City Council Study Session Agenda and Packet 2017 05 09

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Kaiser Permanente Benefits Summary Benefits Summary HMO HDHP w/ HSA Family Annual Deductible None $5,000 Out -of -Pocket Max (Individual/Family) $2,000 / $4,500 (includes all copays) $2,500 / $5,000 Office Copay Preventive: $0 copay PCP: $30 copay Specialist: $50 copay $0 for Preventive: $0 PCP & Specialist: 100% after deductible Urgent Care NO PLAN $50 if after hours Plan pays 100% after deductible Emergency Care DESIGN $250 copay CHANGES Plan pays 100% after deductible Inpatient Hospital $500 copay Plan pays 100% after deductible Outpatient Facility $200 copay Plan pays 100% after deductible Ambulance Services 20% coinsurance up to a max of $500/trip Plan pays 100% after deductible Physical Therapy $30 copay / 20 visits maximum Plan pays 100% after deductible 20 visits maximum Chiropractic Services $30 copay / 20 visits maximum Not Covered Acupuncture $30 copay / 20 visits maximum Not Covered Prescription Drugs Retail 30 -day supply $15/$40 copay Plan pays 100% after deductible Prescription Drugs Mail Order 90 -day supply $30/$80 copay Plan pays 100% after deductible Benefit Summary Option 1 Kaiser Permanente Triple Option POS* Option 2* PHCS Network Option 3 Out -of -Network Annual Deductible (Individual/Family) $1,000 / $2,000 $2,000 / $4,000 $5,000 / $15,000 Maximum Annual Out -of -Pocket Cost (OPM) (Individual/Family) $3,000 / $6,000 $3,500 / $7,000 $12,000 / $36,000 Preventative Care 100% Covered 100% Covered $70 copay — 50% co -ins for services received during a visit Office Copay NO PLAN DESIGN PCP: $15 copay Specialist : $30 copay 20% co -ins for services rec'd at visit PCP: $30 copay Specialist : $50 copay 30% co -ins for services rec'd at visit PCP & Specialist: Deductible; then 50% co -ins CHANGES Emergency Care Deductible; then 20% co -ins Option 1 Deductible; then 20% co -ins Deductible; then 50% co -ins Inpatient Hospital Deductible; then 20% co -ins Deductible; then 30% co -ins Deductible; then 50% co -ins Outpatient Facility Deductible; then 20% co -ins Deductible; then 30% co -ins Deductible; then 50% co -ins Prescription Medication 30 -day supply $15 Generic $30 Preferred Brand $50 Non -preferred Brand 20% co -ins specialty Rx $25 Generic $40 Preferred Brand $50 Non -preferred Brand 20% co -ins specialty Rx 50% Generic 50% Preferred Brand 50% Non -preferred Brand 20% co -ins specialty Rx Financial Counseling: get cost estimates; set up a payment plan for Kaiser Services. Physician Selection Team: assistance in choosing a Primary Care Physician. Member Services: for questions about the plan benefits, location of services. 24 Hour Advice Line: quick medical advice or help determining if you should see a dr. or go to the ER. Triple Option ONLY: *PCHS Network is Kaiser's contracted Option 2 Provider Network. *Medimpact is Kaiser's contracted Option 2 Prescription Drug Provider. 6 303-338-3025 303-338-4477 303-338-3900 303-338-4545 www.multiplan.com/Kaiser 11.866.680.7427 www.medimpact.com 11.800.788.2949