Retiree Health Summary Plan Description
As of February 1, 2018
En Español (PDF)

2.2 Summary of Benefits

2.2.1 Early Retirees (Under Age 62 and not eligible or enrolled in Medicare)

This section modified by Amendment 8. View old language.

Early Retirees (Under Age 62 and not eligible or enrolled in Medicare)

Summary of Benefits for Early Retirees (Under Age 62 and not eligible or enrolled in Medicare)
	Kaiser Permanente HMO (In Network Only)	UnitedHealthcare HMO (In Network Only)	Out-of-Area Plan UnitedHealthcare (In Network Benefits)
Member Customer Service Number	(800) 464-4000	(800) 624-8822	Northern California (800) 624-8822 Out-of-state (866)633-2446
Website	*www.kp.org*	*www.myuhc.com*	www.myuhc.com
General Features
Calendar Year Deductible	None	None	$500 per Individual $1,000 per Family
Maximum Benefits	Unlimited	Unlimited	Unlimited
Annual Co-payment Maximum	$1,500 per Individual $3,000 per Family	$2,500 per Individual $5,000 per Family	$4,500 per Individual $9,000 per Family
Hospital Benefits	No charge	$250 Co-Payment	80% after deductible has been met
Emergency Services Co-payment waived if admitted	$5 co-payment	$250 co-payment	$100 co-payment; deductible does not apply
Urgently Needed Services Medically Necessary services required outside geographic area service by Primary Medical Group	$5 co-payment	$50 co-payment	$50 co-payment; deductible does not apply
Pre-existing Conditions	All Medically Necessary conditions are covered provided they are a covered benefit
Inpatient Hospital Benefits
Alcohol, Drug or Other Substance Abuse Detoxification	No charge	No charge	80% after deductible
Mental Health Services As required by law, coverage includes treatment for Severe Mental Illness of adults and the treatment of Serious Emotional Disturbance.	No charge	No charge	80% after deductible
Physician Care	No charge	No charge	No charge
Reconstructive Surgery	No charge	No charge	80% after deductible
Rehabilitative Care Including physical, occupational and speech therapy	No charge	No charge	$20 co-payment
Skilled Nursing Facility Up to 100 Consecutive Days from the first treatment per disability	No charge	No charge	80% after deductible
Outpatient Benefits
Alcohol, Drug or Other Substance Abuse Detoxification	$5 per visit	No charge	$20 co-payment
Ambulance	No charge	No charge	80% after deductible
Durable Medical Equipment	No charge	No charge	80% after deductible
Voluntary Termination of Pregnancy (medical, medication, surgical): 1st Trimester	$5 co-payment	$75 co-payment	The amount you pay is based on where the covered service is provided.
Laboratory Services When available through or authorized by PCP	No charge	No charge	No charge
Maternity Care, Tests Procedures	No charge	No charge	The amount you pay is based on where the covered service is provided.

Prescription Drugs
	Kaiser HMO	UnitedHealthcare HMO *	Out-of-Area Plan UnitedHealthcare
Retail Pharmacy: Generic	$0 co-payment Up to a 100-day supply	$10co-payment Up to a 30-day supply	$10 co-payment Up to a 30-day supply
Retail Pharmacy: Brand — Formulary	$10 co-payment Up to a 30-day supply	$20 co-payment Up to a 30-day supply	$25 co-payment Up to a 30-day supply
Retail Pharmacy — Brand — Non-Formulary	N/A	N/A	$45 co-payment up to a 30-day supply

Mail Order: Generic	$0 co-payment Up to a 100-day supply	$20 co-payment Up to a 90-day supply	$25 co-payment Up to a 90-day supply
Mail Order: Brand - Formulary	$20 co-payment Up to a 100-day supply	$40 co-payment Up to a 90-day supply	$62.50 co-payment Up to a 90-day supply
Mail Order — Brand — Non-Formulary	N/A	N/A	$112.50 co-payment Up to a 90-day supply

Early Retirees (Under Age 62 and not eligible or enrolled in Medicare)

