2022 medical option coverage summaries

2022 medical option

coverage summaries

For retirees and/or family members who aren’tyet Medicare-eligible

Table of contents

If you and/or your family members are not yet eligible for Medicare (due to age or disability), you can each

enroll in:

• An HP medical option available in your ZIP code (as shown on your personalized statement), or

• An individual insurance option through a public health exchange (marketplace).

This document provides summaries of all HP non-Medicare medical options. Click on the name of a

medical option below to go directly to that medical option’s summary.

Aetna CDHP w/HRA........................................................................................................................................................................ 1

Aetna EPO........................................................................................................................................................................................ 3

Aetna HDHP (pre-65 option) ........................................................................................................................................................ 5

Aetna Premium PPO...................................................................................................................................................................... 7

Aetna Value PPO ............................................................................................................................................................................ 9

Anthem BCBS Basic CMP.............................................................................................................................................................11

Anthem BCBS CDHP w/HRA........................................................................................................................................................13

Anthem BCBS EPO .......................................................................................................................................................................15

Anthem BCBS HDHP (pre-65 option) ........................................................................................................................................17

Anthem BCBS Premium CMP......................................................................................................................................................19

Anthem BCBS Premium PPO......................................................................................................................................................21

Anthem BCBS Standard CMP......................................................................................................................................................23

Anthem BCBS Value PPO ............................................................................................................................................................25

Blue Essentials HMO....................................................................................................................................................................27

Cigna CDHP w/HRA ......................................................................................................................................................................29

Cigna EPO ......................................................................................................................................................................................31

Cigna HDHP (pre-65 option).......................................................................................................................................................33

Cigna Premium PPO.....................................................................................................................................................................35

Cigna Value PPO ...........................................................................................................................................................................37

HMSA PPO .....................................................................................................................................................................................39

Kaiser (Hawaii) ..............................................................................................................................................................................41

Kaiser HMO (Colorado) ................................................................................................................................................................43

Kaiser HMO (Georgia)...................................................................................................................................................................45

Kaiser HMO (Hawaii) (pre-65 option) ........................................................................................................................................47

Kaiser HMO (Mid-Atlantic) ...........................................................................................................................................................49

Kaiser HMO (NorthWest) .............................................................................................................................................................51

Kaiser HMO (Northern CA)...........................................................................................................................................................53

Kaiser HMO (Southern CA) ..........................................................................................................................................................55

1

Aetna CDHP w/HRA

Plan Facts

Member services phone number 1-800-545-5810

Hours of operation 8:00 a.m. to 6:00 p.m. in the member's time zone

Web site address www.aetna.com; network name: Choice POS II

This coverage summary provides an overview of benefits available under the Aetna CDHP w/HRA medical plan for the year 2022. Keep in mind that this is only a summary,

and does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network providers

(“in-network”) or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member services

department at the number(s) shown above.

Coverage Highlights In-Network Benefits Out-of-Network Benefits

Annual Deductible

Individual/Family

$1,300 Individual; $3,900 Family $1,950 Individual; $5,850 Family; separate from in-network

Annual HP-Funded Health

Reimbursement Account

$500 Individual; $1,000 Family; available to reimburse eligible

expenses; combined in and out-of-network



Out-of-Pocket Maximum

Individual/Family

$3,150 Individual; $9,450 Family; includes deductible and copays;

includes MH/SU; Rx copays excluded


includes MH/SU; Rx copays excluded; separate from in-network

Rx Out-of-Pocket Maximum

Individual/Family

$2,300 Individual; $4,600 Family; includes Rx copays and

coinsurance


coinsurance

Primary Doctor Office Visit 80% covered after deductible is met 50% covered after deductible is met

Specialist Office Visit 80% covered after deductible is met; 100% covered for preventive

services

50% covered after deductible is met

Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or

video; visit grandrounds.com/hp or call 1-855-633-9251

No copay to use HP Health Hub to talk with a provider by phone or


Hospital Copay Not applicable Not applicable

Hospital Coinsurance 90% covered after Plan deductible is met 60% covered after Plan deductible is met

Emergency Care

• Emergency room

(not followed by admission)

$200 copay then 90% covered for emergency; non-emergency 80%

covered after deductible is met

$200 copay then 90% covered for emergency; non-emergency


• Urgent care clinic visit (facility) $50 copay $50 copay

Inpatient Care

• Inpatient surgery 90% covered after Plan deductible is met 60% covered after Plan deductible is met

• Physician/Surgeon services 90% covered after Plan deductible is met 60% covered after Plan deductible is met

• Inpatient lab and X-ray services 90% covered after Plan deductible is met 60% covered after Plan deductible is met

Outpatient Care

• Second surgical opinion 80% covered after deductible is met 50% covered after deductible is met

• Outpatient laboratory services 80% covered after deductible is met 50% covered after deductible is met

• Outpatient X-ray services 80% covered after deductible is met 50% covered after deductible is met

• Outpatient surgery 80% covered after deductible is met 50% covered after deductible is met

• Outpatient physical, occupational

and speech therapy

80% covered after deductible is met; limited to 30 visits per calendar

year; combined in and out-of-network

50% covered after deductible is met; limited to 30 visits per

calendar year; combined in and out-of-network

• Chiropractic services 80% covered after deductible is met; limited to 10 visits per calendar




• Allergy tests and treatments 80% covered after deductible is met 50% covered after deductible is met

• Acupuncture 80% covered after deductible is met; limited to $500 per calendar


80% covered after deductible is met; limited to $500 per calendar


Effective January – December 2022

2

Aetna CDHP w/HRA


Prescription Drug Coverage* Administered by CVS Caremark

Pre-enrollment: Go here to link to the CVS Caremark website

Beginning January 1, 2022: Register at caremark.com

Retail

• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit

caremark.com or contact your pharmacy

Reimbursed at the contracted rate less applicable copay

• Tier 2 70% covered; $30 min/$60 max copay; 30-day supply; 90-day supply

available; visit caremark.com or contact your pharmacy


• Tier 3 60% cov; $45 min/$90 max copay; 30-day supply; 90-day supply



• Tier 4 (ED/sleep aids) 50% covered; $75 min/$125 max copay; 30-day supply; 90-day

supply available; visit caremark.com or contact your pharmacy


Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs

in Tiers 1-4 shown above; provides cost savings and convenience for a

90-day supply sent direct to your home

Not covered

Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's

specialty pharmacy)

Not covered

Adult Preventive Care

• Annual physical exam 100% covered for preventive services; check with Plan for preventive

schedule

50% covered after deductible is met; check with Plan for preventive

schedule

• Well-woman exam (includes pap) 100% covered for preventive services; 80% covered after deductible

for non-preventive services; check with Plan for preventive schedule


schedule

• Mammogram 100% covered for preventive services; 1 per calendar year; check with

Plan for preventive schedule


schedule

• Cancer screenings 100% cov for preventive services; 80% cov after ded is met for

non-preventive services; check w/Plan for preventive sched


schedule

Family Planning/Maternity Care

• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy,

then 100% covered for routine prenatal care; postnatal visits covered

at applicable coinsurance/deductible


• In-hospital doctor's services 90% covered after deductible is met 60% covered after deductible is met

• Newborn nursery services 90% covered after deductible is met 60% covered after deductible is met

• Midwives, licensed and certified 90% cov inpatient; 80% cov outpatient; after ded is met 60% cov inpatient; 50% cov outpatient; after ded is met

• Infertility services 90% inpatient; 80% outpatient; after deductible is met; limited to

$10,000 per family per lifetime, $5,000 for Rx and $5,000 for medical

svcs; check with Plan for details

Covered; after ded is met; limited to $10,000 per family per lifetime,

$5,000 for Rx and $5,000 for medical svcs; subject to R&C limits;

check with Plan for details

• Oral contraceptives Retail and mail order avail; 100% cov for T1 contraceptives; applicable

Rx copay/coinsurance applies for other tiers

Nonparticipating pharmacies reimbursed at contracted rate less

applicable copay/coinsurance

Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773,

or login to www.guidanceresources.com, click “Register” and use the

Org Web ID “HP”

Administered by ComPsych—to find a provider, call 1-844-819-4773,


Org Web ID “HP”

• Outpatient coverage/visits 80% covered 50% covered

• Inpatient coverage/days 90% covered; precertification is required 60% covered; precertification is required

Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773,


Org Web ID “HP”



Org Web ID “HP”

• Rehab: outpatient coverage/visits 80% covered 50% covered

• Rehab: inpatient coverage/days 90% covered; precertification is required 60% covered; precertification is required

Hearing Care

• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for

preventive schedule


schedule

• Hearing hardware (hearing aid) 80% cov after deductible is met; limited to one pair per lifetime 50% cov after deductible is met; limited to one pair per lifetime

Other Medical Services

• Noncustodial home health care 80% covered after deductible is met; limited to 120 visits per calendar




• Hospice care 90% cov inpatient; 80% cov outpatient; after ded is met 60% cov inpatient; 50% cov outpatient; after ded is met

• Prescribed care in a noncustodial

skilled nursing facility

90% covered after deductible is met; limited to 120 days per calendar




• Durable medical equipment 80% cov after ded is met; repair and maintenance covered 50% cov after ded is met; repair and maintenance covered

Special Messages

All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible out-of-network expenses are limited to the reasonable and customary (R&C) amount charged for a particular

service in a particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be

covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and

exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.

*Generic oral contraceptives and brands with no generic alternatives, no charge. If you fill a brand-name prescription drug (all tiers) and that drug has a generic equivalent, you pay your normal share of the

brand-name drug cost, plus the difference between the generic drug ingredient cost and the brand-name drug ingredient cost.

https://leplb0550.upoint.alight.com/web/hp4x/contentPage?articleId=E7F27364-E855-4E45-A219-52421958BEBD

https://www.caremark.com

www.guidanceresources.com



3

Aetna EPO

Plan Facts



Web site address www.aetna.com; network name: Open Access Aetna Select

This coverage summary provides an overview of benefits available under the Aetna EPO medical plan for the year 2022. Keep in mind that this is only a summary, and does

not provide complete information about the medical plan, its benefits, provisions, or coverages. For in-network services subject to an office visit copayment, coverage may

vary based on where services are provided and how services are billed. If services are provided in a hospital setting, benefits may be paid as Hospital services and paid at

90% of eligible expenses after the annual deductible. For additional information and details about benefits under this medical plan, call the member services department at

the number(s) shown above.

