2019 Medical Plan Comparison Tool

What medical plan is right for you? You have several medical plans to choose from and selecting the one with the right combination of services and health benefits can be challenging. This tool helps you compare the provisions of each plan side-by-side. Choose the plans you want to compare by selecting from the options below.

Your Plan Options
Plan Overview
  UHC - HSA Med Plan UHC - Med PPO Choice Plus UHC - Prem PPO Choice Plus UHC - EPO Choice Kaiser NoCal UHC - Med OOA UHC - Prem OOA Kaiser Colorado Kaiser Atlanta Kaiser Mid-Atlantic Kaiser SoCal UHC - HPHC Passport Kaiser Foundation Health Plan of Washington Kaiser Northwest UHC - HI EPO Choice
  Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network
How The Plan Works General information about medical plan related to physician access. You may use any doctor or facility. You receive a higher level of benefits when you use Network providers. You are responsible for ensuring all providers are in the network. You may use any doctor or facility. You receive a higher level of benefits when you use Network providers. You are responsible for ensuring all providers are in the network. You may use any doctor or facility. You receive a higher level of benefits when you use Network providers. You are responsible for ensuring all providers are in the network. You may use only Network doctors and facilities except for certain services (See Non-Network) Not Covered - except for certain services including: prescription drugs, emergency, acupuncture, and certain Autism treatment services You may use only Kaiser doctors and facilities except in emergencies Not covered Offered only to employees who live outside of the UHC Provider Network Area. You may use any doctor or facility. Claims are paid based on provider's billed charges. Offered only to employees who live outside of the UHC Provider Network Area. You may use any doctor or facility. Claims are paid based on provider's billed charges. You may use only Kaiser doctors and facilities except in emergencies Not covered You may use only Kaiser doctors and facilities except in emergencies Not covered You may use only Kaiser doctors and facilities except in emergencies Not covered You may use only Kaiser doctors and facilities except in emergencies Not covered While in the HPHC service area you may use only HPHC doctors and facilities - except for certain services (See Non-Network).
If you are outside of the HPHC service area you may access the UHC Choice Network.
Not Covered - except for certain services including: prescription drugs, emergency, acupuncture, and certain Autism treatment services You may use only Kaiser Washington (formerly GHC) doctors and facilities except in emergencies Not covered You may use only Kaiser doctors and facilities except in emergencies Not covered This plan is available for residents of Hawaii only. You may use only Network doctors and facilities except for certain services (See Non-Network) Not Covered - except for certain services including: emergency, acupuncture, and certain Autism treatment services
Calendar Year Deductible The amount you owe for health care services that your health insurance or plan covers before your health insurance or plan begins to pay. Employee Only = $1,5005;
Employee + Spouse/DP = $2,7005;
Employee + Child(ren) = $2,7005;
Employee + Family = $3,0005
$400 individual/$1,200 family 5 $800 individual/$2,400 family 5 $400 individual/$1,200 family 5 $800 individual/$2,400 family 5 $200 individual/$600 family 5 Not applicable except for certain services (See "How the Plan Works") No deductible Not covered $200 individual/$600 family 5 $100 individual/$300 family 5 No deductible Not covered No deductible Not covered No deductible Not covered No deductible Not covered $200 individual/$600 family 5 Not applicable except for certain services (See "How the Plan Works") No deductible Not covered No deductible Not covered No deductible Not applicable except for certain services (See "How the Plan Works")
Coinsurance The percentage of cost shares between you and the plan of a covered health care service, calculated as a percent of the allowed amount for the service. You pay coinsurance plus any deductibles you owe. For example - 80% coinsurance means you are responsible for 20% and the plan is responsible for 80%. 90% after deductible 70% of UCR 2 after deductible 90%5 70%5 100% 5 80% 5 100% 5 Not applicable except for certain services (See "How the Plan Works") 100% after applicable copays Not covered 80% after deductible (unless otherwise stated, coinsurance is based on UCR) 2 80% after deductible (unless otherwise stated, coinsurance is based on UCR) 2 100% after applicable copays Not covered 100% after applicable copays Not covered 100% after applicable copays Not covered 100% after applicable copays Not covered 100% Not applicable except for certain services (See "How the Plan Works") 100% after applicable copays Not covered 100% after applicable copays Not covered 100% 5 Not applicable except for certain services (See "How the Plan Works")
Calendar Year Out-of-Pocket Maximum The most you pay during a policy period (usually a year) before your health insurance or plan begins to pay 100% of the allowed amount. This limit never includes your premium, balance-billed charges or health care costs your health insurance or plan doesn't cover. Some health insurance or plans don't count all of your co-payments, deductibles, co-insurance payments, out-of-network payments or other expenses toward this limit. Employee Only = $2,600;
Employee + Spouse/DP = $4,000;
Employee + Child(ren) = $4,000;
Employee + Family = $5,250
Employee Only = $5,200;
Employee + Spouse/DP = $8,000;
Employee + Child(ren) = $8,000;
Employee + Family = $10,500
$2,000 individual/$4,000 family10 $5,000 individual/$10,000 family10 $2,000 individual/$4,000 family10 $5,000 individual/$10,000 family10 $2,000 individual/$4,000 family 10 Not applicable except for certain services (See "How the Plan Works") $1,500 individual/$3,000 family 10 Not covered $2,200 individual/$4,600 family 10 $1,100 individual/$2,300 family 10 $2,000 individual/$4,500 family 10 Not covered $6,350 individual/$12,700 family Not covered $3,500 individual/$9,400 family 10 Not covered $1,500 individual/$3,000 family 10 Not covered $1,000 individual/$2,000 family 10 Not applicable except for certain services (See "How the Plan Works") $1,500 individual/$3,000 family 10 Not covered $600 individual/$1,200 family 10 Not covered $1,000 individual/$2,000 family 10 Not applicable except for certain services (See "How the Plan Works")
