Kaiser HMO Plan

Plan Description

Medical coverage may be elected through Kaiser. Kaiser benefits are described in detail by Kaiser brochures, which are available, upon request, from the Plan Administrator at no additional cost.

Eligibility Requirements

Available for Employees who reside in certain geographic areas covered by Kaiser Permanente

Prescription Program

Employees enrolled in the Kaiser Permanente Plan, prescription drug benefits are provided by the Kaiser Permanente Plan.

Claims Procedures

The Trust Administrative Office is responsible for reviewing claims concerning eligibility and the Plan.

  1. Time Requirements
    1. Written notice of a claim must be given to the Trust Administrative Office as soon as reasonably possible.
    2. Proof of claim for Hospital confinement must be given to the Trust Administrative Office within ninety (90) days after release from the Hospital.
    3. Proof of claim for any other service, supply or treatment must be given to the Trust Administrative Office within ninety (90) days after the service or treatment.
    4. If proof of any claim is not given within ninety (90) days, the claim will not be denied or reduced if the proof of the claim was given as soon as reasonably possible. However, no claim will be paid if submitted to the Trust Administrative Office for more than one year after the date of service or treatment. “Proof” means proof satisfactory to the Board of Trustees.
  2. Examination
    1. The Board of Trustees, at the expense of the Trust, has the right to have You examined by a Provider, as often as it may require, whenever Your Illness or Injury is the basis of a claim.
    2. The Board of Trustees has the right to require an autopsy, if not prohibited by law. A disputed Illness is a basis for this requirement.

Vision claims are processed and paid by:

Vision Service Plan
P.O. Box 997100 Sacramento CA 95899-7100
TDD/Hearing Impaired 1-800-735-2922

If You are using Postal Prescription Services (PPS) mail-order prescription drug program, You must submit claim forms directly to Postal Prescription Services. Claim forms are available from the Trust Administrative Office or on the web at www.soundcommbenefits.com. Mail Your claim form to:

Postal Prescription Services
P.O. Box 2718
Portland, OR 97208-2718

For Kaiser Permanente enrollees, present Your ID card at Your Kaiser Permanente facility for services and prescription drugs.

If You have a claim concerning benefits provided by Kaiser Permanente Plan, the claim should be filed with the organization in accordance with its claims appeal procedures.

Plan Summary

Annual Copayment Limit
For each member $1,500
For each Family Unit $3,000
Professional Services (Plan Provider Office Visits)
Primary & specialty care visits (includes routine and Urgent Care appointments) $15 per visit
Routine preventive physical exams No per visit
Well-child preventive care visits (0-23 months) No per visit
Family planning visits $10 per visit
Scheduled prenatal care and first postpartum visit $15 per visit
Routine preventive refraction exams $0 charge
Routine preventive hearing tests $0 charge
Physical, occupational, and speech therapy visits $15 per visit
Outpatient Services
Outpatient surgery $15 per procedure
Allergy injection visits $10 per visit
Allergy testing visits $15 per visit
Immunizations No charge
Physical, occupational, and speech therapy visits $15 per visit
X-rays and lab tests No charge
Hospital Inpatient Care
Hospital room and board, surgery, anesthesia, X-rays, lab tests, and medications No charge
Skilled Nursing Facility (up to 100 days per benefit period) No charge
Prescription Drugs
Covered items in accord with our formulary when obtained at Plan pharmacies:
Generic $10 up to a 100-day supply (or 3 cycles for oral contraceptives)
Brand name or compounded drugs $25 up to a 100-day supply (or 3 cycles for oral contraceptives)
Drugs related to the treatment of sexual dysfunction disorders (episodic drugs are limited to 27 doses in any 100-day period) 50% Coinsurance up to a 100-day supply
Mental Health Services
Inpatient psychiatric care (up to 45 days per the calendar year) No charge
Outpatient visits:
Up to a total of 20 individual and/or group therapy visits per calendar year
Individual therapy visits $10 per visit
Group therapy visits $5 per visit
Up to 20 additional group therapy visits that meet Medical Group criteria in the same calendar year $5 per visit
Note: Visit and day limits do not apply to severe mental illnesses and serious emotional disturbances of children.
Chemical Dependency Services
Inpatient detoxification No charge
Outpatient group therapy visits $5 per visit
Outpatient individual therapy visits $10 per visit
Transitional residential recovery Services (up to 60 days per the calendar year, not to exceed 120 days in any five-year period) $100 per admission
Other Services
Ambulance Services No charge
Durable medical equipment in accord with our formulary 20% Coinsurance
Health education for specific conditions:
Individual visits $10 per visit
Group visits No charge
Home health care No charge
Hospice care No charge
Emergency Care
Emergency Department visits $100 per visit (waived if admitted directly to the hospital)