Colorado Dept of Personnel and Administration (DPA) - Division of Human Resources (DHR)

Division of Human Resources

Kaiser HMO

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Description (Denver-Boulder or Colo. Spgs.) Plan Details & Exclusions (Denver-Boulder or Colo. Spgs.)

Summary of 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	Total Premium (monthly / annually)	State Pays... (monthly / annually)	Employee Pays... (monthly / annually)
	Employee only $386.74 / $4640.88 Employee + Spouse $844.96/ $10,139.52 Employee + Child(ren) $692.22/ $8306.64 Employee + Family $1112.26/ $13,347.12	Employee only $285.84 / $3430.08 Employee + Spouse $491.18 / $5894.16 Employee + Child(ren) $442.84 / $5314.08 Employee + Family $663.96 / $7967.52	Employee only $100.90 / $1210.80 Employee + Spouse $353.78 / $4245.36 Employee + Child(ren) $249.38 / $2992.56 Employee + Family $448.30 / $5379.60
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	Generic - $20 co-pay Brand Name - $60 co-pay	For more prescription information, contact Clinical Pharmacy Call Center at 303-338-4503
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
	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.
(3) Primary Care Physician
Note: This is only a summary, not a contract. Consult the "Plan Details & Exclusions" (also called a Summary Plan Description) to determine the exact terms and conditions of coverage.

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

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For more information about Benefits contact the DPA Benefits Unit.

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