Summary of Benefits for Early Retirees (Under Age 62 and not eligible or enrolled in Medicare)
	Kaiser Permanente HMO (In Network Only)	UnitedHealthcare HMO (In Network Only)	Out-of-Area Plan UnitedHealthcare (In Network Benefits)
Member Customer Service Number	(800) 464-4000	(800) 624-8822	Northern California (800) 624-8822 Out-of-state (866)633-2446
Website	www.members.kp.org	www.myuhc.com	www.myuhc.com
General Features
Calendar Year Deductible	None	None	$500 per Individual $1,000 per Family
Maximum Benefits	Unlimited	Unlimited	Unlimited
Annual Co-payment Maximum	$1,500 per Individual $3,000 per Family	$2,500 per Individual $5,000 per Family	$4,500 per Individual $9,000 per Family
Hospital Benefits	$250 Co-Payment per admission	$250 Co-Payment per admission	80% after deductible has been met
Emergency Services Co-payment waived if admitted	$100 co-payment	$250 co-payment	$100 co-payment: deductible does not apply
Urgently Needed Services Medically Necessary services required outside geographic area service by Primary Medical Group	$20 co-payment	$20 co-payment	$50 co-payment: deductible does not apply
Pre-existing Conditions	All Medically Necessary conditions are covered provided they are a covered benefit
Benefits Available While Hospitalized as an Inpatient
Alcohol, Drug or Other Substance Abuse Detoxification	$250 co-payment per admission	$250 co-payment per admission	80% after deductible
Mental Health Services As required by law, coverage includes treatment for Severe Mental Illness of adults and the treatment of Serious Emotional Disturbance. (SED)	$250 co-payment per admission	$250 co-payment per admission	80% after deductible
Physician Care	$250 co-payment	No charge	80% after deductible
Reconstructive Surgery	$250 co-payment	$250 co-payment	80% after deductible
Rehabilitative Care Including physical, occupational and speech therapy	$250 co-payment	$250 co-payment	$20 co-payment
Skilled Nursing Facility Up to 100 Consecutive Days from the first treatment per disability	No charge	$250 co-payment	80% after deductible
Benefits Available on an Outpatient Basis
Ambulance	$100 per trip	No charge	80% after deductible
Alcohol, Drug or Other Substance Abuse Detoxification	$20 per visit per individual visit: $5 co-payment per group visit	$20 per visit	$20 co-payment
Durable Medical Equipment	No charge	No charge	80% after deductible
Laboratory Services When available through or authorized by PCP	No charge	No charge	No charge
Maternity Care, Tests Procedures	No charge	No charge	The amount you pay is based on where the covered service is provided.
Mental Health Services (As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and the treatment of Serious Emotional Disturbance (SED))	$20 per visit	$25 per visit	80% after deductable
Outpatient Medical Rehabilitation Therapy at Participating Free Standing or Outpatient Surgery Facility	$20 co-payment	$20 co-payment	80% after deductable
Outpatient Surgery at Participating Free Standing or Outpatient Surgery Facility	$250 co-payment per procedure	No Charge	80% after deductable
Preventive Care Physician Office Visits (Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics (AAP). Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Services Task Force and authorized through PCP for children).	No Charge	No Charge	No Charge
Well-Woman Care (includes PAP smear (By PCP or an OB/GYN in PMG and a referral by the PMG for screening mammography as recommended by the U.S. Preventive Services Task Force)).	No Charge	No Charge	No Charge

Prescription Drugs
	Kaiser HMO	UnitedHealthcare HMO *	Out-of-Area Plan UnitedHealthcare
Retail Pharmacy: Generic	%10 co-payment Up to a 30-day supply	$10 co-payment Up to a 30-day supply	$25 co-payment Up to a 30-day supply
Retail Pharmacy: Brand - Formulary	$30 co-payment Up to a 30-day supply	$30 co-payment Up to a 31-day supply	$25 co-payment Up to a 30-day supply
Retail Pharmacy � Brand � Non-Formulary	N/A	N/A	$45 co-payment up to a 30-day supply
Mail Order: Generic	$20 co-payment Up to a 100-day supply	$20 co-payment Up to a 90-day supply	$25 co-payment Up to a 90-day supply
Mail Order: Brand - Formulary	$60 co-payment Up to a 100-day supply	$60 co-payment Up to a 90-day supply	$62.50 co-payment Up to a 90-day supply
Mail Order � Brand � Non-Formulary	N/A	N/A	$112.50 co-payment Up to a 90-day supply

2.2.2 Medicare Eligible Retirees (Enrolled in Medicare Parts A and B)

This section modified by Amendment 8. View old language.