Overall Lifetime Maximum Benefit The maximum amount paid by the plan (Medical and Mental Health/Substance Abuse) over the course of the insured's lifetime. No maximum No maximum No maximum No maximum No maximum Not covered No maximum No maximum No maximum Not covered No maximum Not covered No maximum Not covered No maximum Not covered No maximum No maximum Not covered No maximum Not covered No maximum
Employee/Employer HSA Contribution The amount you plan to deposit and the amount your employer will contribute into your Health Savings Account (HSA) HSA Medical Plan Resource Center Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable Not applicable
Plan Details
  • Preventive Care
      UHC - HSA Med Plan UHC - Med PPO Choice Plus UHC - Prem PPO Choice Plus UHC - EPO Choice Kaiser NoCal UHC - Med OOA UHC - Prem OOA Kaiser Colorado Kaiser Atlanta Kaiser Mid-Atlantic Kaiser SoCal UHC - HPHC Passport Kaiser Foundation Health Plan of Washington Kaiser Northwest UHC - HI EPO Choice
      Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network
    Preventive Care - Infant/Baby A preventive care exam is an eligible exam (including lab/x-ray) performed to evaluate and monitor overall wellness per preventive care guidelines. Services include routine exams, non-diagnostic x-ray and laboratory services, vaccinations, screenings, and an expanded list of services specific to women's preventive health. 100% 100% of UCR 2 100% 100% of UCR 2 100% 100%of UCR 2 100% Not covered 100% Not covered 100% 100% 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered
    Preventive Care - Adult/Children Health care services used in the prevention or early detection of disease. The health reform law requires plans to provide free coverage for certain services in accordance with the applicable agencies including the US Preventive Care Taskforce and the Centers for Disease Control and Prevention (CDC). Services covered for adults and children include (but not limited to): Yearly preventive care visits, standard immunizations, and screenings. Speak with your physician or health plan for specifics. 100% 100% of UCR 2 100% 100% of UCR 2 100% 100% of UCR 2 100% Not covered 100% Not covered 100% 100% 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered
    Mammography (Preventive) X-ray to evaluate and monitor the wellness of the breasts; aids in the early detection of cancer. 100% 100% of UCR 2 100% 100% of UCR 2 100% 100% of UCR 2 100% Not covered 100% Not covered 100% 100% 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered
    Preventive Care Immunizations (Adults/Children) A set of shots given to children at different ages to help keep them from getting dangerous childhood diseases. Immunizations are prepared to help the body recognize and produce antibodies to fight, thus preventing many illnesses. 100% 100% of UCR 2 100% 100% of UCR 2 100% 100% of UCR 2 100% Not covered 100% Not covered 100% 100% 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% Not covered
  • Outpatient Medical Services
      UHC - HSA Med Plan UHC - Med PPO Choice Plus UHC - Prem PPO Choice Plus UHC - EPO Choice Kaiser NoCal UHC - Med OOA UHC - Prem OOA Kaiser Colorado Kaiser Atlanta Kaiser Mid-Atlantic Kaiser SoCal UHC - HPHC Passport Kaiser Foundation Health Plan of Washington Kaiser Northwest UHC - HI EPO Choice
      Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network
    Telehealth Visit Telehealth is the delivery of health-related services and information via telecommunications technologies. Available through American Well: 90% after deductible; General Physician, Nutritionist, and Mental Health Counseling14 Not covered Available through American Well: General Physician $5 copay, Nutritionist $5 copay, Mental Health Counseling $10 copay14 Not covered Available through American Well: General Physician $5 copay, Nutritionist $5 copay, Mental Health Counseling $10 copay14 Not covered Available through American Well: General Physician $5 copay, Nutritionist $5 copay, Mental Health Counseling $10 copay14 Not covered Telehealth availability varies - contact Kaiser to verify services Not covered Available through American Well: General Physician $5 copay, Nutritionist $5 copay, Mental Health Counseling $10 copay14 Not covered Available through American Well: General Physician $5 copay, Nutritionist $5 copay, Mental Health Counseling $10 copay14 Not covered Telehealth availability varies - contact Kaiser to verify services Not covered Telehealth availability varies - contact Kaiser to verify services Not covered Telehealth availability varies - contact Kaiser to verify services Not covered Telehealth availability varies - contact Kaiser to verify services Not covered Available through American Well: General Physician $5 copay, Nutritionist $5 copay, Mental Health Counseling $10 copay14 Not covered Telehealth availability varies - contact Group Health to verify services Not covered Telehealth availability varies - contact Kaiser to verify services Not covered Available through American Well: General Physician $5 copay, Nutritionist $5 copay, Mental Health Counseling $10 copay14 Not covered
    General Physician Office Visit Coverage for visits in a general physician office setting. 90% after deductible 70% of UCR 2 after deductible $25 copay 70% of UCR 2 after deductible $20 copay 80% of UCR 2 after deductible $20 copay Not covered $10 copay Not covered 80% after deductible 80% after deductible $10 copay Not covered $10 copay Not covered $10 copay Not covered $10 copay Not covered $20 copay Not covered $10 copay Not covered $10 copay Not covered $15 copay Not covered
    Specialist Office Visit Coverage for visits in a specialist physician office setting (examples of specialists include cardiologist, dermatologist, therapists, or urologist). 90% after deductible 70% of UCR 2 after deductible $35 copay 70% of UCR 2 after deductible $30 copay 80% of UCR 2 after deductible $30 copay Not covered $20 copay Not covered 80% after deductible 80% after deductible $20 copay Not covered $20 copay Not covered $20 copay Not covered $20 copay Not covered $30 copay Not covered $20 copay Not covered $20 copay Not covered $25 copay Not covered
    X-ray and Laboratory (Non-Preventive) Non-preventive diagnostic testing including radiology services, lab tests (e.g. blood/urinalysis). 90% after deductible 70% of UCR 2 after deductible.
    A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum.
    90% after deductible 70% of UCR 2 after deductible.
    A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum.
    100% after deductible 80% of UCR 2 after deductible.
    A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum.