Coverage Highlights In-Network Benefits

Annual Deductible

Individual/Family

$600 Individual; $1,200 Family


Individual/Family

$3,150 Individual; $6,300 Family; includes deductible and copays; includes MH/SU; Rx copays excluded


Individual/Family

$2,100 Individual; $4,200 Family; includes Rx copays and coinsurance

Primary Doctor Office Visit $20 copay

Specialist Office Visit $45 copay; 100% covered for preventive services

Virtual Urgent Care No copay to use HP Health Hub to talk with a provider by phone or video; visit grandrounds.com/hp or call

1-855-633-9251

Hospital Copay Not applicable

Hospital Coinsurance 90% covered after Plan deductible is met

Emergency Care

• Emergency room (not followed by admission) $200 copay; then 90% covered

• Urgent care clinic visit (facility) $50 copay

Inpatient Care

• Inpatient surgery 90% covered after Plan deductible is met

• Physician/Surgeon services 90% covered after Plan deductible is met

• Inpatient lab and X-ray services 90% covered after Plan deductible is met

Outpatient Care

• Second surgical opinion $20 copay PCP; $45 copay specialist

• Outpatient laboratory services 90% covered after deductible is met

• Outpatient X-ray services 90% covered after deductible is met

• Outpatient surgery 90% covered after deductible is met

• Outpatient physical therapy $45 copay; limited to 30 visits per calendar year; costs may vary based on place of service

• Outpatient occupational therapy $45 copay; limited to 30 visits per calendar year; costs may vary based on place of service

• Outpatient speech therapy $45 copay; limited to 30 visits per calendar year; costs may vary based on place of service

• Chiropractic services $20 copay PCP; $45 copay specialist; limited to 10 visits per calendar year

• Allergy tests and treatments $20 copay PCP; $45 copay specialist; copay based on place of service and service performed

• Acupuncture $20 copay PCP; $45 copay specialist; limited to $500 per calendar year


4

Aetna EPO





Nonparticipating pharmacies not covered (Retail and Mail Order)

Retail

• Tier 1 $10 copay; 30-day supply; 90-day supply available; visit caremark.com or contact your pharmacy

• Tier 2 70% covered; $30 min/$60 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your

pharmacy

• Tier 3 60% cov; $45 min/$90 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your

pharmacy

• Tier 4 (ED/sleep aids) 50% covered; $75 min/$125 max copay; 30-day supply; 90-day supply available; visit caremark.com or contact your

pharmacy

Mail Order $20 copay generic; 2.5x the retail 30-day copay for brand name drugs in Tiers 1-4 shown above; provides cost

savings and convenience for a 90-day supply sent direct to your home

Specialty Drug Program Specialty drugs must be filled through PrudentRx (CVS Caremark's specialty pharmacy)


• Annual physical exam 100% covered for preventive services; limited to one exam per calendar year; check with Plan for preventive

schedule

• Well-woman exam (includes pap) 100% covered for preventive services; $20 copay PCP; $45 copay specialist for non-preventive services; check with


• Mammogram 100% covered for preventive services; 1 per calendar year; check with Plan for preventive schedule

• Cancer screenings 100% covered for preventive services; $20 copay PCP; $45 copay specialist for non-preventive services; check with



• Office visit: pre/postnatal Physician OV cost share may apply to initial visit to confirm pregnancy, then 100% covered for routine prenatal care;

postnatal visits covered at applicable cost share

• In-hospital doctor's services 90% covered after deductible is met

• Newborn nursery services 90% covered after deductible is met

• Midwives, licensed and certified Covered; copay based on location of services

• Infertility services $20 copay PCP; $45 copay specialist; 90% cov after ded; inpatient; ltd to $10,000 per family per lifetime; $5,000 for

Rx and $5,000 for all medical services; check with Plan for details

• Oral contraceptives Retail and mail order available; 100% covered for T1 contraceptives; applicable Rx copay/coinsurance applies for

other tiers

Mental Health Care Administered by ComPsych—to find a provider, call 1-844-819-4773, or login to www.guidanceresources.com, click

“Register” and use the Org Web ID “HP”

• Outpatient coverage/visits $20 copay

• Inpatient coverage/days 90% covered; precertification is required

Substance Use Disorder Administered by ComPsych—to find a provider, call 1-844-819-4773, or login to www.guidanceresources.com, click


• Rehab: outpatient coverage/visits $20 copay

• Rehab: inpatient coverage/days 90% covered; precertification is required

Hearing Care

• Hearing evaluation test 100% covered as part of preventive care program; check with Plan for preventive schedule

• Hearing hardware (hearing aid) 90% covered after deductible is met; limited to one pair per lifetime


• Noncustodial home health care 100% covered; limited to 120 visits per calendar year

• Hospice care 100% covered

• Prescribed care in a noncustodial skilled nursing facility 90% covered after deductible is met; limited to 120 days per calendar year

• Durable medical equipment 100% covered; repair and maintenance covered

Special Messages

All services must meet the definition of “eligible expenses” as defined by the medical plan. The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be

different, or a service might not be covered at all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For

information on covered benefits and exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary.







5

Aetna HDHP (pre-65 option)

Plan Facts




This coverage summary provides an overview of benefits available under the Aetna HDHP medical plan for the year 2022. Keep in mind that this is only a summary, and

does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network providers




Annual Deductible

Individual/Family



Individual/Family

$6,750 Individual; $13,500 Family; with embedded $8,150 individual

OOP limit for family coverage; includes deductible; includes Rx and

MH/SU

$13,500 Individual; $27,000 Family; with embedded $13,500

individual OOP limit for family coverage; includes deductible;

includes Rx and MH/SU; separate from in-network



services








Emergency Care

• Emergency room


80% covered after Plan deductible is met 80% covered after Plan deductible is met

• Urgent care clinic visit (facility) 80% covered after Plan deductible is met 60% covered after Plan deductible is met

Inpatient Care




Outpatient Care






and speech therapy



60% covered after deductible is met; limited to 30 visits per year;

combined in and out-of-network








60% covered after deductible is met; limited to $500 per year;



6

Aetna HDHP





Some preventive Rx not subject to deductible

Retail

• Tier 1 80% cov after ded is met; 30-day supply; 90-day supply available; visit

caremark.com or contact your pharmacy; check with Plan for details

Reimbursed at contracted rate less applicable copay







• Tier 4 (ED/sleep aids) 80% cov after ded is met; 30-day supply; 90-day supply available; visit



Mail Order 80% covered after deductible is met; provides cost savings and

convenience for a 90-day supply sent direct to your home

Not covered

Specialty Drug Program Specialty drugs must be filled through CVS Specialty Pharmacy Not covered



schedule


schedule




schedule




schedule




schedule








• Midwives, licensed and certified 80% covered after deductible is met 60% covered after deductible is met

• Infertility services 80% covered after deductible is met; limited to $10,000 per family per

lifetime, $5,000 for Rx and $5,000 for medical svcs; check with Plan

for details




• Oral contraceptives Retail and mail order available; 100% covered for Tier 1

contraceptives; applicable coinsurance and deductible applies for

other tiers


applicable coinsurance and deductible



Org Web ID “HP”



Org Web ID “HP”

• Outpatient coverage/visits 80% covered after deductible is met 60% covered after deductible is met

• Inpatient coverage/days 80% covered after deductible is met; precertification required 60% covered after deductible is met; precertification is required



Org Web ID “HP”



Org Web ID “HP”

• Rehab: outpatient coverage/visits 80% covered after deductible is met 60% covered after deductible is met

• Rehab: inpatient coverage/days 80% covered after deductible is met; precertification required 60% covered after deductible is met; precertification is required

Hearing Care


preventive schedule


• Hearing hardware (hearing aid) 80% cov after deductible is met; limited to one pair per lifetime 60% cov after ded is met; limited to one pair per lifetime




60% covered after deductible is met; 120 visits per calendar year;


• Hospice care 80% covered after deductible is met 60% covered after deductible is met





60% covered after deductible is met; 120 days per calendar year;



Special Messages












7

Aetna Premium PPO

Plan Facts




This coverage summary provides an overview of benefits available under the Aetna Premium PPO medical plan for the year 2022. Keep in mind that this is only a summary,


(“in-network”) or non-participating providers (“out-of-network”). For in-network services subject to an office visit copayment, coverage may vary based on where services

are provided and how services are billed. If services are provided in a hospital setting, benefits may be paid as Hospital services and paid at 90% of eligible expenses after

the annual deductible. For additional information and details about benefits under this medical plan, call the member services department at the number(s) shown above.