Summary of Benefits for Medicare Eligible Retirees (Enrolled in Medicare Parts A & B)
	Kaiser Permanente Senior Advantage HMO	UnitedHealthcar® Group Medicare Advantage HMO	Out-of-Area Plan UnitedHealthcare® Group Medicare Advantage
Member Customer Service Number	(800) 464-4000	(800) 457-8506	(800) 457-8506
Website	*www.kp.org*	*www.uhcretiree.com*	*www.uhcretiree.com*
General Features
Calendar Year Deductible	None	None	None
Maximum Benefits	Unlimited	Unlimited	Unlimited
Annual Co-Payment Maximum	$1,500 per Individual $3,000 per Family	$6,700	$6,700
Hospital Benefits	No charge	No charge	No charge
Emergency Services Co-payment waived if admitted	$5 co-payment	$20 co-payment	$20 co-payment
Urgently Needed Services Medically Necessary services required outside geographic area service by Primary Medical Group	$5 co-payment	$15 co-payment	$15 co-payment
Pre-existing Conditions	All Medically Necessary conditions are covered provided they are a covered benefit.
Inpatient Hospital Benefits
Alcohol, Drug or Other Substance Abuse Detoxification	No charge	No charge	No charge
Mental Health Services As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and the treatment of Serious Emotional Disturbance (SED)	No charge	No charge	No charge
Physician Care	No charge	No charge	No charge
Reconstructive Surgery	No charge	No charge	No charge
Rehabilitative Care Including physical, occupational and speech therapy	No charge	No charge	No charge
Skilled Nursing Facility Up to 100 Consecutive Days from the first treatment per disability	No charge	No charge up to 100 days	No charge up to 100 days
Outpatient Benefits
Alcohol, Drug or Other Substance Abuse Detoxification	$5 per individual visit co-payment $2 per group visit co-payment	$5 co-payment	$5 co-payment
Ambulance	No charge	No charge	No charge
Durable Medical Equipment	No charge	No charge	No charge
Mental Health Services As required by law, coverage includes treatment for Severe Mental Illness of adults and the treatment of Serious Emotional Disturbance	$5 per individual visit co-payment $2 per group visit co-payment	$5 co-payment	$5 co-payment
Oral Surgery Services No dental	No charge	No charge	No charge
Outpatient Medical Rehabilitation Therapy at a Participating Free-Standing or Outpatient Surgery Facility	$5 co-payment	No charge	No charge
Outpatient Surgery at a Participating Free-Standing or Outpatient Surgery Facility	$5 co-payment	No charge	No charge
Periodic Health Evaluations Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics, Advisory Committee on Immunization Practices and U.S. Preventive Services Task Force and authorized through the patient's primary care physician	%5 co-payment	No charge	No charge
Physician Office Visit	$5 co-payment	$5 co-payment	$5 co-payment
Well-Woman Care Office Visit Includes PAP smear by PCP or an OB/GYN in Primary Medical Group and a referral by the Primary Medical Group for screening mammography as recommended by the U.S. Preventive Services Task Force	$5 co-payment	No charge	No charge
Prescription Drugs
Retail Pharmacy; Generic Drugs	$5 co-payment Up to a 100-day supply	$5 co-payment Up to a 30-day supply	$10 co-payment Up to a 30-day supply
Retail Pharmacy; Brand Retail Drugs	$15 co-payment Up to a 100-day supply	$15 co-payment Up to a 30-day supply	$20 co-payment Up to a 30-day supply
Mail Order; Generic Drugs	$5 co-payment Up to a 100-day supply	$10 co-payment Up to a 30-day supply	$20 co-payment Up to a 90-day supply
Mail Order; Brand Name Drugs	$15 co-payment Up to a 100-day supply	$30 co-payment Up to a 30-day supply	$40 co-payment Up to a 90-day supply

