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Kaiser Permanente Hawaii Group #45041

Basics

Full-Time Employee * Contribution Per Pay Period

Employee Only $0.00
Employee & Spouse/Registered Domestic Partner $164.97
Employee & Child(ren) $141.40
Employee & Family $227.81

Part-Time Employee * Contribution Per Pay Period

Employee Only $218.21
Employee & Spouse/Registered Domestic Partner $540.72
Employee & Child(ren) $463.48
Employee & Family $746.69

Lifetime maximum

No maximum

Plan Year

2023

Pre-Authorization Requirement

In general, benefits are available only for the care you receive from or arranged by your PCP, and at a KP
facility. A listing of KP providers and facilities can be found at www.kp.org.

Offered To

Employees

Care Management

Health Education and Disease Management Programs
- Covered, for the education in appropriate use of Health Plan services, and general health education
publications distributed by Health Plan.
- Covered, for general health education services (including diabetes self-management training and
education) and disease management for members diagnosed with specific medical conditions such as
asthma, diabetes, cardiovascular disease, chronic obstructive pulmonary disease (COPD), and behavioral
health conditions (mental health and substance abuse).
These programs offer services to help you learn self-care skills to understand, monitor, manage and/or improve your condition. Covered, for tobacco cessation classes and counseling sessions.

We also provide programs available through our Healthy Living classes and resources. These classes are
not covered benefits but are available upon payment of reasonable class fees. Healthy living classes and
support groups include educational programs directed to members who wish to make changes in their
behavior that reduce health risks and enhance the quality of their lives or maintain their level of health.
Classes and support groups may include, but are not limited to: weight management, bariatric surgery
program, stress management, and Lamaze. For more information, please see Healthy Living in Chapter 5:
Wellness and Other Special Features, or visit www.kp.org/classes for a list of available classes and
registration fees.

Body/Description

You may use only Kaiser Permanente doctors and facilities except in emergencies.

Coinsurance

100% after applicable co-pays

Office co-pay

$15 co-pay primary/$15 co-pay specialist

Deductible

No deductible

Benefit Type

Medical

Annual maximum

$2,500 per individual/ $7,500 family

X-rays

Basic $15 per day
Specialty 20% of applicable charges

Maternity Hospital Stay

100%

Baby's First Exam

100%

Birthing Centers

100%

Midwives

100% in hospital; if out-patient office visit: $50 co-pay

If midwife is available at Kaiser Permanente

Prenatal Visits

100%

Doctor Delivery Charge

100%

Reproductive Health

$15 per day

Mental Health

$15 per visit.

Substance Abuse

$15 per visit

Acupuncture

Not covered

Allergy Tests

$50 co-pay specialist

Allergy Treatment

Primary and Specialty $15 per visit

Alternative Medicine

Not covered

Ambulance charges

Air Ambulance 20% of applicable charges

Ground Ambulance 20% of applicable charges

CT Scans

Specialty 20% of applicable charges

Chiropractors

$20 co-pay

Up to 40 combined chiropractic and acupuncture visits per year

American Specialty Health (ASH) Plans Participating Chiropractors

Christian Science Practitioners

Not covered

Cosmetic Surgery

Not covered

Dental Treatment

Not covered

Emergency Room

Emergency Services $100 per visit in area,
$100 per visit out of area.

Urgent Care

Within Service Area (Primary Care) $15 per visit
Outside Service Area, 20% of applicable charges

Hearing Care

Hearing Exam (for correction)
- Primary Care $15 per visit
- Specialty Care $15 per visit
- Hearing Test
- Primary Care $15 per visit
- Specialty Care $15 per visit
- Appliances 60% of applicable charges for lowest-priced model, per ear, every 36 months

Home Health Care

100%

Hospice Care

100%

Hospital Stay

Inpatient Hospital Services 10% of applicable charges

Infertility Treatment

Infertility Consultation: Primary Care $15 per visit, Specialty Care $15 per visit
In Vitro Fertilization 20% of applicable charges

Laboratory Charges

Basic $15 per day; Specialty 20% of applicable charges

Magnetic resonance imaging - MRI

Specialty 20% of applicable charges

Durable Medical Equipment

Outpatient 20% of applicable charges
Total Care Settings Included in Total Care Services

Occupational Therapy

"Medical Office $15 per visit

Organ Transplants

Transplant Care for Transplant Recipients:
- Primary Care $15 per visit
- Specialty Care $15 per visit
- Total Care Settings Included in Total Care Services
- Transplant Care for Transplant Donors (based on health plan approval)

Skilled Nursing

Skilled Nursing Facility 10% of applicable charges up to 120 days per calendar year

Physical Therapy

Medical Office $15 per visit

Surgery : Physician Services

Inpatient Hospital Services 10% of applicable charges
Outpatient Surgery and Procedures in a Hospital-
Based Setting or Ambulatory Surgery Center (ASC)
10% of applicable charges

Surgery : Facility Charges

Inpatient Hospital Services 10% of applicable charges
Outpatient Surgery and Procedures in a Hospital-
Based Setting or Ambulatory Surgery Center (ASC)
10% of applicable charges

Speech Therapy

Medical Office $15 per visit

Tubal Ligation

Voluntary Sterilization (including tubal ligation)
Medical Office 100%
Total Care Settings Included in Total Care Settings

Vasectomy

Prostate Specific Antigen (screening) $15 per visit;
Primary Care $15 per visit;
Specialty Care $15 per visit;
Total Care Settings Included in Total Care Settings

X-rays

Basic $15 per day
Specialty 20% of applicable charges

Pharmacy (Retail)

KAISER PERMANENTE PHARMACY
- Generic Maintenance Drugs: $3 per prescription
- Other Generic Drugs: $10 per prescription
- Brand-Name Drugs: $35 per prescription
- Specialty drugs: $200

Brand: $40 for up to a 30-day supply, $80 for a 31- to 60-day supply, or $120 for a 61- to 100-day supply

Mail order drug program

KAISER PERMANENTE MAIL ORDER PHARMACY
Prescription drug mail-order incentive;
Two drug copayments for a 90-consecutive-day supply

Physical exams for adults

100%

Physical exams for children

100%

Pap smears

100%

Mammograms

100%

Immunizations

Office visit for Travel Immunization;
Primary Care $15 per visit;
Specialty Care $15 per visit

Prostate Specific Antigen test - PSA

Prostate Specific Antigen (screening)
- Primary Care $15 per visit
- Specialty Care $15 per visit

Well-woman visits

Preventive Care
- Annual Gynecological Exam 100%
- Mammography (screening) 100%
- Pap Smears (cervical cancer screening) 100%

Vision care

Vision Exam (for glasses)
Primary Care $15 per visit
Specialty Care $15 per visit