copy of this brochure or click lik below if it's available olie