    100% after deductible Not covered 100% Not covered 80% after deductible 80% after deductible 100% Not covered 100% Not covered 100% Not covered 100% Not covered 100% after deductible Not covered 100% Not covered 100% Not covered 100% Not covered
    Minor Surgery at a Doctor's Office A surgical procedure performed in a Dr's office setting, as opposed to a hospital. 90% after deductible 70% of UCR 2 after deductible Applicable Doctor/Specialist copay applies 70% of UCR 2 after deductible Applicable Doctor/Specialist copay applies 80% of UCR 2 after deductible Applicable Doctor/Specialist copay applies Not covered Applicable Doctor/Specialist copay applies Not covered 80% after deductible 80% after deductible Applicable Doctor/Specialist copay applies Not covered Applicable Doctor/Specialist copay applies Not covered Applicable Doctor/Specialist copay applies Not covered Applicable Doctor/Specialist copay applies Not covered Applicable Doctor/Specialist copay applies Not covered Applicable Doctor/Specialist copay applies Not covered Applicable Doctor/Specialist copay applies Not covered Applicable Doctor/Specialist copay applies Not covered
    Outpatient Surgery Surgery performed in an outpatient setting without being admitted to the hospital. 90% after deductible 70% of UCR 2 after deductible 90% after deductible and $100 copay 70% of UCR 2 after deductible and $100 copay 100% after deductible and $100 copay 80% of UCR 2 after deductible and $100 copay 100% after deductible and $100 copay Not covered $20 copay Not covered 100% after deductible 100% after deductible $50 copay Not covered $20 copay Not covered $40 copay Not covered $20 copay Not covered 100% after deductible Not covered $20 copay Not covered $20 copay Not covered $100 copay Not covered
    Mental Health / Substance Abuse Outpatient Visit Individual receiving services under the direction of a plan provider but not as an inpatient. Plan providers may be classified as psychoanalysis, psychotherapy, counseling, medical management, or other services provided by a psychiatrist, psychologist, licensed clinical social worker, or licensed marriage and family therapist, for diagnosis or treatment of a mental, emotional disorder, mental or emotional problems associated with an illness, injury or any other condition. 100% for first 6 EAP visits through United Behavioral Health 6; Additional sessions 90% after deductible 90% of UCR 2 after deductible 100% for first 6 EAP visits through United Behavioral Health 6; Additional sessions $25/visit 90% of UCR 2 after deductible 100% for first 6 EAP visits through United Behavioral Health 6; Additional sessions $20/visit 90% of UCR 2 after deductible 100% for first 6 EAP visits through United Behavioral Health 6; Additional sessions $20/visit Not covered 100% for first 6 EAP visits through United Behavioral Health 6; Additional Mental Health & Substance Abuse Therapy sessions are covered by Kaiser: $10 copay/visit (individual therapy); $5 copay/visit (group therapy) Not covered 90% of UCR 2 after deductible 90% of UCR 2 after deductible 100% for first 6 EAP visits through United Behavioral Health 6; Additional Mental Health & Substance Abuse Therapy sessions are covered by Kaiser: $10 copay/visit (individual therapy); $5 copay/visit (group therapy) Not covered 100% for first 6 EAP visits through United Behavioral Health 6; Additional Mental Health & Substance Abuse Therapy sessions are covered by Kaiser: $10 copay/visit (Individual and Substance Abuse Group Therapy); $5 copay/visit (Mental Health Group Therapy) Not covered 100% for first 6 EAP visits through United Behavioral Health 6; Additional Mental Health & Substance Abuse Therapy sessions are covered by Kaiser: $10 copay/visit (individual therapy); $5 copay/visit (group therapy) Not covered 100% for first 6 EAP visits through United Behavioral Health 6; Additional Mental Health & Substance Abuse Therapy sessions are covered by Kaiser: $10 copay/visit (individual therapy); $5 copay/visit (group therapy) Not covered 100% for first 6 EAP visits through United Behavioral Health 6; Additional sessions $20/visit Not covered 100% for first 6 EAP visits through United Behavioral Health 6; Additional sessions are covered by Group Health: $10 copay Not covered 100% for first 6 EAP visits through United Behavioral Health 6; Additional Mental Health & Substance Abuse Therapy sessions are covered by Kaiser: $10 copay Not covered 100% for first 6 EAP visits through United Behavioral Health 6; Additional sessions $15/visit Not covered
  • Inpatient Hospital Services
      UHC - HSA Med Plan UHC - Med PPO Choice Plus UHC - Prem PPO Choice Plus UHC - EPO Choice Kaiser NoCal UHC - Med OOA UHC - Prem OOA Kaiser Colorado Kaiser Atlanta Kaiser Mid-Atlantic Kaiser SoCal UHC - HPHC Passport Kaiser Foundation Health Plan of Washington Kaiser Northwest UHC - HI EPO Choice
      Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network
    Precertification Requirement The attending physician must prescribe care, and the carrier must be notified prior to receiving services. Required for all hospitalizations and certain outpatient surgeries and diagnostic tests. Provider responsibility Patient responsibility.  A $200 penalty applies to non-certified hospitalizations/inpatient stays. Penalty does not apply towards plan deductible or out of pocket maximum. Provider responsibility Patient responsibility.  A $200 penalty applies to non-certified hospitalizations/inpatient stays. Penalty does not apply towards plan deductible or out of pocket maximum. Provider responsibility Patient responsibility.  A $200 penalty applies to non-certified hospitalizations/inpatient stays. Penalty does not apply towards plan deductible or out of pocket maximum. Provider Responsibility Not applicable Kaiser manages required referrals and pre-certifications Not covered Patient responsibility. A $200 penalty applies to non-certified Non-Network hospitalizations. Penalty does not apply towards plan deductible or out of pocket maximum Patient responsibility. A $200 penalty applies to non-certified Non-Network hospitalizations. Penalty does not apply towards plan deductible or out of pocket maximum Kaiser manages required referrals and pre-certifications Not covered Kaiser manages required referrals and pre-certifications Not covered Kaiser manages required referrals and pre-certifications Not covered Kaiser manages required referrals and pre-certifications Not covered Provider responsibility Not covered Group Health manages required referrals and pre-certifications Not covered Kaiser manages required referrals and pre-certifications Not covered Provider responsibility Not applicable
    Inpatient semi-private room & board Expenses associated with a hospital admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be considered outpatient care. 90% after deductible 70% of UCR 2 after deductible 90% after deductible and $250 copay 70% of UCR 2 after deductible and $250 copay 100% after deductible and $250 copay 80% of UCR 2 after deductible and $250 copay 100% after deductible and $250 copay Not covered 100% Not covered 80% after deductible 80% after deductible $250 copay Not covered 100% Not covered 100% Not covered 100% Not covered 100% after deductible Not covered 100% Not covered 100% Not covered $250 copay Not covered
