| Under the Kaiser HMO Plan, you must receive services at a Kaiser facility in order to receive coverage, except in an emergency. |
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| KAISER PLAN RATES - MEMBER COST PER PAY PERIOD - EFFECTIVE 7/1/11 |
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| PART CODES |
Coverage Category |
Monthly Premium Rate |
| 10 |
Single |
$0.00 |
| 91 |
Two Party |
$0.00 |
| 05 |
Family |
$34.72 |
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| KAISER PLAN BENEFIT OVERVIEW - EFFECTIVE 7/1/11 |
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| CALENDAR YEAR DEDUCTIBLE |
NA |
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| HOSPITAL SERVICES |
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| EMERGENCY ROOM |
$50 co-pay; waived if admitted |
| URGENT CARE VISITS |
For visits at an assigned medical group $10 co-pay |
| INPATIENT (Room, Board and Support Services) |
No Charge 365 days/cal year |
| INPATIENT MATERNITY CARE |
No Charge |
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| PHYSICIAN SERVICES |
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| OFFICE VISITS |
$10 co-pay |
| Physical Therapy, Physical Medicine, Occupational Therapy, Acupuncture Services |
$10 co-pay |
| Chiropractic Care (through American Specialty Health Plans - ASHN) limited to 40 visits/cal yr) |
$10 co-pay |
| Speech Therapy (outpatient speech therapy following injury or organic disease) |
$10 co-pay |
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| HEALTH MAINTENANCE |
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| ROUTINE PHYSICAL EXAMINATIONS FOR SUBSCRIBERS AND DEPENDENTS |
No Charge |
| WELL WOMAN CARE |
No Charge |
| WELL BABY AND WELL CHILD CARE |
No Charge |
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| MENTAL HEALTH / SUBSTANCE ABUSE |
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| OUTPATIENT PHYSICIAN SERVICES |
$10 copay individual therapy
$5 copay group therapy |
| INPATIENT HOSPITAL |
No Charge |
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| OTHER COVERED EXPENSES |
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| HEARING AID BENEFIT |
No Charge (limited to one aid per ear, every 36 months) |
| PRESCRIPTION DRUGS - RETAIL PHARMACY |
$10 for Generic. $15 for Brand (up to a 100 day supply ) |
| PRESCRIPTION DRUGS - MAIL ORDER |
$10 for Generic. $15 for Brand (up to a 100 day supply ) |
| VISION CARE |
No charge for vision exams. $350 allowance for medically necessary eyewear every 24 months. |
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| The foregoing brief description of benefits is provided for your convenience and is subject to all terms, conditions, limitations and exclusions of the Kaiser contract. Please refer to the Kaiser evidence of coverage for details on benefits. |
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| All members and their families are encouraged to utilize the Los Angeles Police Protective League’s Employee Assistance Program (EAP) prior to accessing your selected medical plan. The EAP provides 10 sessions covered at no cost to the family. |
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