PEBB - Kaiser Permanente Senior Advantage Classic

Notice

The HCA will close its Lacey office at 3 p.m. Friday, February 17, to relocate staff to its office at Cherry Street Plaza, 626 8th Avenue SE, in Olympia. Details.

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Toll-Free Phone: 1-877-221-8221
TTY/TDD Phone: 1-800-735-2900
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Benefits Booklet (Certificate of Coverage)

Kaiser Permanente Senior Advantage Classic Certificate of Coverage

If you have questions about the certificate of coverage, or to receive a copy, contact the plan.

Benefits Summary

Annual Costs	2012 Coverage
	Member Pays
Deductible What is the difference between deductibles and out-of-pocket maximums?	$0
Out-of-pocket maximum What is the difference between deductibles and out-of-pocket maximums?	$1,500/person $3,000/family
Prescription drug deductible	N/A

Medical Benefits	2012 Coverage
	Member Pays
Ambulance
Per trip, air	$50
Per trip, ground	$50
Diagnostic tests, laboratory, and x-rays	$0
Durable medical equipment, supplies, and prostheses	$0
Emergency room (Copay waived if admitted) When should I go to the emergency room?	$50
Hearing
Hardware	Any amount over $800 every 36 months after deductible has been met for hearing aid and rental/repair combined.
Routine annual exam	$30
Home health	See the plan’s Certificate of Coverage for details.
Hospital services
Inpatient	$500/admission
Outpatient	$50
Mental health care
Outpatient	Information unavailable, contact your plan
Obstetric care
Inpatient	Information unavailable, contact your plan
Outpatient	Information unavailable, contact your plan
Office visit
Chemotherapy	$0
Mental health	$30
Primary care	$30
Radiation	$0
Specialist	$30
Urgent care	$35
Physical, occupational and speech therapy (Per-visit cost for 60 visits/year combined)	$30**
Prescription drugs How can I find out more about drugs and supplements?
Mail order (up to a 90-day supply) Value tier	N/A
Mail order (up to a 90-day supply) Tier 1	$40
Mail order (up to a 90-day supply) Tier 2	$80
Mail order (up to a 90-day supply) Tier 3	N/A
Retail pharmacy (up to a 30-day supply) Value tier	N/A
Retail pharmacy (up to a 30-day supply) Tier 1	$20
Retail pharmacy (up to a 30-day supply) Tier 2	$40
Retail pharmacy (up to a 30-day supply) Tier 3	N/A
Preventive care Which immunizations are needed and when?	$0; See certificate of coverage or check with plan for full list of services.
Spinal manipulations	$30
Vision care
Exam (annual)	$30
Glasses and contact lenses	Any amount over $150 every 24 months (or two calendar years for UMP) for frames, lenses, contacts, and fitting fees combined.

** The 60 visit per year limit does not apply.