    Inpatient Surgery Expenses associated with a hospital admission as an inpatient and usually requires an overnight stay. An overnight stay for observation could be considered outpatient care. 90% after deductible 70% of UCR 2 after deductible 90% after deductible and $250 copay 70% of UCR 2 after deductible and $250 copay 100% after deductible and $250 copay 80% of UCR 2 after deductible and $250 copay 100% after deductible and $250 copay Not covered 100% Not covered 80% after deductible 80% after deductible $250 copay Not covered 100% Not covered 100% Not covered 100% Not covered 100% after deductible Not covered 100% Not covered 100% Not covered $250 copay Not covered
    Inpatient Detoxification On-site detoxification services. 90% after deductible 90% of UCR 2 after deductible 90% after deductible 90% of UCR 2 after deductible 100% after deductible 90% of UCR 2 after deductible 100% after deductible Not covered 100% (detoxification only) Not covered 90% of UCR 2 after deductible 90% of UCR 2 after deductible $250 copay Not covered 100% Not covered 100% Not covered 100% (detoxification only) Not covered 100% after deductible Not covered 100% Not covered 100% Not covered 100% Not covered
    Inpatient Substance Abuse Therapy Inpatient treatment for alcoholism and drug abuse. 90% after deductible 90% of UCR 2 after deductible 90% after deductible 90% of UCR 2 after deductible 100% after deductible 90% of UCR 2 after deductible 100% after deductible Not covered Not covered Not covered 90% of UCR 2 after deductible 90% of UCR 2 after deductible Not covered Not covered Not covered Not covered 100% Not covered Not covered Not covered 100% after deductible Not covered 100% Not covered 100% Not covered 100% Not covered
  • Family Planning / Maternity Care
      UHC - HSA Med Plan UHC - Med PPO Choice Plus UHC - Prem PPO Choice Plus UHC - EPO Choice Kaiser NoCal UHC - Med OOA UHC - Prem OOA Kaiser Colorado Kaiser Atlanta Kaiser Mid-Atlantic Kaiser SoCal UHC - HPHC Passport Kaiser Foundation Health Plan of Washington Kaiser Northwest UHC - HI EPO Choice
      Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network
    Facility Physician Services (Mother) Initial exam to determine pregnancy and monthly/weekly visits to monitor pregnancy; does not include the hospital charges for delivery. 90% after deductible3 70% of UCR 2 after deductible 3 90% after deductible3 70% of UCR 2 after deductible 3 100% after deductible3 80% of UCR 2 after deductible 3 100% after deductible 3 Not covered 100% 3 Not covered 80% after deductible 3 80% after deductible 3 100% 3 Not covered 100% 3 Not covered 100% 3 Not covered 100% 3 Not covered 100% after deductible 3 Not covered Inpatient 100%, Outpatient $10 Copay 3 Not covered 100% 3 Not covered 100% 3 Not covered
    Facility Services (Mother) Series of OB/GYN visits for pre natal and post natal care. 90% after deductible3 70% of UCR 2 after deductible 3 90% after deductible and $250 copay3 70% of UCR 2 after deductible and $250 copay 3 100% after deductible and $250 copay3 80% of UCR 2, after deductible and $250 copay 3 100% after deductible and $250 copay 3 Not covered 100% 3 Not covered 80% after deductible3 80% after deductible 3 $250 copay 3 Not covered 100% 3 Not covered 100% 3 Not covered 100% 3 Not covered 100% after deductible 3 Not covered 100% 3 Not covered 100% 3 Not covered $250 copay 3 Not covered
    Facility Physician Services (Newborn) Hospital services related to pregnancy and delivery. 90% after deductible3 70% of UCR2 after deductible3
    A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum.
    90% after deductible3 70% of UCR2 after deductible3
    A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum.
    100% after deductible3 70% of UCR2 after deductible3
    A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum.
    100% after deductible 3 Not covered 100% 3 Not covered 80% after deductible 3 80% after deductible 3 100% 3 Not covered 100% 3 Not covered 100% 3 Not covered 100% 3 Not covered 100% after deductible 3 Not covered Inpatient 100%, Outpatient $10 copay 3 Not covered 100% 3 Not covered 100% 3 Not covered
    Facility Services (Newborn) Facility charges for the newborn. 90%3 70% of UCR 2 3 90%3 11 70% of UCR 2 3 11 100%3 11 80% of UCR 2 3 11 100% after deductible 3,11 Not covered 100% 3 Not covered 80% after deductible 3,11 80% after deductible 3,11 100% 3 Not covered 100% 3 Not covered 100% 3 Not covered 100% 3 Not covered 100% after deductible 3 Not covered 100% 3 Not covered 100% 3 Not covered 100% 3,11 Not covered
    Birthing Centers A birthing facility other than a hospital. 90% after deductible3 70% of UCR 2 after deductible 3 90% after deductible and $100 copay3 70% of UCR 2 after deductible and $100 copay3 100% after deductible and $100 copay3 80% of UCR 2 after deductible and $100 copay3 100% after deductible and $100 copay3 Not covered 100%3 Not covered $100 copay 3 $100 copay 3 Not covered Not covered Not covered Not covered 100% (Pre-authorization required) Not covered 100%3 Not covered 100% after deductible 3 Not covered 100%3 Not covered 100%3 Not covered $100 copay3 Not covered
    Midwife An individual trained to assist a women during childbirth. 90% after deductible3 70% of UCR 2 after deductible3 90% after deductible3 70% of UCR 2 after deductible3 100% after deductible3 80% of UCR 2 after deductible3 100% after deductible3 Not covered 100%3 Not covered 80% after deductible 3 80% after deductible 3 Not covered Not covered 100%3 Not covered 100% Not covered 100%3 Not covered 100% after deductible 3 Not covered $10 copay3 Not covered 100%3 Not covered 100%3 Not covered
    Abortion Family planning charges made by a hospital or doctor, even though they are not provided in conjunction with the diagnosis or treatment of a disease or injury. 90% after deductible 70% of UCR 2 after deductible Coverage varies by plan guidelines/procedure setting (e.g. hospital, office visit, outpatient surgical center) Coverage varies by plan guidelines/procedure setting (e.g. hospital, office visit, outpatient surgical center) Coverage varies by plan guidelines/procedure setting (e.g. hospital, office visit, outpatient surgical center) Not covered $20 copay Not covered 80% after deductible 80% after deductible $50 copay Not covered $20 copay Not covered $20 copay Not covered $20 copay Not covered Coverage varies by plan guidelines/procedure setting (e.g. hospital, office visit, outpatient surgical center) Not covered $10 PCP/$20 specialist copay; 100% inpatient Not covered $20 copay Not covered Coverage varies by plan guidelines/procedure setting (e.g. hospital, office visit, outpatient surgical center) Not covered
