MEDICAL Y O U R J O U R N E Y T O HEALTH Medical insurance helps you pay for preventive care, routine health needs, prescriptions, and advanced procedures by cost-sharing with your insurance provider. Hoverovertheinsurancetermsbelowtolearnwhattheymean! Kaiser Permanente DHMO 750 Kaiser Permanente DHMO 5500 (Northern/Southern California) (Northern/Southern California) Individual: $750 Individual: $5,500 REVIEW DEDUCTIBLE Family: $1,500 Family: $11,000 PLAN SBC’S Primary Care: $25 copay Primary Care: $50 copay OFFICE VISITS Specialist: $25 copay Specialist: $50 copay Urgent Care: $25 copay Urgent Care: $50 copay Inpatient: *20% Coinsurance Inpatient: *40% Coinsurance PROCEDURES Outpatient: *20% Coinsurance Outpatient: *40% Coinsurance Click on the links below for Emergency Room: *20% Coinsurance Emergency Room: *40% Coinsurance Kaiser resources: Tier 1: $10 (retail) / $20 (home delivery) Tier 1: $15 (retail) / $30 (home delivery) • National Enrollment Guide PRESCRIPTIONS Tier 2: $30 (retail) / $60 (home delivery) Tier 2: $40 (retail) / $100 (home delivery) • Health & Wellness Resource Guide Tier 3: $30 (retail) / $60 (home delivery) Tier 2: $40 (retail) / $100 (home delivery) • Healthy Resources Guide Tier 4: 20% coinsurance up to $250 Tier 4: 40% coinsurance up to $250 Individual: $3,000 Individual: $7,500 • Maternity Care Flyer OUT-OF-POCKET • Mental Health Resources MAXIMUM Family: $6,000 Family: $15,000 • Care Away From Home *Deductible applies first. The benefits and rates in this guide are for illustrative purposes only. Please refer to the Summary of Benefits and Coverage for specific benefits. To the extent the rates or the benefit plan information summarized herein differs from the underlying plan details specified in the insurance documents that govern the terms and conditions of the plans of insurance described in this guide, the underlying insurance documents will govern in all cases.