Annual Deductible

Individual/Family

$650 Individual; $1,950 Family $1,300 Individual; $3,900 Family; separate from in-network


Individual/Family






Individual/Family


coinsurance


coinsurance

Primary Doctor Office Visit $20 copay 60% covered after deductible is met

Specialist Office Visit $45 copay; 100% covered for preventive services 60% covered after deductible is met







Emergency Care

• Emergency room







Inpatient Care




Outpatient Care

• Second surgical opinion $20 copay PCP; $45 copay specialist 60% covered after deductible is met





and speech therapy

$20 copay PCP; $45 copay specialist; limited to 30 visits per calendar

year; combined in-network and out-of-network; costs may vary

based on place of service



• Chiropractic services $20 copay PCP; $45 copay specialist; limited to 10 visits per calendar


$20 copay PCP; $45 copay specialist; limited to 10 visits per


• Allergy tests and treatments $20 copay PCP; $45 copay specialist; copay based on place of

service and service performed


• Acupuncture $20 copay PCP; $45 copay specialist; limited to $500 per calendar


$20 copay PCP; $45 copay specialist; limited to $500 per calendar



8

Aetna Premium PPO





Retail










• Tier 4 (ED/sleep aids) $100 copay; 30-day supply; 90-day supply available; visit






Not covered


specialty pharmacy)

Not covered



schedule


schedule

• Well-woman exam (includes pap) 100% covered for preventive services; $20 copay PCP; $45 copay

specialist for non-preventive services; check with Plan for preventive

schedule


schedule




schedule

• Cancer screenings 100% covered for preventive services; $20 copay PCP; $45 copay


schedule


schedule




at applicable cost share





• Infertility services $20 copay PCP; $45 copay specialist; 90% cov after ded inpatient;

limited to $10,000 per family per lifetime, $5,000 for Rx and $5,000

for all medical services; check with Plan for details




• Oral contraceptives Retail and mail order available; 100% covered for T1 contraceptives;

applicable Rx copay/coinsurance applies for other tiers





Org Web ID “HP”



Org Web ID “HP”

• Outpatient coverage/visits $20 copay 60% covered




Org Web ID “HP”



Org Web ID “HP”

• Rehab: outpatient coverage/visits $20 copay 60% covered


Hearing Care


preventive schedule


schedule















Special Messages












9

Aetna Value PPO

Plan Facts




This coverage summary provides an overview of benefits available under the Aetna Value PPO medical plan for the year 2022. Keep in mind that this is only a summary,





Annual Deductible

Individual/Family



Individual/Family






Individual/Family


coinsurance


coinsurance

Primary Doctor Office Visit 100% cov; up to $250; then 80% cov after ded is met; $250 ann limit

is cmbnd for all office visits


Specialist Office Visit 100% covered up to $250; then 80% covered after deductible is

met; 100% covered for preventive services; $250 annual limit is

combined for all office visits








Emergency Care

• Emergency room







Inpatient Care




Outpatient Care

• Second surgical opinion 100% covered up to $250; then 80% covered after deductible is

met; $250 annual limit is combined for all office visits






and speech therapy





• Chiropractic services 100% covered; up to $250; then 80% covered after ded; limited to

10 visits per calendar year; combined in and out-of-network; $250

annual limit is combined for all office visits

100% covered; up to $250; then 80% covered after ded; limited to



• Allergy tests and treatments 100% covered up to $250 for office visit charges only; other services

80% covered after deductible is met; $250 annual limit is combined

for all office visit services


• Acupuncture 100% covered; up to $250; then 80% covered after ded; limited to

$500 per calendar year; combined in and out-of-network; $250






10

Aetna Value PPO





Retail




• Tier 2 65% covered; $35 min/$75 max; 30-day supply; 90-day supply






• Tier 4 (ED/sleep aids) 50% covered; $80 min/$140 max; 30-day supply; 90-day supply






Not covered


specialty pharmacy)

Not covered



schedule


schedule

• Well-woman exam (includes pap) 100% covered for preventive services; check with Plan for preventive

schedule


schedule




schedule

• Cancer screenings 100% covered for preventive services; check with Plan for preventive

schedule


schedule









• Infertility services 80% covered after ded is met; limited to $10,000 per family per

lifetime, $5,000 for Rx and $5,000 for all medical services; check with

Plan for details










Org Web ID “HP”



Org Web ID “HP”

• Outpatient coverage/visits $0 copay first 3 visits, then 80% covered 50% covered




Org Web ID “HP”



Org Web ID “HP”

• Rehab: outpatient coverage/visits $0 copay first 3 visits, then 80% covered 50% covered


Hearing Care


preventive schedule


schedule

• Hearing hardware (hearing aid) 80% covered after deductible is met; limited to one pair per lifetime 50% covered after deductible is met; limited to one pair per lifetime














Special Messages












11

Anthem BCBS Basic CMP

Plan Facts


Hours of operation 5:30 a.m. to 8:00 p.m. PST

Web site address www.anthem.com/ca

This coverage summary provides an overview of benefits available under the Anthem BCBS Basic CMP medical plan for the year 2022. Keep in mind that this is only a

summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. You may qualify to receive services at discounted rates

when you use Anthem BCBS network providers. For additional information and details about benefits under this medical plan, call the member services department at the

number(s) shown above.

Coverage Highlights Benefits

Annual Deductible

Individual/Family

$5,150 Individual; $15,450 Family


Individual/Family

$7,150 Individual; $21,450 Family; includes deductible; copays not included; includes MH/SU

Primary Doctor Office Visit 80% covered after deductible is met; 100% covered for preventive services

Specialist Office Visit 80% covered after deductible is met; 100% covered for preventive services


1-855-633-9251

Hospital Copay $100 copay per admission

Hospital Coinsurance 80% covered after hospital copay and Plan deductible is met

Emergency Care

• Emergency room (not followed by admission) 80% covered after deductible is met

• Urgent care clinic visit (facility) 80% covered after deductible is met

Inpatient Care

• Inpatient surgery 80% covered after hospital copay and Plan deductible is met

• Physician/Surgeon services 80% covered after hospital copay and Plan deductible is met

• Inpatient lab and X-ray services 80% covered after hospital copay and Plan deductible is met

Outpatient Care

• Second surgical opinion 80% covered after deductible is met




• Outpatient physical therapy 80% covered after deductible is met; limited to 30 visits per calendar year

• Outpatient occupational therapy 80% covered after deductible is met; limited to 30 visits per calendar year

• Outpatient speech therapy 80% covered after deductible is met; limited to 30 visits per calendar year

• Chiropractic services 80% covered after deductible is met; limited to 10 visits per calendar year

• Allergy tests and treatments 80% covered after deductible is met

• Acupuncture 80% covered after deductible is met; limited to $500 per calendar year


12

Anthem BCBS Basic CMP


Prescription Drug Coverage* Administered by Anthem

Non participating pharmacies: member must submit claim to administrator for reimbursement after paying full out

of pocket cost

Retail

• Tier 1 80% covered after deductible is met



• Tier 4 (ED/sleep aids) 80% covered after deductible is met

Mail Order Not covered

Specialty Drug Program Check with Plan for details


• Annual physical exam 100% covered for preventive services; check with Plan for preventive schedule

• Well-woman exam (includes pap) 100% covered for preventive services; 80% covered after deductible for non-preventive services; check with Plan for

preventive schedule


• Cancer screenings 100% covered for preventive services; 80% covered after deductible for non-preventive services; check with Plan for

preventive schedule



postnatal visits covered at applicable coinsurance/deductible



• Midwives, licensed and certified 80% covered after deductible is met

• Infertility services 80% covered after deductible is met; limited to $10,000 per family per lifetime, $5,000 for Rx and $5,000 for

medical services; check with Plan for details

• Oral contraceptives Retail available; 100% covered for Tier 1 contraceptives; applicable Rx copay/coinsurance applies for other tiers

Mental Health Care

• Outpatient coverage/visits 80% covered

• Inpatient coverage/days $100 copay per admit; then 80% covered; precertification required

Substance Use Disorder

• Rehab: outpatient coverage/visits 80% covered

• Rehab: inpatient coverage/days $100 copay per admit; then 80% covered; precertification required

Hearing Care




• Noncustodial home health care 80% covered after deductible is met; limited to 120 visits per calendar year

• Hospice care 80% covered after deductible is met


• Durable medical equipment 80% covered after deductible is met; repair and maintenance covered

Special Messages

All services must meet the definition of “eligible expenses” as defined by the medical plan. Eligible expenses are limited to the reasonable and customary (R&C) amount charged for a particular service in a

particular area (including emergency care). The benefits shown assume all necessary approvals and authorizations have been obtained. Benefit amounts could be different, or a service might not be covered at

all, if the necessary approvals and referrals are not received. This coverage summary does not replace official plan documents or subscriber certificates. For information on covered benefits and exclusions,

contact the medical plan directly at the number(s) shown on the front side of this coverage summary.

*Cost for brand-name drugs—If your doctor writes “dispense as written” for a brand-name drug that has a generic equivalent, you will pay the difference between the higher cost brand-name drug and the

lower cost generic drug, plus your cost-share for the drug. For information on in-network retail locations, or for any prescription drug information, go to www.anthem.com/ca, or call 1-800-364-3301.

13

Anthem BCBS CDHP w/HRA

Plan Facts



Web site address www.anthem.com/ca; network name: National PPO (Bluecard PPO)

This coverage summary provides an overview of benefits available under the Anthem BCBS CDHP w/HRA medical plan for the year 2022. Keep in mind that this is only a

summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network

providers (“in-network”) or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member

services department at the number(s) shown above.


Annual Deductible

Individual/Family









Individual/Family

$3,150 Individual; $9,450 Family; includes deductible and copays; Rx

copays excluded; includes MH/SU




Individual/Family


coinsurance


coinsurance


Specialist Office Visit 80% covered after deductible is met; 100% covered; preventive

services








Emergency Care

• Emergency room


80% covered for emergency; non-emergency 80% covered after

deductible is met

80% covered for emergency; non-emergency 50% covered after

deductible is met

• Urgent care clinic visit (facility) 80% covered 80% covered

Inpatient Care




Outpatient Care






and speech therapy















14

Anthem BCBS CDHP w/HRA





Retail
















Not covered




schedule


schedule

• Well-woman exam (includes pap) 100% cov for preventive services; 80% cov after deductible for

non-preventive services; check w/Plan for preventive schedule


schedule




schedule

• Cancer screenings 100% cov for preventive services; 80% cov after deductible for

non-preventive services; check w/Plan for preventive schedule


schedule





















Org Web ID “HP”



Org Web ID “HP”





Org Web ID “HP”



Org Web ID “HP”



Hearing Care


preventive schedule


schedule

• Hearing hardware (hearing aid) 80% cov after deductible is met; limited to one pair per lifetime 50% cov after deductible is met; limited to one pair per lifetime














Special Messages












15

Anthem BCBS EPO

Plan Facts




This coverage summary provides an overview of benefits available under the Anthem BCBS EPO medical plan for the year 2022. Keep in mind that this is only a summary,

and does not provide complete information about the medical plan, its benefits, provisions, or coverages. For in-network services subject to an office visit copayment,

coverage may vary based on where services are provided and how services are billed. If services are provided in a hospital setting, benefits may be paid as Hospital services

and paid at 90% of eligible expenses after the annual deductible. For additional information and details about benefits under this medical plan, call the member services