Summary of Benefits for Medicare Eligible Retirees (Enrolled in Medicare Parts A & B)
	Kaiser Permanente Senior Advantage HMO	Anthem Blue Cross Medicare Preferred PPO (In Network)
Member Customer Service Number	(800) 464-4000	(833) 848-8730
Website	*www.kp.org*	*www.anthem.com/ca*
General Features
Calendar Year Deductible	None	None
Maximum Benefits	Unlimited	Unlimited
Annual Co-Payment Maximum	$1,000 per Individual	$6,700
Hospital Benefits	No charge	No charge
Emergency Services Co-payment waived if admitted	$5 co-payment	$20 co-payment
Urgently Needed Services Medically Necessary services required outside geographic area service by Primary Medical Group	$5 co-payment	$10 co-payment
Pre-existing Conditions	All Medically Necessary conditions are covered provided they are a covered benefit.
Inpatient Hospital Benefits
Alcohol, Drug or Other Substance Abuse Detoxification	No charge	No charge
Mental Health Services As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and the treatment of Serious Emotional Disturbance (SED)	No charge	No charge
Physician Care	No charge	No charge
Reconstructive Surgery	No charge	No charge
Rehabilitative Care Including physical, occupational and speech therapy	No charge	No charge
Skilled Nursing Facility Up to 100 Consecutive Days from the first treatment per disability	No charge	No charge up
Outpatient Benefits
Alcohol, Drug or Other Substance Abuse Detoxification	$5 per individual visit co-payment $2 per group visit co-payment	$10 co-payment
Ambulance	No charge	$50 per trip
Durable Medical Equipment	No charge	5% co-payment
Mental Health Services As required by law, coverage includes treatment for Severe Mental Illness of adults and the treatment of Serious Emotional Disturbance	$5 per individual visit co-payment $2 per group visit co-payment	$10 co-payment
Outpatient Medical Rehabilitation Therapy at a Participating Free-Standing or Outpatient Surgery Facility	$5 co-payment	$10 co-payment
Outpatient Surgery at a Participating Free-Standing or Outpatient Surgery Facility	$5 co-payment	No charge
Periodic Health Evaluations Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics, Advisory Committee on Immunization Practices and U.S. Preventive Services Task Force and authorized through the patient's primary care physician	No charge	No charge
Well-Woman Care Office Visit Includes PAP smear by PCP or an OB/GYN in Primary Medical Group and a referral by the Primary Medical Group for screening mammography as recommended by the U.S. Preventive Services Task Force	$5 co-payment	No charge
Prescription Drugs
Retail Pharmacy; Generic Drugs	$5 co-payment Up to a 100-day supply	$5 co-payment Up to a 30-day supply
Retail Pharmacy; Brand Retail Drugs	$15 co-payment Up to a 100-day supply	$15 co-payment Up to a 30-day supply
Mail Order; Generic Drugs	$5 co-payment Up to a 100-day supply	$10 co-payment Up to a 30-day supply
Mail Order; Brand Name Drugs	$15 co-payment Up to a 100-day supply	$30 co-payment Up to a 30-day supply

New Participant Portal

Retiree Health Summary Plan Description
As of February 1, 2018
En Español (PDF)

2.2 Summary of Benefits

2.2.1 Early Retirees (Under Age 62 and not eligible or enrolled in Medicare)

2.2.2 Medicare Eligible Retirees (Enrolled in Medicare Parts A and B)

New Participant Portal

New Participant Portal

Retiree Health Summary Plan DescriptionAs of February 1, 2018En Español (PDF)

2.2 Summary of Benefits

2.2.1 Early Retirees (Under Age 62 and not eligible or enrolled in Medicare)

2.2.2 Medicare Eligible Retirees (Enrolled in Medicare Parts A and B)

New Participant Portal

Retiree Health Summary Plan Description
As of February 1, 2018
En Español (PDF)