Benefits Summary Sheet 2012 Plan Year Kaiser Permanente Added ...

Added Choice In Network
Contracted Physicians in a
Kaiser Facility
(All care and services provided,
prescribed or directed by Kaiser
Permanente Physicians in
Kaiser Permanente Facilities)
Deductible None
Out of pocket maximums
Copayments/Coinsurance
Preventive health
services
Added Choice Out of
Network*
Contracted Physicians not located
in a Kaiser Facility
Single $100
Family $300
Single $2000 Single $2500
Family $6000 Family $7500
None
(Member responsibility is a copayment
where applicable)
Covered at 100% for well-child
visits, well-woman visits,
immunizations, physical exams
and preventive care screenings
20% of the Maximum Allowable
Charge (MAC)*
Covered at 80% of MAC for wellchild
visits, well-woman visits,
immunizations (birth through age
5 covered at 100% of MAC,
deductible waived), physical
exams (birth through age 5
covered at 80% of MAC,
deductible waived), and
preventive care screenings
covered at 80% of MAC
Added Choice Out of
Network*
Non-Contracted
Physicians
20% of the Maximum
Allowable Charge (MAC)*
Covered at 80% of MAC
for well-child visits, wellwoman
visits,
immunizations (birth
through age 5 covered at
100% of MAC, deductible
waived), physical exams
(birth through age 5
covered at 80% of MAC,
deductible waived), and
preventive care
screenings covered at
80% of MAC
Inpatient services Covered at 100% Covered at 80% of MAC Covered at 80% of MAC
Outpatient services
Mental
health
services
Substance
abuse
services
Inpatient
services
Outpatient
services
Inpatient
services
$15 co-payment per visit; lab,
imaging and testing services
covered at 100%
Covered at 80% of MAC per visit;
lab, imaging, and testing services
covered at 80% of MAC
Covered at 80% of MAC
per visit; lab, imaging,
and testing services
covered at 80% of MAC
Covered at 100% Covered at 80% of MAC Covered at 80% of MAC
$15 co-payment per visit Covered at 80% of MAC Covered at 80% of MAC
Covered at 80% of MAC Covered at 80% of MAC
Covered at 100%
Residential Residential benefit is 80% of MAC
Outpatient
services
Benefits Summary Sheet
2012 Plan Year
Kaiser Permanente Added Choice/Hawaii
(Option 64) Group #506
Residential benefit is
80% of MAC
$15 co-payment per visit Covered at 80% of MAC Covered at 80% of MAC

Emergency
services
Pre-admission
certification
E/R
Urgent
Care
$50 co-payment plus other applicable plan charges
$15 co-payment per visit; lab,
imaging and testing services
covered at 100% at a Kaiser
Permanente facility within the
Hawaii service area; covered at
80% at a non-Kaiser
Permanente facility outside the
Hawaii service area
Primary Care Physician must
authorize
Covered at 80% of MAC per visit;
lab, imaging, and testing services
covered at 80% of MAC
Precertification is required three
days prior to receiving select out
of network services; refer to the
Certificate of Insurance for the
current listing
Covered at 80% of MAC
per visit; lab, imaging,
and testing services
covered at 80% of MAC
Precertification is
required three days prior
to receiving select out of
network services; refer to
the Certificate of
Insurance for the current
listing
Pre-existing conditions None None None
Hearing Aids (and
fitting)
Speech Therapy
Infertility services (IVF
limited to a one-time
only benefit per member
per lifetime)
Durable Medical Supplies
Chiropractic
External Prosthetic
Appliance
Bariatric Surgery
$500 allowance; up to two aids
every three years
$15 co-payment per office visit
limited by certain clinical criteria
and Kaiser Permanente
physician determination
$15 co-payment per office visit
for services including artificial
insemination; IVF covered at
80%
Covered at 80% of applicable
charges; includes internal
prosthetics covered at 100%
and diabetes equipment
covered at 50%
Not Covered Not Covered
Covered at 80% of MAC Covered at 80% of MAC
Limited to 60 days of therapy per calendar year
Covered at 80% of MAC Covered at 80% of MAC;
Covered at 80% of MAC, includes
internal prosthetics and diabetes
equipment
Covered at 80% of MAC,
includes internal
prosthetics and diabetes
equipment
Chiropractic coverage is available through a separate rider with Kaiser; Members may receive
up to 20 visits per calendar year for a $15 co-payment per visit when utilizing providers who
participate with American Specialty Health Networks (ASHN); To find providers, visit
www.ashcompanies.com, or call ASH Member Services toll free at 1-800-678-9133; Services
are not covered for providers outside of the ASHN network
Covered at 80% of applicable
charges
Covered according to Plan
benefits; see Plan for details
Covered at 80% of MAC Covered at 80% of MAC
Not Covered Not Covered
Autism Therapies Not Covered Not Covered Not Covered
Choice of doctors and
facilities
Member self refers to Kaiser
primary care physicians in the
network
For provider listing:
1. Type
www.kaiserpermanente.org
in your web browser
2. Under “Locate Our
Services”, click on “Medical
Member not required to use
providers in the Kaiser Facility
network, however plan pays
higher benefits when utilizing
network providers
For provider listing:
1. Type
www.kaiserpermanente.org in
your web browser
2. Under “Locate Our Services”,
click on “Medical Staff
Member not required to
use providers in the
network, however plan
pays higher benefits
when utilizing network
providers

Staff Directory”
3. Select Hawaii from the drop
down box for your region
4. Under “Search for a
practitioner”, click on the
”Medical Staff Directory”
link
Prescription drugs $5 generic; $15 brand name
Directory”
3. Select Hawaii from the drop
down box for your region
4. Under “Search for a
practitioner”, click on the
“Added Choice Directory”
link
Member pays 20% of MAC, but
no less than $5 generic or $15
brand name at contracted
pharmacies.
Member has the ability to fill a
formulary prescription at a Kaiser
facility even though it may be
issued by an out-of-network
physician.
No coverage at out-ofnetwork
non-contracted
pharmacies.
Customer service Kaiser Member Services 432-5955 (Oahu) or 1-800-966-5955 (Neighbor Islands)
Life Events
Life Events are events that affect or alter your life. It is important for you to understand the
benefit choices that you make when you are first eligible and during subsequent annual
enrollment periods, because your benefits are binding and cannot be changed unless you
experience a qualified Life Event. These Qualified Life Events can be found in the Life Events
Section of the Summary Plan Description, on i-Connect. To be eligible to make a Benefit
Change, you must contact the Employee Help Line (EHL) to Request the Change during
business hours CT, no later than the 30 th calendar day after the date of the event (or 60 th
calendar day after a Medicaid/CHIP-related Life Event). If you do not satisfy the enrollment
requirements, coverage will not be added and no benefits for expenses incurred will be
payable.
Note: This represents a summary of coverage. Details in the Summary Plan Description (SPD) govern in all cases.
* Maximum Allowable Charge (MAC) is the lesser of (1) the usual and customary charge, (2) the
negotiated rate, or (3) the actual billed charges. The member is responsible for charges that exceed the
MAC when receiving services from non-participating providers.