MEDICAL Y O U R J O U R N E Y T O (CONT’D) HEALTH Click on the links below for Kaiser resources: Medical insurance helps you pay for preventive care, routine health needs, prescriptions, and • National Enrollment Guide advanced procedures by cost-sharing with your insurance provider. • Health & Wellness Resource Guide Hover over the insurance terms below to learn what they mean. • Healthy Resources Guide • Maternity Care Flyer KAISER PERMANENTE DHMO 750 KAISER PERMANENTE DHMO 5500 • Mental Health Resources (NORTHERN/SOUTHERN CALIFORNIA) (NORTHERN/SOUTHERN CALIFORNIA) • Care Away From Home Individual: $750 Individual: $5,500 Review DEDUCTIBLE Family: $1,500 Family: $11,000 Plan SBC’s Primary Care: $30 copay Primary Care: $50 copay Kaiser Permanente DHMO 750 OFFICE VISITS Specialist: $40 copay Specialist: $50 copay (Northern California) Urgent Care: $30 copay Urgent Care: $50 copay Inpatient: 20% coinsurance* Inpatient: 40% coinsurance* Kaiser Permanente DHMO 750 PROCEDURES Outpatient: 20% coinsurance* Outpatient: 40% coinsurance* (Southern California) Emergency Room: 20% coinsurance* Emergency Room: 40% coinsurance* Tier 1: $10 (retail) / $20 (home delivery) Tier 1: $15 (retail) / $30 (home delivery) Kaiser Permanente DHMO 5500 PRESCRIPTIONS Tier 2: $30 (retail) / $60 (home delivery) Tier 2: Preferred Brand - 40% coinsurance up to $100 (Northern California) Tier 3: $30 (retail) / $60 (home delivery) Tier 2: Non-Preferred Brand - 40% coinsurance up to $100 Tier 4: 20% coinsurance up to $250 Tier 4: 40% coinsurance up to $250 OUT-OF-POCKET Individual: $3,000 Individual: $7,500 Kaiser Permanente DHMO 5500 MAXIMUM Family: $6,000 Family: $15,000 (Southern California) *Deductible applies first. The benefits and rates in this guide are for illustrative purposes only. Please refer to the Summary of Benefits 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.