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FY09 Kaiser HMO
Information
Return to FY09 Medical Page
Return to FY08
Medical Page Enroll/Change
Descriptions (Denver-Boulder
or Colo. Spgs.)
Plan
Details & Exclusions
Summary of
FY09 Benefits for the Kaiser HMO Plan
Note:
This is only a
summary, not a contract. For more details, see the
"Description" above and consult the "Plan Details &
Exclusions" above to determine the exact terms and
conditions of coverage.
| Availability |
Denver, Boulder,
parts of Colo. Springs
- by zip code |
Denver/Boulder zip code list |
Colo.
Spgs. zip code list |
Plan
Administrator |
Kaiser Permanente |
kaiserpermanente.org |
303-338-3800 /
1-800-632-9700
|
| Type of Plan |
Health Maintenance
Organization |
There are NO
Out-of-
Network benefits. |
|
Premiums -
FY09 |
Total Premium
(monthly / annually) |
State Pays...
(monthly / annually) |
Employee
Pays...
(monthly / annually) |
| |
Employee
only
$396.42/ $4757.04
Employee + Spouse
$866.92/ $10,403.04
Employee + Child(ren)
$710.08/ $8520.96
Employee + Family
$1180.60/ $14,167.20 |
Employee
only
$340.26 / $4083.12
Employee + Spouse
$565.44/ $6785.28
Employee + Child(ren)
$499.80 / $5997.60
Employee + Family
$782.92 / $9395.04 |
Employee
only
$56.16 / $673.92
Employee + Spouse
$301.48 / $3617.76
Employee + Child(ren)
$210.28 / $2523.36
Employee + Family
$397.68 / $4772.16 |
| Deductibles |
none,
co-pay for
services |
|
|
Out-of-Pocket
Maximums |
In-Network |
Individual - $1000
+ co-pays
Family (1) - $3000 + co-pays |
|
| |
Out-of-Network |
No Out-of-Network
benefits |
|
| Prescriptions |
30-day supply |
90-day supply
(mail order) (2) |
Find your meds on
approved drug
list |
| |
Generic - $10 co-pay
Brand Name
- $30 co-pay
Specialty
drugs, including
self-administered injectables -
20% co-insurance, up to
a $75 max per drug
dispensed |
Generic - $20 co-pay
Brand Name
- $60 co-pay
|
For more
prescription
information, contact
Clinical Pharmacy
Call Center at
303-338-4503 or
1-800-632-9700. |
Preventive
Care |
In-Network |
$15 co-pay |
|
| |
Out-of-Network |
No Out-of-Network
benefits |
|
Routine Office
Visit |
In-Network |
PCP (3)
- $30 co-pay
Specialist - $50 co-pay |
|
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Out-of-Network |
No Out-of-Network
benefits |
|
In-Patient
Hospital |
In-Network |
$750 co-pay per
admission |
|
| |
Out-of-Network |
No Out-of-Network
benefits |
|
Out-Patient
Surgery |
In-Network |
$150 co-pay per
visit |
|
| |
Out-of-Network |
No Out-of-Network
benefits |
|
(1) Family out-of-pocket maximum
amounts apply to Employee + Spouse, Employee + Child(ren)
& Employee + Family levels.
(2) For more information on Mail Order prescriptions,
contact Kaiser's Clinical Pharmacy Call Center at
303-338-4503 / 1-800-632-9700.
(3) Primary Care Physician
Note: This is only a summary of the
Kaiser plan
information, not a contract. Consult the "Plan
Details & Exclusions" (also called a Summary Plan
Description) to determine the exact terms and conditions
of coverage. Contact Kaiser
Permanente at 303-338- 3800 / 1-800-632-9700 with specific questions about treatments,
prescriptions, doctors and hospitals.
More Kaiser HMO Information
KaiserPermanente.org (physician/facility directory,
appointment center, health & wellness, and more)
Medicare Part D
Notice for Kaiser HMO Plan
Application for Disabled Dependent Form
Related Links
Premiums
(now includes new FY09
Premiums)
Who is my
human resources contact?
Insurance
Companies’ Phone Numbers
What do
“Pre-tax” and “After tax” mean?
Instructions for Online Enrollment
HealthLine
Glossary of
Insurance Terms
Forms
Return to Benefits Home
Page
For
more information about Benefits contact the
DPA
Benefits Unit.
Email
comments to: DPA
Benefits
These
documents may be presented in PDF format, which requires the Adobe®
Reader.
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Division of Human Resources