Annual Deductible

Individual/Family



Individual/Family



Individual/Family





1-855-633-9251



Emergency Care



Inpatient Care




Outpatient Care





• Outpatient physical therapy $45 copay; limited to 30 visits per calendar year; costs may vary based on place of service

• Outpatient occupational therapy $45 copay; limited to 30 visits per calendar year; costs may vary based on place of service

• Outpatient speech therapy $45 copay; limited to 30 visits per calendar year; costs may vary based on place of service

• Chiropractic services $20 copay PCP; $45 copay specialist; limited to 10 visits per calendar year




16

Anthem BCBS EPO






Retail



pharmacy


pharmacy


pharmacy






schedule

• Well-woman exam (includes pap) 100% covered for preventive services; $20 copay PCP; $45 copay specialist for non-preventive services; copay

based on place of service and services performed; check with Plan for preventive schedule


• Cancer screenings 100% covered for preventive services; $20 copay PCP; $45 copay specialist for non-preventive services; copay

based on place of service and services performed; check with Plan for preventive schedule






• Midwives, licensed and certified Covered if contracted; copay based on location of services

• Infertility services $20 copay PCP; $45 copay specialist; 90% cov after ded is met inpatient; limited to $10,000 per family per lifetime,

$5,000 for Rx and $5,000 for all medical services; check with Plan for details

• Oral contraceptives Retail and mail order available; 100% covered for Tier 1 contraceptives; applicable Rx copay/coinsurance applies for

other tiers









Hearing Care




• Noncustodial home health care 100% covered; limited to 120 visits per calendar year




Special Messages










17

Anthem BCBS HDHP (pre-65 option)

Plan Facts




This coverage summary provides an overview of benefits available under the Anthem BCBS HDHP medical plan for the year 2022. Keep in mind that this is only a summary,





Annual Deductible

Individual/Family



Individual/Family



MH/SU






services








Emergency Care

• Emergency room




Inpatient Care




Outpatient Care






and speech therapy















18

Anthem BCBS HDHP






Retail


caremark.com or contact your pharmacy; some preventive Rx not

subject to deductible; check with Plan for details
















Not covered


specialty pharmacy)

Not covered



schedule


schedule




schedule




schedule




schedule











for details






other tiers





Org Web ID “HP”



Org Web ID “HP”





Org Web ID “HP”



Org Web ID “HP”



Hearing Care


preventive schedule






60% covered after deductible is met; 120 visits per calendar year;










Special Messages












19

Anthem BCBS Premium CMP

Plan Facts




This coverage summary provides an overview of benefits available under the Anthem BCBS Premium CMP medical plan for the year 2022. Keep in mind that this is only a





Annual Deductible

Individual/Family



Individual/Family

$2,150 Individual; $6,450 Family; includes deductible and copays; includes MH/SU; Rx excluded


Individual/Family


Primary Doctor Office Visit 80% covered after deductible is met



1-855-633-9251



Emergency Care



Inpatient Care




Outpatient Care












20

Anthem BCBS Premium CMP






of pocket cost

Retail



pharmacy


pharmacy


pharmacy







preventive schedule



preventive schedule










other tiers









Hearing Care








Special Messages











21

Anthem BCBS Premium PPO

Plan Facts




This coverage summary provides an overview of benefits available under the Anthem BCBS Premium PPO medical plan for the year 2022. Keep in mind that this is only a


providers (“in-network”) or non-participating providers (“out-of-network”). For in-network services subject to an office visit copayment, coverage may vary based on where

services are provided and how services are billed. If services are provided in a hospital setting, benefits may be paid as Hospital services and paid at 90% of eligible

expenses after the annual deductible. For additional information and details about benefits under this medical plan, call the member services department at the number(s)

shown above.


Annual Deductible

Individual/Family



Individual/Family






Individual/Family


coinsurance


coinsurance









Emergency Care

• Emergency room







Inpatient Care




Outpatient Care






and speech therapy

$20 copay PCP; $45 copay specialist; limited to 30 visits per calendar

year; combined in and out-of-network; coverage may vary based on

place of service



• Chiropractic services $20 copay PCP; $45 copay specialist; limited to 10 visits per calendar


$20 copay PCP; $45 copay specialist; limited to 10 visits per










22

Anthem BCBS Premium PPO





Retail
















Not covered


specialty pharmacy)

Not covered



schedule


schedule



schedule


schedule




schedule



schedule


schedule





















Org Web ID “HP”



Org Web ID “HP”





Org Web ID “HP”



Org Web ID “HP”



Hearing Care


preventive schedule


schedule















Special Messages












23

Anthem BCBS Standard CMP

Plan Facts




This coverage summary provides an overview of benefits available under the Anthem BCBS Standard CMP medical plan for the year 2022. Keep in mind that this is only a





Annual Deductible

Individual/Family

$1,150 Individual; $3,450 Family


Individual/Family

$3,150 Individual; $9,450 Family; includes deductible and copays; includes MH/SU; Rx excluded


Individual/Family


Primary Doctor Office Visit 80% covered after deductible is met



1-855-633-9251



Emergency Care



Inpatient Care




Outpatient Care












24

Anthem BCBS Standard CMP






of pocket cost

Retail



pharmacy


pharmacy


pharmacy







preventive schedule



preventive schedule










other tiers









Hearing Care








Special Messages











25

Anthem BCBS Value PPO

Plan Facts




This coverage summary provides an overview of benefits available under the Anthem BCBS Value PPO medical plan for the year 2022. Keep in mind that this is only a


providers (“in-network”) or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member

services department at the number(s) shown above.


Annual Deductible

Individual/Family



Individual/Family






Individual/Family


coinsurance


coinsurance














Emergency Care

• Emergency room







Inpatient Care




Outpatient Care








and speech therapy





• Chiropractic services 100% covered; up to $250; then 80% covered after ded; limited to






• Allergy tests and treatments 100% cov up to $250 for office visit charges only; other services

80% cov after deductible is met; $250 annual limit is combined for

all office visit services


• Acupuncture 100% covered; up to $250; then 80% covered after ded; limited to







26

Anthem BCBS Value PPO





Retail
















Not covered


specialty pharmacy)

Not covered



schedule


schedule


schedule


schedule




schedule


schedule


schedule











Plan for details










Org Web ID “HP”



Org Web ID “HP”





Org Web ID “HP”



Org Web ID “HP”



Hearing Care


preventive schedule


schedule

• Hearing hardware (hearing aid) 80% covered after deductible is met; limited to one pair per lifetime 50% covered after deductible is met; limited to one pair per lifetime














Special Messages












27

Blue Essentials HMO

Plan Facts


Hours of operation 8:00 a.m. to 8:00 p.m. CST

Web site address www.bcbstx.com; network name: Blue Essentials

This coverage summary provides an overview of benefits available under the Blue Essentials HMO medical plan for the year 2022. Keep in mind that this is only a summary,

and does not provide complete information about the medical plan, its benefits, provisions, or coverages. For additional information and details about benefits under this

medical plan, call the member services department at the number(s) shown above.


Annual Deductible

Individual/Family



Individual/Family

$3,150 Individual; $6,150 Family; includes deductible; medical, mental health copays and coinsurance

included; Rx copays excluded


Individual/Family

$2,100 Individual; $4,200 Family; includes all Rx copays and coinsurance; separate from the medical

out-of-pocket maximum


Specialist Office Visit $45 copay

Virtual Urgent Care Not covered

Hospital Copay Not applicable; coinsurance and deductible apply


Emergency Care



Inpatient Care




Outpatient Care

• Second surgical opinion 100% covered; office visit copay may apply; PCP referral required




• Outpatient physical therapy $20 copay PCP; $45 copay specialist

• Outpatient occupational therapy $20 copay PCP; $45 copay specialist

• Outpatient speech therapy $20 copay PCP; $45 copay specialist

• Chiropractic services $45 copay

• Allergy tests and treatments $20 copay PCP; $45 copay specialist

• Acupuncture $45 copay


28

Blue Essentials HMO


Prescription Drug Coverage Check with the Plan for exclusions.

Retail

• Tier 1 $10 copay; 30-day supply

• Tier 2 70% cov; $30 min/$60 max; 30-day supply; member will pay the lesser of the cost of drug or minimum copay up to

the maximum copay

• Tier 3 60% covered; $45 min/$90 max copay; 30-day supply; mbr will pay the lesser of the cost of the drug or min copay

up to the max copay

• Tier 4 (ED/sleep aids) 50% covered; $75 min/$125 max copay for ED, sleep aids and PPIs; mbr will pay the lesser of the cost of the drug or

min copay up to the max copay



Specialty Drug Program Specialty drugs can be filled through any network pharmacy; check with Plan for details


• Annual physical exam 100% covered for preventive services

• Well-woman exam (includes pap) 100% covered for preventive services

• Mammogram 100% covered for preventive services

• Cancer screenings 100% covered for preventive services


• Office visit: pre/postnatal $20 copay; initial visit only




• Infertility services $20 copay PCP; $45 copay specialist; limited to $10,000 per family per lifetime; $5,000 for Rx and $5,000 for all


• Oral contraceptives Retail and mail order available; 100% covered for FDA approved contraceptives

Mental Health Care


• Inpatient coverage/days 90% covered after deductible is met



• Rehab: inpatient coverage/days 90% covered after deductible is met

Vision Care

• Routine eye exams Covered only if part of preventive screening

Hearing Care

• Hearing evaluation test $20 copay PCP; $45 copay specialist; limited to one exam every 36 months; 100% covered for preventive services

• Hearing hardware (hearing aid) 90% covered after deductible is met; limited to 1 pair every 36 months


• Noncustodial home health care 90% covered after deductible is met



• Durable medical equipment 100% covered

Special Messages




29

Cigna CDHP w/HRA

Plan Facts

Member services phone number 1-800-Cigna-24

Hours of operation 24 hours/day; 7 days/week; 365 days/year

Web site address www.cigna.com; network name: Open Access Plus (OAP)

