Plan Benefits Chart
For medical, prescription drug, dental/orthodontics, vision, mental/behavioral health and substance abuse, chiropractic care/acupuncture, and podiatry benefits
View ChartKey Medical Plan Features
Indemnity PPO Medical Plan
See a brief summary of how you and the plan share costs for health care services, as well as your opportunity to earn extra money to pay for eligible health care expenses through a Health Reimbursement Account
If You Use In-Network Providers
- Preventive Care: The plan pays 100% of the allowed amounts for designated preventive care services. There is no deductible for these services.
- Deductible: You pay $1,000 per person or $2,000 per family per calendar year.
- Coinsurance (applies for most services, e.g., office visits, urgent/emergency care, hospital visits, outpatient procedures): You pay 20% of allowed amounts
- Annual Medical Out-of-Pocket Maximum (includes deductible and coinsurance): You pay $2,500 per person or $5,000 per family per calendar year.
Health Reimbursement Account (HRA) Funding
Your HRA funding opportunity is based on who’s enrolled in the plan. You receive an automatic “Base HRA Contribution” from the Fund, and you and your enrolled spouse/domestic partner can earn additional contributions to your HRA by completing “Healthy Activities.”
SINGLE COVERAGE
- Automatic Base HRA Contribution from the Fund: $175
- You can EARN $150 more for each Healthy Activity completed, up to a maximum of $575 per year (for four activities).
- Total HRA Funding Opportunity (Base + Earned): $750 maximum
EMPLOYEE + CHILDREN ONLY
- Automatic Base HRA Contribution from the Fund: $500
- You can EARN $150 more for each Healthy Activity completed, up to a maximum of $750 per year (for five activities).
- Total HRA Funding Opportunity (Base + Earned): $1,250 maximum
EMPLOYEE + SPOUSE/DOMESTIC PARTNER, WITH OR WITHOUT CHILDREN
- Automatic Base HRA Contribution from the Fund: $275
- You and your enrolled spouse/domestic partner can EARN $150 more for each Healthy Activity completed, up to a maximum of $975 per year (for seven activities).
- Total HRA Funding Opportunity (Base + Earned): $1,250 maximum
Kaiser Permanente HMO
- Preventive Care: Kaiser pays 100% for covered services.
- Deductible: None
- You pay set copays at the point of care for most services. For example:
-$25 per visit for primary care physician office visits
-$35 per visit for specialist office visits
-$25 per visit for urgent care
-$150 per procedure for outpatient surgery
-$500 per admission for hospital services
- Annual Medical Out-of-Pocket Maximum: You pay $1,500 per person or $3,000 per family per calendar year.