    Birth Control Devices Birth control options other than oral contraceptives. Examples include Norplant, cervical caps and IUDs. Covers FDA-approved devices that cannot be purchased over the counter. Coverage varies by plan - contact UHC to verify 1 Covers FDA-approved devices that cannot be purchased over the counter. Coverage varies by plan - contact UHC to verify 1 Covers FDA-approved devices that cannot be purchased over the counter. Coverage varies by plan - contact UHC to verify 1 Covers FDA-approved devices that cannot be purchased over the counter. Coverage varies by plan - contact UHC to verify 1 Not covered 100% Covers prescribed FDA-approved devices. Coverage varies by device - contact Kaiser to verify 1 Not covered Covers FDA-approved devices that cannot be purchased over the counter. Coverage varies by plan - contact UHC to verify 1 Covers FDA-approved devices that cannot be purchased over the counter. Coverage varies by plan - contact UHC to verify 1 Covers FDA-approved devices that cannot be purchased over the counter. Coverage varies by device - contact Kaiser to verify 1 Not covered Covers FDA-approved devices that cannot be purchased over the counter. Coverage varies by device - contact Kaiser to verify 1 Not covered Covers FDA-approved devices that cannot be purchased over the counter. Coverage varies by device - contact Kaiser to verify 1 Not covered 100% Covers prescribed FDA-approved devices. Coverage varies by device - contact Kaiser to verify 1 Not covered Covers FDA-approved devices that cannot be purchased over the counter. Coverage varies by plan - contact UHC to verify 1 Not covered Women's preventive care services (including contraceptive drugs, devices, and sterilization) are covered in full 1 Not covered Covers FDA-approved devices that cannot be purchased over the counter. Coverage varies by device - contact Kaiser to verify 1 Not covered Covers FDA-approved devices that cannot be purchased over the counter. Coverage varies by plan - contact UHC to verify 1 Not covered
    Oral Contraceptives Oral form of birth control. Refer to Prescription Drug Benefits 1 Refer to Prescription Drug Benefits 1 Refer to Prescription Drug Benefits 1 Refer to Prescription Drug Benefits 1 Not covered Refer to Prescription Drug Benefits 1 Not covered Refer to Prescription Drug Benefits 1 Refer to Prescription Drug Benefits 1 Refer to Prescription Drug Benefits 1 Not covered Refer to Prescription Drug Benefits 1 Not covered Refer to Prescription Drug Benefits 1 Not covered Refer to Prescription Drug Benefits 1 Not covered Refer to Prescription Drug Benefits 1 Not covered Covered in full. Refer to Prescription Drug Benefits 1 Not covered Refer to Prescription Drug Benefits 1 Not covered Refer to Prescription Drug Benefits 1 Not covered
    Tubal Ligation A surgical procedure performed on women that results in sterilization. 100% 1 70% of UCR 2 after deductible 100% 1 70% of UCR 2 after deductible and applicable facility copay 9 100% 1 80% of UCR 2 after deductible and applicable facility copay 9 100% 1 Not covered 100% 1 Not covered 100% 1 100% 1 100% 1 Not covered 100% 1 Not covered 100% 1 Not covered 100% 1 Not covered 100% 1 Not covered 100% 1 Not covered 100% 1 Not covered 100% 1 Not covered
    Vasectomy A surgical procedure performed on men that results in sterilization. 90% after deductible 70% of UCR 2 after deductible 3 Applicable copay if performed in doctors office, otherwise 90% after deductible and applicable facility copay 9 70% of UCR 2 after deductible and applicable facility copay 9 Applicable copay if performed in doctors office, otherwise 100% after applicable facility copay 9 80% of UCR 2 after deductible and applicable facility copay 9 Applicable copay if performed in doctors office, otherwise 100% after deductible and applicable facility copay 9 Not covered $20 copay Not covered 80% after deductible 80% after deductible $50 copay Not covered $20 copay Not covered $20 copay Not covered $20 copay Not covered Applicable copay if performed in doctors office; if performed in facility 100% Not covered Applicable copay if performed in doctors office, otherwise 100% Not covered $20 copay Not covered Applicable copay if performed in doctors office, otherwise 100% after applicable facility copay 9 Not covered
    Infertility Treatment Precertification Requirement Certain precertification and authorization is required prior to receiving infertility services. Please contact your health plan for details. RRS Network: Provider responsibility. Services must be performed by Reproductive Resource Services. Non-RRS services are not covered. 4 RRS Network: Provider responsibility. Services must be performed by Reproductive Resource Services. Non-RRS services are not covered. 4 RRS Network: Provider responsibility. Services must be performed by Reproductive Resource Services. Non-RRS services are not covered. 4 Provider responsibility. Services must be performed by Reproductive Resource Services. 4 Not covered Kaiser manages required referrals and pre-certifications Not covered No RRS Network Available - Precertification not required No RRS Network Available - Precertification not required Kaiser manages required referrals and pre-certifications Not covered Kaiser manages required referrals and pre-certifications Not covered Kaiser manages required referrals and pre-certifications Not covered Kaiser manages required referrals and pre-certifications Not covered Provider responsibility. Services must be performed by Reproductive Resource Services. 4 Not covered Not covered Not covered Kaiser manages required referrals and pre-certifications Not covered RRS Network: Provider responsibility. Services must be performed by Reproductive Resource Services. 4 Not covered
    Coinsurance for Physician & Facility Services Percentage amount that you are obliged to pay for these as covered medical services. 70%; Infertility medical services must be received by Reproductive Resource Services 4 Not covered 70%; Infertility medical services must be received by Reproductive Resource Services 4 Not covered 70%; Infertility medical services must be received by Reproductive Resource Services 4 Not covered 70%; Infertility medical services must be received by Reproductive Resource Services 4 Not covered Artificial Insemination - 100% after $20 copay per visit. Coverage is limited and does not include all infertility methods. Contact Kaiser for plan details. Not covered Non-RRS Network: 70% up to plan maximum. Non-RRS Network: 70% up to plan maximum. Artificial Insemination - 50% after applicable copay. Coverage is limited and does not include all infertility methods. Contact Kaiser for plan details. Not covered Artificial Insemination - 50% after applicable copay. Coverage is limited and does not include all infertility methods. Contact Kaiser for plan details. Not covered Artificial Insemination/Drugs/In-Vitro Fertilization - 50% after applicable copay. Coverage is limited and does not include all infertility methods. Contact Kaiser for plan details. Not covered Artificial Insemination - 100% after $20 copay per visit. Coverage is limited and does not include all infertility methods. Contact Kaiser for plan details. Not covered 70%; Infertility medical services must be received by Reproductive Resource Services 4 Not covered Not covered Not covered Treatment and diagnosis 50%. Coverage is limited and does not include all infertility methods. Contact Kaiser for plan details. Not covered 70%; Infertility medical services must be received by Reproductive Resource Services 4 Not covered