This coverage summary provides an overview of benefits available under the Cigna CDHP w/HRA medical plan for the year 2022. Keep in mind that this is only a summary,





Annual Deductible

Individual/Family









Individual/Family






Individual/Family


coinsurance


coinsurance



services








Emergency Care

• Emergency room


80% covered 80% covered

• Urgent care clinic visit (facility) 80% covered 80% covered

Inpatient Care




Outpatient Care






and speech therapy



50% covered after deductible is met; limited to 30 days per


• Chiropractic services 80% covered after deductible is met; limited to 10 days per calendar










30

Cigna CDHP w/HRA





Retail
















Not covered


specialty pharmacy)

Not covered



schedule


schedule




schedule




schedule


non-preventive services; chk with Plan for preventive sched


schedule





















Org Web ID “HP”



Org Web ID “HP”





Org Web ID “HP”



Org Web ID “HP”



Hearing Care


preventive schedule


schedule

• Hearing hardware (hearing aid) 80% cov after deductible is met; limited to $6,000 per lifetime 50% cov after deductible is met; limited to $6,000 per lifetime


• Noncustodial home health care 80% covered after deductible is met; limited to 120 days per calendar












Special Messages












31

Cigna EPO

Plan Facts




This coverage summary provides an overview of benefits available under the Cigna EPO medical plan for the year 2022. Keep in mind that this is only a summary, and does

not provide complete information about the medical plan, its benefits, provisions, or coverages. For in-network services subject to an office visit copayment, coverage may

vary based on where services are provided and how services are billed. If services are provided in a hospital setting, benefits may be paid as Hospital services and paid at

90% of eligible expenses after the annual deductible. For additional information and details about benefits under this medical plan, call the member services department at



Annual Deductible

Individual/Family



Individual/Family



Individual/Family





1-855-633-9251



Emergency Care



Inpatient Care




Outpatient Care





• Outpatient physical therapy $45 copay; limited to 30 days per calendar year; costs may vary based on place of service

• Outpatient occupational therapy $45 copay; limited to 30 days per calendar year; costs may vary based on place of service

• Outpatient speech therapy $45 copay; limited to 30 days per calendar year; costs may vary based on place of service

• Chiropractic services $20 copay PCP; $45 copay specialist; limited to 10 days per calendar year




32

Cigna EPO






Retail



pharmacy


pharmacy


pharmacy






schedule

• Well-woman exam (includes pap) 100% covered for preventive services; $20 copay PCP; $45 copay specialist for non-preventive services; check with



• Cancer screenings 100% covered for preventive services; $20 copay PCP; $45 copay specialist for non-preventive services; check with







• Midwives, licensed and certified Covered; copay based on location of services

• Infertility services $20 copay PCP; $45 copay specialist; 90% cov after ded is met inpatient; limited to $10,000 per family per lifetime,

$5,000 for Rx and $5,000 for all medical services; check with Plan for details

• Oral contraceptives Retail and mail order avail; 100% cov for T1 contraceptives; applicable Rx copay/coinsurance applies for other tiers









Hearing Care


• Hearing hardware (hearing aid) 90% covered after deductible is met; limited to $6,000 per lifetime


• Noncustodial home health care 100% covered; limited to 120 days per calendar year




Special Messages










33

Cigna HDHP (pre-65 option)

Plan Facts




This coverage summary provides an overview of benefits available under the Cigna HDHP medical plan for the year 2022. Keep in mind that this is only a summary, and





Annual Deductible

Individual/Family



Individual/Family



MH/SU






services








Emergency Care

• Emergency room




Inpatient Care




Outpatient Care






and speech therapy





• Chiropractic services 80% covered after deductible is met; limited to 10 days per calendar










34

Cigna HDHP






Retail















Not covered




schedule


schedule




schedule




schedule




schedule











for details






other tiers





Org Web ID “HP”



Org Web ID “HP”





Org Web ID “HP”



Org Web ID “HP”



Hearing Care


preventive schedule
















Special Messages












35

Cigna Premium PPO

Plan Facts




This coverage summary provides an overview of benefits available under the Cigna Premium PPO medical plan for the year 2022. Keep in mind that this is only a summary,


(“in-network”) or non-participating providers (“out-of-network”). For in-network services subject to an office visit copayment, coverage may vary based on where services

are provided and how services are billed. If services are provided in a hospital setting, benefits may be paid as Hospital services and paid at 90% of eligible expenses after

the annual deductible. For additional information and details about benefits under this medical plan, call the member services department at the number(s) shown above.


Annual Deductible

Individual/Family



Individual/Family






Individual/Family


coinsurance


coinsurance









Emergency Care

• Emergency room


$200 copay then 90% covered $200 copay then 90% covered


Inpatient Care




Outpatient Care






and speech therapy

$20 copay PCP; $45 copay specialist; limited to 30 days per calendar

year; combined in-network and out-of-network; costs may vary

based on place of service



• Chiropractic services $20 copay PCP; $45 copay specialist; limited to 10 days per calendar


$20 copay PCP; $45 copay specialist; limited to 10 days per










36

Cigna Premium PPO





Retail
















Not covered


specialty pharmacy)

Not covered



schedule


schedule



schedule


schedule


Plan for preventive care schedule


schedule



schedule


schedule





















Org Web ID “HP”



Org Web ID “HP”





Org Web ID “HP”



Org Web ID “HP”



Hearing Care


preventive schedule


schedule















Special Messages












37

Cigna Value PPO

Plan Facts




This coverage summary provides an overview of benefits available under the Cigna Value PPO medical plan for the year 2022. Keep in mind that this is only a summary, and





Annual Deductible

Individual/Family



Individual/Family


includes MH/SUs; Rx copays excluded




Individual/Family


coinsurance


coinsurance














Emergency Care

• Emergency room


$200 copay then 90% covered $200 copay then 90% covered


Inpatient Care




Outpatient Care








and speech therapy





• Chiropractic services 100% covered up to $250, then 80% covered after deductible is

met; limited to 10 days per calendar year; combined in and

out-of-network; $250 annual limit is combined for all office visits

100% covered up to $250, then 80% covered after deductible is



• Allergy tests and treatments 100% covered up to $250 for office visit charges only; other services

80% covered after deductible is met; $250 annual limit is combined

for all office visit services


• Acupuncture 100% covered up to $250, then 80% covered after deductible is







38

Cigna Value PPO





Retail
















Not covered


specialty pharmacy)

Not covered



schedule


schedule


schedule


schedule




schedule


schedule


schedule











Plan for details










Org Web ID “HP”



Org Web ID “HP”





Org Web ID “HP”



Org Web ID “HP”



Hearing Care


preventive schedule


schedule

• Hearing hardware (hearing aid) 80% covered after deductible is met; limited to $6,000 per lifetime 50% cov after deductible is met; limited to $6,000 per lifetime














Special Messages












39

HMSA PPO

Plan Facts


Hours of operation8:00 a.m. to 6:00 p.m.; time varies by location; Hawaii time; hours

may change; visit HMSA.com for updates

Web site address www.hmsa.com

This coverage summary provides an overview of benefits available under the HMSA PPO medical plan for the year 2022. Keep in mind that this is only a summary, and does

not provide complete information about the medical plan, its benefits, provisions, or coverages. Benefits vary based on whether you use network providers (“in-network”)

or non-participating providers (“out-of-network”). For additional information and details about benefits under this medical plan, call the member services department at



Annual Deductible

Individual/Family

$0 Individual; $0 Family $100 Individual; $300 Family


Individual/Family

$2,500 Individual; $7,500 Family; deductible not included; copays

apply; Rx not included

$2,500 Individual; $7,500 Family; includes deductible; copays

apply; Rx not included


Individual/Family

$3,600 Individual; $4,200 Family; in and out-of-network combined $3,600 Individual; $4,200 Family; in and out-of-network combined


Specialist Office Visit $12 copay 70% covered after deductible is met

Virtual Urgent Care No copay applies; go to hmsa.com to get started Not covered


Hospital Coinsurance 90% covered 70% covered after Plan deductible is met

Emergency Care

• Emergency room


80% covered facility; $12 copay; physician visits; all other services

and supplies see deductible and copay amounts listed

80% covered facility; $12 copay; physician visits; all other services

and supplies see deductible and copay amounts listed

• Urgent care clinic visit (facility) $12 copay 70% covered after deductible is met

Inpatient Care

• Inpatient surgery 90% covered; surgical services; $12 copay per physician visit and

surgeon consultations


• Physician/Surgeon services 90% covered; surgical services; $12 copay per physician visit and

surgeon consultations


• Inpatient lab and X-ray services 90% covered 70% covered after deductible is met

Outpatient Care

• Second surgical opinion $12 copay 70% covered after deductible is met

• Outpatient laboratory services 80% covered 70% covered after deductible is met

• Outpatient X-ray services 80% covered 70% covered after deductible is met

• Outpatient surgery 90% covered (cutting); 80% covered (non-cutting) 70% covered after deductible is met

• Outpatient physical therapy 80% covered; precertification required after initial visit; maximums

determined by service

70% covered after deductible is met; precertification required after

initial visit; maximums determined by service

• Outpatient occupational therapy 80% covered; precertification required after initial visit; maximums


70% covered after deductible is met; precertification required after

initial visit; maximums determined by service

• Outpatient speech therapy 80% covered; certain services subject to precertification; maximums


70% covered after deductible is met; certain services subject to

precertification; maximums determined by service

• Chiropractic services Regular Plan benefits apply; check with Plan for details Regular Plan benefits apply; check with Plan for details

• Allergy tests and treatments 80% covered 70% covered after deductible is met

• Acupuncture Not covered Not covered


40

HMSA PPO


Prescription Drug Coverage Check with the Plan for exclusions. Check with the Plan for exclusions.

