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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.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 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