    Infertility Treatment Lifetime Maximum Coverage for testing and treatment in connection with conditions of infertility, includes procedures to restore fertility (e.g., artificial insemination and IVF). Medical - $18,000 / Prescription Drugs - $12,000 (Infertility charges do not apply to out of pocket maximum) Medical - $18,000 / Prescription Drugs - $12,000 (Infertility charges do not apply to out of pocket maximum) Medical - $18,000 / Prescription Drugs - $12,000 (Infertility charges do not apply to out of pocket maximum) Medical - $18,000 / Prescription Drugs - $12,000 (Infertility charges do not apply to out of pocket maximum) Not covered No maximum Not covered Medical - $18,000 / Prescription Drugs - $12,000 (Infertility charges do not apply to out of pocket maximum) Medical - $18,000 / Prescription Drugs - $12,000 (Infertility charges do not apply to out of pocket maximum) Medical - Unlimited / Prescription Drugs - Not Covered Not covered No maximum Not covered In vitro fertilization $100,000 or 3 procedures maximum Not covered No maximum Not covered Medical - $18,000 / Prescription Drugs - $12,000 (Infertility charges do not apply to out of pocket maximum) Not covered Not covered Not covered Treatment and diagnosis 50% covered Not covered Medical - $18,000 / Prescription Drugs - $12,000 (Infertility charges do not apply to out of pocket maximum) Not covered
  • Emergency Medical Services
      UHC - HSA Med Plan UHC - Med PPO Choice Plus UHC - Prem PPO Choice Plus UHC - EPO Choice Kaiser NoCal UHC - Med OOA UHC - Prem OOA Kaiser Colorado Kaiser Atlanta Kaiser Mid-Atlantic Kaiser SoCal UHC - HPHC Passport Kaiser Foundation Health Plan of Washington Kaiser Northwest UHC - HI EPO Choice
      Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network
    Emergency Room (True Emergency) Hospital care performed in the emergency room for a condition that, if not treated immediately, could seriously jeopardize or impair your health, such as a suspected heart attack, severe lacerations or broken bones. 90% after deductible 90% of billed charges after deductible $150 copay (waived if admitted to hospital) $150 copay (waived if admitted to hospital) $150 copay (waived if admitted to hospital) $150 copay (waived if admitted to hospital) $150 copay (waived if admitted to hospital) $150 copay (waived if admitted to hospital) $35 copay $35 copay 80% after deductible 80% after deductible $100 copay $100 copay $75 copay $75 copay $50 copay $50 copay $35 copay $35 copay $150 copay (waived if admitted to hospital) $150 copay (waived if admitted to hospital) $75 copay (waived if admitted to hospital) $75 copay (waived if admitted to hospital) $35 copay (waived if admitted to hospital) $35 copay (waived if admitted to hospital) $50 copay (waived if admitted to hospital) $50 copay (waived if admitted to hospital)
    Emergency Room - Non Emergency Hospital care performed in the Emergency Room for a condition that is not deemed a true emergency. 90% after deductible 70% of UCR2 after deductible 70% after deductible 70% of UCR2 after deductible 80% after deductible 80% of UCR2 after deductible 80% after deductible 80% of UCR 2 after deductible Not covered Not covered 50% after deductible 50% after deductible Not covered Not covered Not covered Not covered $50 copay (Not Covered unless authorized) $50 copay (Not Covered unless authorized) Not covered Not covered 80% after deductible 80% of UCR 2 after deductible Not covered Not covered Not covered Not covered $50 copay $50 copay
    Ambulance (for medical emergency services) Specially equipped vehicle for transporting a member to the hospital in an emergency situation. 90% of billed charges after deductible 90% of billed charges after deductible 100% of billed charges 100% of billed charges 100% 100% of billed charges 100% 100% 100% 100% $100 copay $100 copay $75 copay $75 copay 100% (Kaiser Approval Required) 100% (Kaiser Approval Required) 100% 100% 100% 100% of billed charges 80% 80% 100% 100% 100% 100% of billed charges
    Urgent Care Center Care for an illness, injury or condition serious enough that a reasonable person would seek care right away, but not so severe as to require emergency room care. 90% after deductible 70% of UCR 2 after deductible $25 copay 70% of UCR 2 after deductible $20 copay 80% of UCR 2 after deductible $20 copay Not covered $10 copay $10 copay 80% after deductible 80% after deductible $25 copay $25 copay $20 copay $20 copay $20 copay $20 copay $10 copay $10 copay $10 copay Not covered $10 copay $75 copay $10 Copay $10 Copay $15 copay Not covered
  • Prescription Drugs
      UHC - HSA Med Plan UHC - Med PPO Choice Plus UHC - Prem PPO Choice Plus UHC - EPO Choice Kaiser NoCal UHC - Med OOA UHC - Prem OOA Kaiser Colorado Kaiser Atlanta Kaiser Mid-Atlantic Kaiser SoCal UHC - HPHC Passport Kaiser Foundation Health Plan of Washington Kaiser Northwest UHC - HI EPO Choice
      Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network
    Prescription Drugs (Retail) Drugs and medications that by law require a prescription that are purchased at a local pharmacy. Preventive Drugs 100% 16; Non-Preventive Drugs 90% after deductible; Limited to a 34-day supply 1,7 Preventive Drugs 70% 16; Non-Preventive Drugs 70% of billed charges, after deductible; Limited to a 34-day supply 1,7 Tier 1 - $5 copay; Tier 2 - 75% ($40 minimum, $80 maximum); Tier 3 - 75% ($60 minimum, $120 maximum); Limited to a 34-day supply; Deductible does not apply 1,7 50% of billed charged per applicable prescription; Limited to a 34-day supply; Deductible does not apply 1,7 Tier 1 - $5 copay; Tier 2 - 80% ($30 minimum, $60 maximum); Tier 3 - 80% ($50 minimum, $100 maximum); Limited to a 34-day supply; Deductible does not apply 1,7 50% of billed charged per applicable prescription; Limited to a 34-day supply; Deductible does not apply 1,7 Tier 1 - $5 copay; Tier 2 - 80% ($30 minimum, $60 maximum); Tier 3 - 80% ($50 minimum, $100 maximum); Limited to a 34-day supply; Deductible does not apply 1,7 Not Covered Kaiser Pharmacy: Generic - $5 copay; Brand Name - $10 copay; up to a 100-day supply Not covered Tier 1 - $5; Tier 2 - 75% ($40 minimum, $80 maximum); Tier 3 - 75% ($60 minimum, $120 maximum); Limited to a 34-day supply; Deductible does not apply 1,7 50% per applicable prescription; Limited to a 34-day supply; Deductible does not apply 1,7 Tier 1 - $5 copay; Tier 2 - 80% ($30 minimum, $60 maximum); Tier 3 - 80% ($50 minimum, $100 maximum); Limited to a 34-day supply; Deductible does not apply 1,7 50% per applicable prescription; Limited to a 34-day supply; Deductible does not apply 1,7 Generic - $5 copay; Brand Name - $15 copay; Non-Preferred - $30 copay; 30 day supply; Injectables - 20% coinsurance up to $250 maximum Not covered Kaiser Pharmacies: Generic - $5 copay; Brand Name - $20 copay; Network Pharmacies: Generic - $15 copay; Brand Name - $30 copay; 30-day supply Not covered Kaiser Pharmacy - $5 copay; Network Pharmacy - $15 copay; 60 day supply Not covered Kaiser Pharmacy: Generic - $5 copay; Brand Name - $10 copay; up to a 100-day supply Not covered Tier 1 - $5 copay; Tier 2 - 80% ($30 minimum, $60 maximum); Tier 3 - 80% ($50 minimum, $100 maximum); Limited to a 34-day supply; Deductible does not apply 1,7 Not Covered Group Health Pharmacy: Generic - $10 copay; Brand Name - $20 copay; 30 day supply Not covered Generic - $5 copay; Brand Name - $10 copay; 30 day supply Not covered Tier 1 - $5; Tier 2 - $15; Tier 3 - $25; Limited to a 34-day supply 1,7 Not covered