Retail

• Generic $7 copay; 30-day supply; Tier 1 (mostly generic drugs) $7 copay; 30-day supply; plus 20% of remaining eligible charge; Tier 1

(mostly generic drugs)

• Formulary $30 copay; 30-day supply; Tier 2 (mostly formulary brand drugs) $30 copay; 30-day supply; plus 20% of remaining eligible charge; Tier

2 (mostly formulary brand drugs)

• Nonformulary $30 copay; 30-day supply; plus $45 Tier 3 cost share (mostly other

brand name drugs)

$30 copay; 30-day supply; plus $45 Tier 3 cost share (mostly other

brand name drugs) and 20% of remaining eligible charge

• ED/sleep aids $100 copay (mostly preferred specialty drugs); check with Plan for

details

Check with Plan for details

Mail Order Covered; provides cost savings and convenience for a 90-day supply

sent direct to your home

Not covered

Specialty Drug Program Check with Plan for details Not covered


• Annual physical exam 100% covered for preventive services 70% covered after deductible is met

• Well-woman exam (includes pap) 100% covered; routine pap smear limited to once every three years 70% covered after deductible is met; routine pap smear limited to

once every three years

• Mammogram 100% covered; screening 70% covered; screening

• Cancer screenings 100% covered for preventive services; screenings are covered based

on USPSTF grade A and B recommendations

70% covered after deductible is met; screenings are covered based on

USPSTF grade A and B recommendations


• Office visit: pre/postnatal $12 copay initial visit only; 90% covered for routine prenatal visits,

delivery and one postpartum visit

70% covered after deductible is met; for routine prenatal visits,

delivery and one postpartum visit

• In-hospital doctor's services $12 copay physician services; 90% covered facility 70% covered after deductible is met

• Newborn nursery services 90% covered 70% covered after deductible is met

• Midwives, licensed and certified 90% covered 70% covered after deductible is met; for delivery and midwife services

• Infertility services Covered; limitations apply; precertification is required; check with Plan

for details

Covered; limitations apply; precertification is required; check with Plan

for details

• Oral contraceptives Retail and mail order available; 100% covered for generic oral

contraceptives

Retail available only; regular drug plan benefits

Mental Health Care

• Outpatient coverage/visits 90% covered (facility); $12 copay (physician) 70% covered after deductible is met

• Inpatient coverage/days 90% covered 70% covered after deductible is met


• Rehab: outpatient coverage/visits 90% covered (facility); $12 copay (physician) 70% covered after deductible is met

• Rehab: inpatient coverage/days 90% covered 70% covered after deductible is met

Vision Care

• Routine eye exams Not covered Not covered

Hearing Care

• Hearing evaluation test Multiple copays may apply; check with Plan for details; limited to

evaluation for use of hearing aids; 100% covered for preventive

services up to age 21

Multiple copays may apply; check with Plan for details; limited to

evaluation for use of hearing aids; 100% covered for preventive

services up to age 21

• Hearing hardware (hearing aid) 80% covered; limited to one device per ear every 60 months 70% covered after deductible is met; limited to one device per ear

every 60 months


• Noncustodial home health care 100% covered; limited to 150 visits per calendar year 70% covered after deductible is met; limited to 150 visits per calendar

year

• Hospice care 100% covered Not covered



90% covered; limited to 120 days per calendar year 70% covered after deductible is met; limited to 120 days per calendar

year

• Durable medical equipment 80% covered; preauthorization required 70% covered after deductible is met; preauthorization required

Special Messages





41

Kaiser (Hawaii)

Plan Facts


Hours of operation 8:00 a.m. to 5:00 p.m.

Web site address https://my.kp.org/hp/

This coverage summary provides an overview of benefits available under the Kaiser (Hawaii) medical plan for the year 2022. Keep in mind that this is only a summary, and





Annual Deductible

Individual/Family

$0 Individual; $0 Family $100 Individual; $300 Family


Individual/Family

$2,000 Individual; $6,000 Family; copays apply $2,000 Individual; $6,000 Family; includes deductible; copays

apply


Specialist Office Visit $15 copay 80% covered after deductible is met

Virtual Urgent Care No copay is required; must be an established patient No copay is required; must be an established patient

Hospital Copay $75 copay per day 80% covered after Plan deductible is met

Hospital Coinsurance 100% covered after hospital copay 80% covered after Plan deductible is met

Emergency Care

• Emergency room


$75 copay $75 copay

• Urgent care clinic visit (facility) $15 copay; at a KP facility within the Hawaii service area 80% covered at a non-KP facility outside the Hawaii service area

Inpatient Care

• Inpatient surgery 100% covered after hospital copay 80% covered after Plan deductible is met

• Physician/Surgeon services 100% covered after hospital copay 80% covered after Plan deductible is met

• Inpatient lab and X-ray services 100% covered after hospital copay 80% covered after Plan deductible is met

Outpatient Care

• Second surgical opinion $15 copay 80% covered after deductible is met

• Outpatient laboratory services 90% covered 80% covered after deductible is met

• Outpatient X-ray services 90% covered 80% covered after deductible is met

• Outpatient surgery $15 copay 80% covered after deductible is met

• Outpatient physical therapy $15 copay; limited by certain clinical criteria and KP physician

determination; limited to 60 PT/OT/ST visits per calendar year

80% covered after deductible is met; limited to 60 PT/OT/ST visits

per calendar year

• Outpatient occupational therapy $15 copay; limited by certain clinical criteria and KP physician



per calendar year

• Outpatient speech therapy $15 copay; limited by certain clinical criteria and KP physician



per calendar year

• Chiropractic services Not covered Not covered

• Allergy tests and treatments $15 copay; 90% covered for lab/imaging/testing 80% covered after deductible is met

• Acupuncture Not covered Not covered


42

Kaiser (Hawaii)


Prescription Drug Coverage Administered by Kaiser Permanente

Retail

• Generic $10 copay generic; $3 copay generic maintenance; 30-day supply 80% covered; at contracted pharmacies; minimum $10 copay

• Formulary $35 copay; 30-day supply 80% covered; at contracted pharmacies; minimum $35 copay

• Nonformulary $35 copay; $200 copay for specialty drugs; 30-day supply; must be

medically necessary, prescribed by a Plan physician and approved

through the exception process

80% covered; out-of-network; must be medically necessary,

prescribed by a Plan physician and approved through the exception

process

• ED/sleep aids Not covered Not covered

Mail Order 2x the retail 30-day copay for generic and brand name drugs in Tiers

1-3 shown above; provides cost savings and convenience for a 90-day

supply sent direct to your home

Not covered

Specialty Drug Program Specialty drugs must be filled through a designated contracted

pharmacy; check with Plan for details

Not covered


• Annual physical exam 100% covered for preventive services 80% covered after deductible is met; check with Plan for preventive

schedule

• Well-woman exam (includes pap) 100% covered for preventive services 80% covered after deductible is met; check with Plan for preventive

schedule

• Mammogram 100% covered for preventive services 80% covered after deductible is met; check with Plan for preventive

schedule

• Cancer screenings 100% covered for mammography, cervical cancer screening, FOBT,

colorectal cancer screening, and PSA


schedule


• Office visit: pre/postnatal 100% covered; applicable cost share applies for first appointment to

determine pregnancy


• In-hospital doctor's services 100% covered after hospital copay 80% covered after deductible is met

• Newborn nursery services 100% covered after hospital copay; provided newborn is added within

31 days of birth

80% covered after deductible is met; provided newborn is added

within 31 days of birth

• Midwives, licensed and certified 100% covered; after confirmation of pregnancy 80% covered after deductible is met

• Infertility services $15 copay for office visits; 80% covered for other services; OOP does

not apply

Not covered

• Oral contraceptives Retail and mail order available; 100% covered for FDA-approved

contraceptives for females of child-bearing age

80% covered, but not less than $10 generic; $35 Brand prescription

for out-of-network contracted pharmacies

Mental Health Care

• Outpatient coverage/visits $15 copay 80% covered after deductible is met

• Inpatient coverage/days $75 copay per day 80% covered after deductible is met


• Rehab: outpatient coverage/visits $15 copay 80% covered after deductible is met

• Rehab: inpatient coverage/days $75 copay per day 80% covered after deductible is met

Vision Care

• Routine eye exams $15 copay; 100% covered for preventive services 80% covered after deductible is met

Hearing Care

• Hearing evaluation test $15 copay; 100% covered for preventive services 80% covered after deductible is met

• Hearing hardware (hearing aid) 40% covered; limited to two aids every three years Not covered


• Noncustodial home health care 100% covered; preauthorization required by Kaiser physician; limited

to 150 days per calendar year


year

• Hospice care 100% covered; limited to 2, 90 day periods; followed by unlimited 60

day periods


year



100% covered; limited to 120 days per calendar year 80% covered after deductible is met; limited to 120 days per calendar

year

• Durable medical equipment 80% covered; 100% covered for internal prosthetics; 50% covered for

diabetes equipment

80% covered

Special Messages




exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary. Binding arbitration is required to resolve medical malpractice and other disputes. By enrolling,

you agree to give up your right to a jury trial for resolution. For more information, please contact the HMO directly.

43

Kaiser HMO (Colorado)

Plan Facts


Hours of operation8:00 a.m. to 6:00 p.m.; IVR capabilities available 24 hours a day,

seven days a week for all members, non-members and providers


This coverage summary provides an overview of benefits available under the Kaiser HMO (Colorado) medical plan for the year 2022. Keep in mind that this is only a

summary, and does not provide complete information about the medical plan, its benefits, provisions, or coverages. For additional information and details about benefits

under this medical plan, call the member services department at the number(s) shown above.


