|
Plan name: |
Kaiser HMO |
|
Plan year: |
2022 |
|
Group number: |
603966 |
|
Carrier: |
Kaiser Permanente Insurance Company |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
|
In-Network |
|
| Annual Deductible | None |
| Annual Out-of-Pocket Max | $1,500 per individual, up to $3,000 per family |
| Lifetime Max | Unlimited |
| Office Visit
Primary Provider Specialist |
$25 copay
$25 copay |
| Preventive Services | No charge |
| Chiropractic Care | $15 per visit (up to 20 visits per calendar year combined with acupuncture) |
| Lab & X-Ray | No charge |
| Inpatient Hospitalization | $250 copay, waived if admitted |
| Outpatient Surgery | $25 per procedure |
| Emergency Room | $100 per visit, waived if admitted |
| Retail Pharmacy | |
| Generic | $10 copay |
| Preferred Brand | $30 copay |
| Specialty | 20% coinsurance, not to exceed $200/Rx |
| Supply Limit | 30 days |
| Mail Order Pharmacy | |
| Generic | $20 copay |
| Preferred Brand | $60 copay |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
|
Employee Rates (monthly) |
Rate |
|
Employee Only |
$94.00 |
|
Employee + Spouse |
$252.00 |
|
Employee + Child(ren) |
$226.00 |
|
Family |
$376.00 |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.
|
Title/Department: |
Kaiser Member Services |
|
State: |
CA |
|
Phone: |
800-464-4000 |
|
URL: |
Disclaimer: Every effort has been made to ensure that the information in this summary is accurate; however no warranty of complete accuracy is made. If a discrepancy is found between this summary and the benefits you selected or the Summary Plan Description (SPD), your selections and the provisions of the SPD will govern.