    Prescription Drugs (Mail Order) Drugs and medications that by law require a prescription that are purchased and delivered through the mail. Preventive Drugs 100% 16; Non-Preventive Drugs 90% after deductible; Limited to a 90-day supply 1,7 Not covered Tier 1 - $10 copay; Tier 2 - 75% ($80 minimum, $160 maximum); Tier 3 - 75% ($120 minimum, $240 maximum); Limited to a 90-day supply; Deductible does not apply 1,7 Not covered Tier 1 - $10 copay; Tier 2 - 80% ($60 minimum, $120 maximum); Tier 3 - 80% ($100 minimum, $200 maximum); Limited to a 90-day supply; Deductible does not apply 1,7 Not covered Tier 1 - $10 copay; Tier 2 - 80% ($60 minimum, $120 maximum); Tier 3 - 80% ($100 minimum, $200 maximum); Limited to a 90-day supply; Deductible does not apply 1,7 Not covered Kaiser Pharmacy: Generic - $5 copay; Brand Name - $10 copay; up to a 100-day supply Not covered Tier 1 - $10 copay; Tier 2 - 75% ($80 minimum, $160 maximum); Tier 3 - 75% ($120 minimum, $240 maximum); Limited to a 90-day supply; Deductible does not apply 1,7 Not covered Tier 1 - $10 copay; Tier 2 - 80% ($60 minimum, $120 maximum); Tier 3 - 80% ($100 minimum, $200 maximum); Limited to a 90-day supply; Deductible does not apply 1,7 Not covered Kaiser Pharmacy: Generic - $10 copay; Brand Name - $30 copay; Non-Preferred - $60 copay ; 90 day supply; Injectables - 20% coinsurance up to $250 maximum Not covered Kaiser Pharmacy: Generic - $10 copay; Brand Name - $40 copay; 90-day supply Not covered Kaiser Pharmacy: $5 copay; 90 day supply (mail order available for 1.5 x copay) Not covered Kaiser Pharmacy: Generic - $5 copay; Brand Name - $10 copay; up to a 100-day supply Not covered Tier 1 - $10 copay; Tier 2 - 80% ($60 minimum, $120 maximum); Tier 3 - 80% ($100 minimum, $200 maximum); Limited to a 90-day supply; Deductible does not apply 1,7 Not covered Group Health Pharmacy: Generic - $20 copay; Brand Name - $40 copay; 90 day supply Not covered Kaiser Pharmacy: Generic - $10 copay; Brand Name - $20 copay; 90 day supply Not covered Tier 1 - $10; Tier 2 - $30; Tier 3 - $50; Limited to a 90-day supply 1,7 Not covered
  • Miscellaneous Services
      UHC - HSA Med Plan UHC - Med PPO Choice Plus UHC - Prem PPO Choice Plus UHC - EPO Choice Kaiser NoCal UHC - Med OOA UHC - Prem OOA Kaiser Colorado Kaiser Atlanta Kaiser Mid-Atlantic Kaiser SoCal UHC - HPHC Passport Kaiser Foundation Health Plan of Washington Kaiser Northwest UHC - HI EPO Choice
      Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network Network Non-Network
    Speech, Physical, Occupational Therapy Health care services that help a person keep, get back or improve skills and functioning for daily living that have been lost or impaired because a person was sick, hurt or disabled. These services may include physical and occupational therapy, speech-language pathology and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings. 90% after deductible; Combined Network & Non-Network limit of 60 visits for each therapy type, per year. Medical review is needed for further visits 70% of UCR 2 after deductible; Combined Network & Non-Network limit of 60 visits for each therapy type, per year. Medical review is needed for further visits $35 copay. Combined Network & Non-Network limit of 60 visits for each therapy type, per year. Medical review is needed for further visits 70% of UCR 2 after deductible. Combined Network & Non-Network limit of 60 visits per year for each therapy type, per year. Medical review is needed for further visits $30 copay. Combined Network & Non-Network limit of 60 visits for each therapy type, per year. Medical review is needed for further visits 80% of UCR 2 after deductible. Combined Network & Non-Network limit of 60 visits per year for each therapy type, per year. Medical review is needed for further visits $30 copay; Limited to 60 visits for each therapy type, per year. Medical review is needed for further visits Not covered $10 copay Not covered 80% after deductible (Limited to 60 visits for each therapy type, per year. Medical review is needed for further visits) 80% after deductible (Limited to 60 visits for each therapy type, per year. Medical review is needed for further visits) $10 copay (Limited to 20 visits per year) Not covered $20 copay (OT & PT / combined limit - 20 visits per year & ST/limited to 20 visits per year) Not covered $20 copay (OT & ST/combined limit - 90 visits per year & PT/limited to 30 visits per year) Not covered $10 copay Not covered $20 copay; Limited to 60 visits for each therapy type, per year.  Medical review is needed for further visits Not covered $10 copay (Combined Limit - 60 visits per year) Not covered $20 copay (Limited to 20 visits per year) Not covered $25 copay; Limited to 60 visits for each therapy type, per year. Medical review is needed for further visits Not covered
    Chiropractic Visit Manipulation of spinal and musculoskeletal structures performed by a licensed Chiropractor. 90% after deductible; Combined Network & Non-Network limit of 20 visits per year. Medical review is needed for further visits 70% of UCR 2 after deductible; Combined Network & Non-Network limit of 20 visits per year. Medical review is needed for further visits $35 copay. Combined Network & Non-Network limit of 20 visits per year. Medical review is needed for further visits 70% of UCR 2 after deductible. Combined Network & Non-Network limit of 20 visits per year. Medical review is needed for further visits $30 copay. Combined Network and Non-Network limit of 20 visits per year. Medical review is needed for further visits 80% of UCR 2 after deductible. Combined Network and Non-Network limit of 20 visits per year. Medical review is needed for further visits $30 copay. Limited to 20 visits per year. Medical review is needed for further visits Not covered $10 copay. Administered by American Specialty Health. Annual limit of 20 visits combined with acupuncture visits. Not covered 80% after deductible (Limited to 20 visits per year. Medical review is needed for further visits) 80% after deductible (Limited to 20 visits per year. Medical review is needed for further visits) $10 copay. Annual limit of 20 combined with acupuncture visits. Not covered $20 copay. Annual limit of 20 combined with acupuncture visits. Not covered $20 copay. Annual limit of 20 combined with acupuncture visits. Not covered $10 copay. Administered by American Specialty Health. Annual limit of 20 visits combined with acupuncture visits. Not covered $30 copay. Limited to 20 visits per year. Medical review is needed for further visits Not covered $10 copay. Annual limit of 20 visits. Not covered $10 copay. Annual limit of 20 combined with acupuncture visits. Not covered $25 copay; Limited to 20 visits per year. Medical review is needed for further visits Not covered
    Acupuncture Therapeutic treatment to relieve pain or produce regional anesthesia. 80% after deductible 80% of billed charges after deductible 80% 80% of billed charges 80% 80% of billed charges 80% 80% of billed charges $10 copay. Administered by American Specialty Health. Annual limit of 20 visits combined with chiropractor visits. Not covered 80% 80% $10 copay. Annual limit of 20 combined with chiropractor visits. Not covered $20 copay. Annual limit of 20 combined with chiropractor visits. Not covered $20 copay. Annual limit of 20 combined with chiropractor visits. Not covered $10 copay. Administered by American Specialty Health. Annual limit of 20 visits combined with chiropractor visits. Not covered 80% 80% of billed charges $10 copay. Annual limit of 12 visits. Not covered $10 copay. Annual limit of 20 combined with chiropractor visits. Not covered 80% 80% of billed charges
    Durable Medical Equipment Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: oxygen equipment, wheelchairs, crutches or blood testing strips for diabetics. 90% after deductible 70% of UCR 2 after deductible.