Annual Deductible

Individual/Family



Individual/Family

$3,150 Individual; $6,150 Family; includes deductible; copays apply; including RX copays and coinsurance



Virtual Urgent Care No copay is required; must be an established patient



Emergency Care

• Emergency room (not followed by admission) $250 copay after deductible is met


Inpatient Care




Outpatient Care


• Outpatient laboratory services 90% covered after deductible is met; 100% covered for preventive services



• Outpatient physical therapy $20 copay; limited to 20 visits per calendar year; visit limits waived for conditions covered under autism state

mandate

• Outpatient occupational therapy $20 copay; limited to 20 visits per calendar year; visit limits waived for conditions covered under autism state

mandate

• Outpatient speech therapy $20 copay; limited to 20 visits per calendar year; visit limits waived for conditions covered under autism state

mandate

• Chiropractic services $20 copay; limited to 30 visits per calendar year

• Allergy tests and treatments Copay for testing varies based on place of service; $20 or $45 copay; $20 copay for injections

• Acupuncture 25% discount available through participating providers


44

Kaiser HMO (Colorado)



Retail

• Tier 1 $10 copay; 30-day supply; sexual dysfunction drugs excluded

• Tier 2 70% covered; $30 min/$60 max; 30-day supply; sexual dysfunction drugs excluded

• Tier 3 60% covered; $45 minimum copay; $75 maximum copay; 30 day supply

• Tier 4 (ED/sleep aids) 50% covered; $50 minimum copay; $100 maximum copay; 30-day supply; for sleep aids, erectile dysfunction and

proton pump inhibitors



Specialty Drug Program Specialty drugs must be filled through a designated contracted pharmacy; check with Plan for details



• Well-woman exam (includes pap) 100% covered for preventive services; $45 specialist copay for subsequent GYN visits




• Office visit: pre/postnatal 90% covered after deductible is met


• Newborn nursery services 90% covered after deductible is met; charges apply under mother's coverage

• Midwives, licensed and certified Not covered

• Infertility services 50% covered; deductible does not apply; drugs not covered

• Oral contraceptives Retail and mail order available; 100% covered; for FDA approved services

Mental Health Care






Vision Care

• Routine eye exams $20 copay; 100% covered for child screenings

Hearing Care

• Hearing evaluation test $20 copay; 100% covered for newborn screenings

• Hearing hardware (hearing aid) Not covered



• Hospice care 100% covered; not subject to deductible


• Durable medical equipment 90% covered; deductible applies for supplemental DME

Special Messages



information on covered benefits and exclusions, contact the medical plan directly at the number(s) shown on the front side of this coverage summary. Binding arbitration is required to resolve medical

malpractice and other disputes. By enrolling, you agree to give up your right to a jury trial for resolution. For more information, please contact the HMO directly.

45

Kaiser HMO (Georgia)

Plan Facts




This coverage summary provides an overview of benefits available under the Kaiser HMO (Georgia) medical plan for the year 2022. Keep in mind that this is only a




Annual Deductible

Individual/Family



Individual/Family

$3,150 Individual; $6,150 Family; includes deductible; copays apply; including RX copays and coinsurance






Emergency Care

• Emergency room (not followed by admission) $200 copay

• Urgent care clinic visit (facility) $50 copay; at designated facilities

Inpatient Care




Outpatient Care

• Second surgical opinion $45 copay if second opinion is provided by a Plan physician; otherwise not covered

• Outpatient laboratory services 90% covered after deductible is met; routine lab in office 100% covered; after applicable office visit copay

• Outpatient X-ray services 90% covered after deductible is met; routine x-ray in office 100% covered; after applicable office visit copay


• Outpatient physical therapy $45 copay; limited to 20 visits per calendar year; combined with occupational therapy

• Outpatient occupational therapy $45 copay; limited to 20 visits per calendar year; combined with physical therapy

• Outpatient speech therapy $45 copay; limited to 20 visits per calendar year


• Allergy tests and treatments 90% for covered tests; $20 copay PCP; $45 copay specialist for injection; serum covered under office visit

copay

• Acupuncture Not covered


46

Kaiser HMO (Georgia)



Retail

• Generic $10 copay; 30-day supply; $20 copay at network pharmacies; network pharmacies limited to a one-time fill per

medication

• Formulary 70% covered; $60 maximum copay; 30-day supply; net difference; network pharmacies limited to a one-time fill per

medication

• Nonformulary 60% covered; $75 maximum copay; 30-day supply; net difference; network pharmacies limited to a one-time fill per

medication

• ED/sleep aids Not covered

Mail Order $20 copay generic from KP pharmacy only; 2x the retail 30-day copay for brand name drugs in Tiers 2-3 shown

above; provides cost savings and convenience for a 90-day supply sent direct to your home








• Office visit: pre/postnatal 90% covered after deductible is met; office visit copay may apply depending on place of service; routine pre-natal

visits and first post-natal visit covered 100%




• Infertility services 90% covered after deductible is met; for diagnosis; 50% covered treatment within Plan guidelines

• Oral contraceptives Retail and mail order available; 100% covered

Mental Health Care






Vision Care

• Routine eye exams $45 copay at Plan providers; 100% covered for preventive services

Hearing Care

• Hearing evaluation test $20 copay PCP; $45 copay specialist; limited to screening only; 100% covered for preventive services



• Noncustodial home health care 90% covered after deductible is met; limited to 120 visits per calendar year; private duty nursing not covered



• Durable medical equipment 100% covered; prosthetics and orthotics covered separately than DME; check with Plan for details

Special Messages





47

Kaiser HMO (Hawaii) (pre-65 option)

Plan Facts




This coverage summary provides an overview of benefits available under the Kaiser HMO (Hawaii) medical plan for the year 2022. Keep in mind that this is only a summary,

and does not provide complete information about the medical plan, its benefits, provisions, or coverages. For additional information and details about benefits under this

medical plan, call the member services department at the number(s) shown above.


Annual Deductible

Individual/Family

$0 Individual; $0 Family


Individual/Family

$2,000 Individual; $6,000 Family; copays apply

Primary Doctor Office Visit $15 copay; 100% covered age 0 - 17 years



Hospital Copay $50 copay per day

Hospital Coinsurance 100% covered after hospital copay

Emergency Care


• Urgent care clinic visit (facility) $15 copay; at a KP facility within the Hawaii service area; 80% covered outside of service area

Inpatient Care

• Inpatient surgery 100% covered after hospital copay

• Physician/Surgeon services 100% covered after hospital copay

• Inpatient lab and X-ray services 100% covered after hospital copay

Outpatient Care

• Second surgical opinion $15 copay

• Outpatient laboratory services 90% covered

• Outpatient X-ray services 90% covered

• Outpatient surgery $15 copay

• Outpatient physical therapy $15 copay; limited by certain clinical criteria and KP physician determination

• Outpatient occupational therapy $15 copay; limited by certain clinical criteria and KP physician determination

• Outpatient speech therapy $15 copay; limited by certain clinical criteria and KP physician determination

• Chiropractic services Not covered

• Allergy tests and treatments $15 copay; 80% covered when administered by skilled personnel

• Acupuncture Not covered


48

Kaiser HMO (Hawaii)


Prescription Drug Coverage Administered by Kaiser Permanente

Retail

• Generic $10 copay generic; $3 copay generic maintenance; 30-day supply

• Formulary $35 copay; 30-day supply

• Nonformulary $35 copay; 30-day supply; must be medically necessary, prescribed by a Plan physician and approved through the

exception process


Mail Order 2x the retail 30-day copay for generic and brand name drugs in Tiers 1-3 shown above; provides cost savings and







• Cancer screenings 100% covered for mammography, cervical cancer screening, FOBT, colorectal cancer screening, and PSA


• Office visit: pre/postnatal 100% covered; applicable cost share applies for first appointment to determine pregnancy

• In-hospital doctor's services 100% covered after hospital copay

• Newborn nursery services 100% covered after hospital copay; provided newborn is added within 31 days of birth

• Midwives, licensed and certified $15 copay; only Kaiser Permanente contracted midwives are covered

• Infertility services $15 copay for office visits; 80% covered for other services; limited to 1 cycle per lifetime

• Oral contraceptives Retail and mail order available; 100% covered for FDA-approved contraceptives for females of child-bearing age

Mental Health Care


• Inpatient coverage/days $50 copay per day



• Rehab: inpatient coverage/days $50 copay per day

Vision Care

• Routine eye exams $15 copay

Hearing Care

• Hearing evaluation test $15 copay; 100% covered for preventive services for children

• Hearing hardware (hearing aid) 40% covered; limited to two aids every three years


• Noncustodial home health care 100% covered


• Prescribed care in a noncustodial skilled nursing facility 100% covered

• Durable medical equipment 80% covered; 50% covered for diabetes equipment

Special Messages





49

Kaiser HMO (Mid-Atlantic)

Plan Facts


Hours of operation 7:30 a.m. to 5:30 p.m. EST


This coverage summary provides an overview of benefits available under the Kaiser HMO (Mid-Atlantic) medical plan for the year 2022. Keep in mind that this is only a




Annual Deductible

Individual/Family



Individual/Family

$3,150 Individual; $6,150 Family; includes deductible; copays apply; including Rx copays






Emergency Care



Inpatient Care




Outpatient Care





• Outpatient physical therapy $45 copay; limited to 30 visits per condition

• Outpatient occupational therapy $45 copay; limited to 30 visits per incident

• Outpatient speech therapy $45 copay; limited to 30 visits per incident


• Allergy tests and treatments $20 copay PCP; $45 copay specialist

• Acupuncture $45 copay; limited to 40 visits per calendar year


50

Kaiser HMO (Mid-Atlantic)



Retail

• Generic $10 copay; 30-day supply; Community Pharmacy $20 copay

• Formulary $30 copay; 30-day supply; Community Pharmacy $60 copay

• Nonformulary $45 copay; 30-day supply; Community Pharmacy $75 copay


Mail Order 2x the retail 30-day copay for brand name drugs in Tiers 1-3 shown above; provides cost savings and convenience

for a 90-day supply sent direct to your home

Specialty Drug Program Specialty drugs must be filled through a KP Mail Order; check with Plan for details







• Office visit: pre/postnatal 100% covered; $45 initial visit copay




• Infertility services 50% covered after deductible is met


Mental Health Care

• Outpatient coverage/visits $20 copay individual visit; $10 copay group visit



• Rehab: outpatient coverage/visits $20 copay individual visit; $10 copay group visit


Vision Care

• Routine eye exams Covered only if part of a preventive screening

Hearing Care

• Hearing evaluation test $20 copay PCP; $45 copay specialist; 100% covered for children up to age 5

