Proposed Benefit Summary 88% KAISER PERMANENTE. ene LA MAR CEBICHERIA PERUANA 703384 Principal Benefits for Kaiser Permanente Traditional HMO Plan (12/1/19—11/30/20) ‘Accumulation Peri The Accumulation Period for this plan is January 1 through December 31 Qutof-Pocket Maximum(s) and Deductible(s) For Services that apply to the Plan Out-of-Pocket Maniriur, you wil not pay any more Cost Share Yor the rest of the Accumulation Period once you have reached the amounts listed below. Fay Coverage Tamy Coverage mounts Per cumulation Pood |, SOR On Coverage sen geerina ray oo] Ene arly foo mre rwoerore Merbers Marber Pion Our orRocaE Sasa Sisto Sei [Plan Deductible None _ None None rg Dedutbe nen ners wens Profesional Serie (an Provider fice vite You Pay st rary Cre Vi nd os Non-Pysan SSaGSTT V Sispera ost Pyidan Spec Vt cc $18 erst Routine vel maintenance xa nding wel woo sae Nochore Wale preventive esos roughage 3 mort I noche Fam eemingcouseing an cottons Nochore Sthedled pent ene es Nocharge foutne ej exe th Pan Spometi OO Necture Urgent care consultation elation andar Sisperwt ost phys cespatons an speth therapy SiSpervat open Serves You ay Site surgery and an Or ORION RE S280 pe poeta Alergy bietore ncn slegy sur) : " Ssperaat bostimmentseton (nltng he ase Nochore Most Xray and boat tet Spar encounter Preven rye stern and laborstoy et Gs nthe EOE Noches hi mos cand PT sen : S00 pr mrocedure Covered nd ea edcaon curing SI Noche Covered heath elation proganssere Nochare Hopton Serves Youay oom and oar sigs SERRE Tas ST Ts ATT 250 pr arson Emergency Health Coverage. —. regency Depart et Sito pera Note: This Cost Share does not apply if you ae admitted directly tothe hospital as an inpatient for covered Services (see "Hospitalization Services" for inpatient Cost Share). ‘Ambulance Services You Pay “Ambulance Services. = . $100 per tip Prescription Drug Coverage You Pay ‘Covered outpatient items in accord with our drag formulary guidelines Most generic items ata Plan Pharmacy. {$10 for upto. 30-day supply Most generic refill through our mallorder sevice 320 for up toa 100-day supply Mos brand-name items ata Plan Pharmacy. {$30 for upto. 30-day supply Most brand-name refs through our mail-order service, 360 for up toa 100-day supply Most specialty tems a aPlan Pharmacy. 10% Coinsurance (not to exceed $150) for upto 220 day supply Durable Metical Equipment (OME) You Pay Base DME items as described in the FOC (zypplemental DME lems are not covered)... 10% Coinsurance -4202006.9.1.5900563555- Larp HMO Metal NCR {continues}Proposed Benefit Summary (continued) ‘Mental Health Services You Pay Inpatient psychiatric hospitalization. $250 per admission Inclvidual outpatient mental health evaluation and treatment... 315 per visit Group outpatient mental health treatment $7 per visit Substance Use Disorder Treatment YouPay Inpatient detoxiieation a 3250 per admission Individual outpatient substance use disorder evaluation and treatment $15 per visit Group outpatient substance use disorder treatment. 37 per visit Home Health Services You Pay Home healthcare (upto 100 visits par Accumulation Period) No charge other You Pay “Salled nursing Taclty care (upto 100 days per benefit period) ‘ase prosthetic and orthotic devices as described in the EOC (supplemental prosthetic and orthotic devices are not covered) Hospice care, This is @ summary of the most frequently asked-about benefits. This chart does not expla ‘$250 per admission No charge No charge in benefits, Cost Share, out oF pocket manimams, «exclusions, or limitations, nor does ist all benefits and Cost Share amounts. Fora camplete explanation, please refer to the EOC. Please note ‘that we provide all benefits required by law (for example, diabetes testing supplies) 4202006.9.1.5000563955 - Lgrp HMO Metal NCR