Disclosure form and evidence of coverage - Kaiser Permanente ...

More documents

Recommendations

Info

2013 University of California Specific Summary of Benefit Changes The following is a summary of the University of California specific coverage changes that we have made for the 2013 Plan year. Please read this Evidence of Coverage for the complete text of these changes. Plan provider office visits: • The Cost Sharing for most primary and specialty care consultations, exams, and treatment is $20 per visit • The Cost Sharing for eye exams for refraction and glaucoma screening is $20 per visit • The Cost Sharing for hearing exams is $20 per visit • The Cost Sharing for urgent care consultations, exams, and treatment is $20 per visit • The Cost Sharing for physical, occupational, and speech therapy is $20 per visit Outpatient Surgery • The Cost Sharing for outpatient surgery provided in an outpatient or ambulatory surgery center or in a hospital operating room is $100 per procedure. • The Cost Sharing for manual manipulation of the spine is $20 per visit Emergency Health Visits The Cost Sharing for Emergency Department visits is $65 per visit. Prescription Drug Coverage The Cost Sharing for prescription drugs is as follows: Generic items at a Plan Pharmacy Generic refills through mail-order service Brand-name items at a Plan Pharmacy Brand-name refills through mail-order service $5 Copayment for up to a 30-day supply $10 Copayment for a 31- to 60-day supply $15 Copayment for a 61- to 100-day supply $5 Copayment for up to a 30-day supply $10 Copayment for a 31- to 100-day supply $25 Copayment for up to a 30-day supply $50 Copayment for a 31- to 60-day supply $75 Copayment for a 61- to 100-day supply $25 Copayment for up to a 30-day supply $50 Copayment for a 31- to 100-day supply Mental Health Services • The Cost Sharing for individual outpatient mental health evaluation and treatment is $20 per visit • The Cost Sharing for group outpatient mental health treatment is $10 per visit Chemical Dependency Services The Cost Sharing for individual outpatient chemical dependency evaluation and treatment is $20 per visit. Page 6
Benefit Highlights Annual Out-of-Pocket Maximum for Certain Services For Services subject to the maximum, you will not pay any more Cost Sharing during a calendar year if the Copayments and Coinsurance you pay for those Services add up to one of the following amounts: For self-only enrollment (a Family of one Member).............................. $1,500 per calendar year For any one Member in a Family of two or more Members .................. $1,500 per calendar year For an entire Family of two or more Members ...................................... $3,000 per calendar year Deductible None Lifetime Maximum Services covered under "Transgender Surgery" in the "Benefits and Cost Sharing" section ........................................................................................ $75,000 All other Services ........................................................................................ None Professional Services (Plan Provider office visits) You Pay Most primary and specialty care consultations, exams, and treatment ........ $20 per visit Annual Wellness visit and the Welcome to Medicare preventive visit ....... No charge Routine physical exam ................................................................................ No charge Eye exams for refraction and glaucoma screening ...................................... $20 per visit Hearing exams ............................................................................................. $20 per visit Urgent care consultations, exams, and treatment ........................................ $20 per visit Physical, occupational, and speech therapy ................................................ $20 per visit Outpatient Services You Pay Outpatient surgery and certain other outpatient procedures ........................ $100 per procedure Allergy injections (including allergy serum) ............................................... $3 per visit Most immunizations (including the vaccine) .............................................. No charge Most X-rays, annual mammograms, and laboratory tests ........................... No charge Manual manipulation of the spine ............................................................... $20 per visit Hospitalization Services You Pay Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs . $250 per admission Emergency Health Coverage You Pay Emergency Department visits ..................................................................... $65 per visit Note: This Cost Sharing does not apply if admitted to the hospital as an inpatient within 24 hours for the same condition for covered Services or if you are admitted directly to the hospital as an inpatient (see "Hospitalization Services" for inpatient Cost Sharing). Ambulance Services You Pay Ambulance Services .................................................................................... No charge Prescription Drug Coverage You Pay Covered outpatient items in accord with our drug formulary guidelines: Most generic items at a Plan Pharmacy ................................................. $5 for up to a 30-day supply, $10 for a 31- to 60- day supply, or $15 for a 61- to 100-day supply Most generic refills through our mail-order service ............................... $5 for up to a 30-day supply or $10 for a 31- to 100- day supply Most brand-name items at a Plan Pharmacy .......................................... $25 for up to a 30-day supply, $50 for a 31- to 60- day supply, or $75 for a 61- to 100-day supply Most brand-name refills through our mail-order service ....................... $25 for up to a 30-day supply or $50 for a 31- to 100-day supply Durable Medical Equipment You Pay Covered durable medical equipment for home use in accord with our durable medical equipment formulary guidelines ..................................... No charge Page 7
Page 1 and 2: KP Library Owned: SEN03018_BW_adj_t
Page 3 and 4: TABLE OF CONTENTS FOR EOC #1 2013 G
Page 5 and 6: Important Phone Numbers and Resourc
Page 7: • You receive Services from a sec
Page 11 and 12: Member Service Contact Center: toll
Page 59 and 60:
Member Service Contact Center: toll
Page 61 and 62:
Page 63 and 64:
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
Page 79 and 80:
Page 81 and 82:
Page 83 and 84:
Page 85 and 86:
Page 87 and 88:
Page 89 and 90:
Page 91 and 92:
Page 93 and 94:
Page 95 and 96:
Page 97 and 98:
Page 99 and 100:
Page 101 and 102:
Page 103 and 104:
Page 105 and 106:
Page 107 and 108:
Page 109 and 110:
Page 111 and 112:
Page 113 and 114:
Page 115 and 116:
Multi-language Interpreter Services
Page 117:
Member Service Contact Center 1-800
show all

Disclosure form and evidence of coverage - Kaiser Permanente ...

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?