• Hearing hardware (hearing aid) State mandates cover children; limited to age 18; limited to 1 hearing aid per ear every 36 months or $1,000

maximum





• Durable medical equipment 100% covered

Special Messages





51

Kaiser HMO (NorthWest)

Plan Facts




This coverage summary provides an overview of benefits available under the Kaiser HMO (NorthWest) medical plan for the year 2022. Keep in mind that this is only a




Annual Deductible

Individual/Family



Individual/Family







Emergency Care

• Emergency room (not followed by admission) $200 copay after deductible is met

• Urgent care clinic visit (facility) $50 copay; at Plan facility or out-of-area non-Plan facility; emergency room copay applies for treatment

received at hospital emergency department

Inpatient Care




Outpatient Care





• Outpatient physical therapy $45 copay after deductible is met; limited to 20 visits per therapy per calendar year

• Outpatient occupational therapy $45 copay after deductible is met; limited to 20 visits per therapy per calendar year

• Outpatient speech therapy $45 copay after deductible is met; limited to 20 visits per therapy per calendar year


• Allergy tests and treatments $45 copay for tests; $10 copay per injection

• Acupuncture Not covered for self-referred acupuncture; $45 copay for physician-referred acupuncture; limited to 12 visits

per calendar year


52

Kaiser HMO (NorthWest)



Retail

• Generic $5 copay; 30-day supply

• Formulary $30 copay; 30-day supply; brand drugs

• Nonformulary $45 copay; 30-day supply


Mail Order 2x the retail copay for brand name drugs in Tiers 1-3 shown above; provides cost savings and convenience for a





• Well-woman exam (includes pap) 100% covered for preventive services; for office visit and/or lab


• Cancer screenings 100% covered for preventive services; for x-ray and laboratory services


• Office visit: pre/postnatal 100% covered



• Midwives, licensed and certified 90% covered after deductible is met; must use participating provider

• Infertility services 50% covered after deductible is met; diagnosis and treatment


Mental Health Care


• Inpatient coverage/days 90% covered after deductible is met; residential care same as hospital inpatient benefit




Vision Care

• Routine eye exams $20 copay per exam; 100% covered for preventive services

Hearing Care

• Hearing evaluation test $20 copay; 100% covered for preventive services; $45 copay for Audiologist



• Noncustodial home health care 90% covered after deductible is met; for homebound patient in the service area upon physician referral; limited to

130 days per calendar year

• Hospice care 100% covered for patient diagnosed with life expectancy of six months or less


• Durable medical equipment 100% covered; Medicare criteria applies

Special Messages





53

Kaiser HMO (Northern CA)

Plan Facts


Hours of operation

24/7; Member Services will close at 10:00 p.m. on the Eve of and

reopen at 4:00 a.m. the day after the following holidays: New Year's

Day, Fourth of July, Memorial Day, Thanksgiving Day, Christmas Day


This coverage summary provides an overview of benefits available under the Kaiser HMO (Northern CA) medical plan for the year 2022. Keep in mind that this is only a




Annual Deductible

Individual/Family



Individual/Family







Emergency Care



Inpatient Care




Outpatient Care


• Outpatient laboratory services 90% covered after deductible is met; per encounter; 100% covered for preventive screening labs

• Outpatient X-ray services 90% covered after deductible is met; per encounter for diagnostic x-ray; 100% covered for preventive

screening; 90% covered for high-cost radiology; deductible does not apply to high-cost radiology


• Outpatient physical therapy $20 copay after deductible is met; must be medically necessary therapy preauthorized by Plan physician

• Outpatient occupational therapy $20 copay after deductible is met; must be medically necessary therapy preauthorized by a Plan physician

• Outpatient speech therapy $20 copay after deductible is met; must be medically necessary therapy preauthorized by Plan physician

• Chiropractic services $15 copay; limited to 30 visits per calendar year; limited to $50 per calendar year allowance toward the

purchase of appliances

• Allergy tests and treatments $20 copay PCP; $45 copay specialist; allergy injections 100% covered

• Acupuncture $45 copay; covered as alternative to standard treatment when, in the judgment of a Plan Dr., it is the most

appropriate treatment for the spec cndtn of the patient


54

Kaiser HMO (Northern CA)



Retail


• Formulary $30 copay; 30-day supply; when medically necessary, prescribed by a Plan physician, and obtained at Plan

pharmacies

• Nonformulary $30 copay; 30-day supply; when medically necessary, prescribed by a Plan physician, and obtained at Plan

pharmacies; must be approved through an exception process

• ED/sleep aids $30 copay; 30-day supply; when medically necessary, prescribed by a Plan physician, and obtained at Plan

pharmacies







• Mammogram 100% covered for preventive screening & imaging



• Office visit: pre/postnatal 100% covered per scheduled prenatal visits and 1st postpartum visit; $20 copay PCP; $45 copay specialist for

diagnostic visits; 90% covered after deductible is met for diagnostic labs


• Newborn nursery services 90% covered after deductible is met; during mother's hospitalization; charges apply under mother's coverage

• Midwives, licensed and certified 90% covered after deductible is met; only at Plan facilities where available

• Infertility services 50% covered; for diagnosis/trtmnt of involuntary infertility when preauthorized by Plan physician; inpat care/outpat

surgery subject to deductible

• Oral contraceptives Retail and mail order available; 100% covered if used for contraceptive purposes; applicable Rx copays apply if not

used for contraceptive purposes

Mental Health Care





• Rehab: inpatient coverage/days 90% covered after deductible is met; $100 copay per admit after deductible for Transitional Residential Recovery

Service (TRRS) in a non-medical setting

Vision Care

• Routine eye exams 100% covered for preventive services and refraction; $20 copay PCP; $45 copay specialist for diagnostic services

Hearing Care

• Hearing evaluation test 100% covered for preventive services; $20 copay PCP; $45 copay specialist visit for diagnostic services



• Noncustodial home health care 100% covered; must be prescribed by a Plan physician and provided within the service area; limited to 3 visits per

day & 100 visits per calendar year

• Hospice care 100% covered; within the service area when selected as an alternative to traditional services; check with Plan for

eligibility requirements


• Durable medical equipment 100% covered; per item when deemed medically necessary and prescribed by a Plan physician in accordance with

DME formulary guidelines

Special Messages





55

Kaiser HMO (Southern CA)

Plan Facts


Hours of operation

24/7; Member Services will close at 10:00 p.m. on the Eve of and

reopen at 4:00 a.m. the day after the following holidays: New Year's

Day, Fourth of July, Memorial Day, Thanksgiving Day, Christmas Day


This coverage summary provides an overview of benefits available under the Kaiser HMO (Southern CA) medical plan for the year 2022. Keep in mind that this is only a




Annual Deductible

Individual/Family



Individual/Family







Emergency Care



Inpatient Care




Outpatient Care


• Outpatient laboratory services 90% covered after deductible is met; per encounter; 100% covered for preventive screening labs

• Outpatient X-ray services 90% covered after deductible is met; per encounter for diagnostic x-ray; 100% covered for preventive

screening; 90% covered for high-cost radiology; deductible does not apply to high-cost radiology


• Outpatient physical therapy $20 copay after deductible is met; must be medically necessary therapy preauthorized by Plan physician

• Outpatient occupational therapy $20 copay after deductible is met; must be medically necessary therapy preauthorized by a Plan physician

• Outpatient speech therapy $20 copay after deductible is met; must be medically necessary therapy preauthorized by Plan physician

• Chiropractic services $15 copay; limited to 30 visits per calendar year; limited to $50 per calendar year allowance toward the

purchase of appliances

• Allergy tests and treatments $20 copay PCP; $45 copay specialist; allergy injections 100% covered

• Acupuncture $45 copay; covered as alternative to standard treatment when, in the judgment of a Plan Dr., it is the most

appropriate treatment for the spec cndtn of the patient


56

Kaiser HMO (Southern CA)



Retail


• Formulary $30 copay; 30-day supply; when medically necessary, prescribed by a Plan physician, and obtained at Plan

pharmacies

• Nonformulary $30 copay; 30-day supply; when medically necessary, prescribed by a Plan physician, and obtained at Plan

pharmacies; must be approved through an exception process

• ED/sleep aids $30 copay; 30-day supply; when medically necessary, prescribed by a Plan physician, and obtained at Plan

pharmacies







• Mammogram 100% covered for preventive screening & imaging



• Office visit: pre/postnatal 100% covered per scheduled prenatal visits and 1st postpartum visit; $20 copay PCP; $45 copay specialist for

diagnostic visits; 90% covered after deductible is met for diagnostic labs


• Newborn nursery services 90% covered after deductible is met; during mother's hospitalization; charges apply under mother's coverage

• Midwives, licensed and certified 90% covered after deductible is met; only at Plan facilities where available

• Infertility services 50% covered; for diagnosis/trtmnt of involuntary infertility when preauthorized by Plan physician; inpat care/outpat

surgery subject to deductible

• Oral contraceptives Retail and mail order available; 100% covered if used for contraceptive purposes; applicable Rx copays apply if not

used for contraceptive purposes

Mental Health Care





• Rehab: inpatient coverage/days 90% covered after deductible is met; $100 copay per admit after deductible for Transitional Residential Recovery

Service (TRRS) in a non-medical setting

Vision Care

• Routine eye exams 100% covered for preventive services and refraction; $20 copay PCP; $45 copay specialist for diagnostic services

Hearing Care

• Hearing evaluation test 100% covered for preventive services; $20 copay PCP; $45 copay specialist visit for diagnostic services



• Noncustodial home health care 100% covered; must be prescribed by a Plan physician and provided within the service area; limited to 3 visits per

day & 100 visits per calendar year

• Hospice care 100% covered; within the service area when selected as an alternative to traditional services; check with Plan for

eligibility requirements


• Durable medical equipment 100% covered; per item when deemed medically necessary and prescribed by a Plan physician in accordance with

DME formulary guidelines

Special Messages





Documents

2022 medical option coverage summaries