    A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum.
    90% after deductible 70% of UCR 2 after deductible.
    A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum.
    100% after deductible 80% of UCR 2 after deductible.
    A $200 penalty is imposed if there is no prior authorization for non-network services. Penalty does not apply towards plan deductible or out of pocket maximum.
    100% after deductible Not covered 100% Not covered 80% after deductible 80% after deductible 80% Not covered 50% Not covered 50% Not covered 100% Not covered 100% after deductible Not covered 80% Not covered 100% Not covered 100% Not covered
    Hearing Aids/Fitting Fees Charges include diagnostic services to determine extent of hearing loss or impairment, hearing aids and fitting fees when necessary. 80% after deductible 80% of UCR 2 after deductible 80% 80% of UCR 2 80% 80% of UCR 2 80% Not covered Hearing test: $10 copay; Hearing audiologist/specialist: $20 copay; Hearing aids are not covered Not covered 80% 80% Hearing test: $10 copay; Hearing audiologist/specialist: $20 copay; Hearing aids not covered for adults; Hearing aids covered for children under 18 every 5 years. Not covered Hearing test: $10 copay; Hearing audiologist/specialist: $20 copay; Hearing aids are not covered Not covered Hearing test: $10 copay; Hearing audiologist/specialist: $20 copay; Hearing aids not covered for adults; Children age 19 and under are covered 1 ear every 36 months; Not covered Hearing test: $10 copay; Hearing audiologist/specialist: $20 copay; Hearing aids are not covered Not covered 80% Not covered Hearing test: $10 copay; Hearing audiologist/specialist: $20 copay; Hearing aids are not covered Not covered Hearing test: $20 copay; Hearing audiologist/specialist: $20 copay; Childern under 18 are covered 1 ear every 48 months, includes Age 19-25 full time students; Hearing aids not covered for adults Not covered 80% Not covered
    Allergy Treatment Charges associated with treating allergy conditions. 90% after deductible 70% of UCR 2 after deductible Treatment w/office visit: Applicable Doctor/Specialist copay applies; Injections only (no office visit): 90% 70% of UCR 2 after deductible Treatment w/office visit: Applicable Doctor/Specialist copay applies; Injections only (no office visit): 100% 80% of UCR 2 after deductible Treatment w/office visit: Applicable Doctor/Specialist copay applies. Injections only (no office visit): 100% Not covered $3 copay (injections) Not covered 80% after deductible 80% after deductible $10 copay Not covered $20 copay Not covered $20 copay Not covered $3 copay (injections) Not covered Treatment w/office visit: Applicable Doctor/Specialist copay applies. Injections only (no office visit): 100% Not covered Applicable Doctor/Specialist copay applies Not covered $5 copay (in Nurse Treatment room) Not covered Treatment w/office visit: Applicable Doctor/Specialist copay applies. Injections only (no office visit): 100% Not covered
    Allergy Testing Charges associated with allergy diagnosis. 90% after deductible 70% of UCR 2 after deductible $35 copay 70% of UCR 2 after deductible; If performed at lab - refer to non-preventive lab benefit $30 copay; If performed at lab - refer to non-preventive lab 80% of UCR 2 after deductible; If performed at lab - refer to non-preventive lab benefit $30 copay; If performed at lab - refer to non-preventive lab Not covered Applicable Doctor/Specialist copay applies Not covered 80% after deductible 80% after deductible $20 copay Not covered $20 copay Not covered Applicable Doctor/Specialist copay applies Not covered Applicable Doctor/Specialist copay applies Not covered $30 copay; If performed at lab - refer to non-preventive lab Not covered $10 copay Not covered $20 copay Not covered $25 copay; If performed at lab - refer to non-preventative lab Not covered
    Applied Behavior Analysis (ABA) Therapy Coverage for Early Intensive Behavior Intervention programs and related interventions for eligible employees and eligible dependents with Autism and Autism Spectrum Disorders (i.e., autism, pervasive developmental disorder, asperger's disorder). This includes but is not limited to Applied Behavior Analysis (ABA) therapy programs. 80% after deductible 12,13,15 80% of billed charges after deductible 12,13,15 80% after deductible 12,13,15 80% of billed charges after deductible 12,13,15 80% after deductible 12,13,15 80% of billed charges after deductible 12,13,15 80% after deductible 12,13,15 80% of billed charges after deductible 12,13,15 Contact Kaiser to verify plan coverage Not covered 80% after deductible12,13,15 80% after deductible12,13,15 $10 copay 12 Not covered Not covered Not covered Not covered Not covered Contact Kaiser to verify plan coverage Not covered 80% after deductible 12,13,15 80% of billed charges 12,13,15 Contact Group Health to verify plan coverage Not covered Contact Kaiser to verify plan coverage Not covered 80% 12,13,15 80% of billed charges 12,13,15
    Applied Behavior Analysis (ABA) Therapy Coverage Maximum The maximum amount paid by the plan for Autism related services over the course of the insured's lifetime. No maximum No maximum No maximum No maximum Contact Kaiser to verify plan coverage Not covered No maximum No maximum Contact Kaiser to verify plan coverage Not covered Not covered Not covered Not covered Not covered Contact Kaiser to verify plan coverage Not covered No maximum No maximum Not covered Contact Kaiser to verify plan coverage Not covered No maximum