Group Forms Kaiser

APPLICATIONS AND FORMS

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Kaiser 2014 Plans Office Visit Copay Prescriptions Deductible & Coinsurance Out-of-Pocket Limit
Gold 0/30 (K-1) $30/$60 $15/$45/50%/20% $0 + 20% $6350 Ind/$12,700 Family
Gold 500/20 (K-2) $20/$40 $15/$45/50%/20% $500 + 20% $6350 Ind/$12,700 Family
Silver 1200/35 (K-3) $35/$65 $15/$500 Deductible, then $45/50%/35% $1200 + 35% $6350 Ind/$12,700 Family
Silver 1500/50 (K-4) $50/$70 $15/$500 Deductible, then $45/50%/35% $1500 + 35% $6350 Ind/$12,700 Family
Silver 2000/30 HSA (K-5) $30/$50 after deductible Deductible then $10/$30/15% $2000 + 15% $6350 Ind/$12,700 Family
Bronze 4500/50 (K-6) $50/$70 $20/40% $4500 + 40% $6350 Ind/$12,700 Family
Bronze 3500/40 HSA (K-7) $40/$60 after deductible Deductible then $20/$45/30% $3500 + 30% $6350 Ind/$12,700 Family
Bronze 4500/50% HSA (K-8) Deductible & Coinsurance Deductible and Coinsurance $4500 + 30% $6350 Ind/$12,700 Family
 
HMO Plans SBC Office Visit Copay Hospital Copay Outpatient Copay
KP 0/35/Rx SBC $35/$70 $1000/day (max 4) $200
KP 0/40/Rx SBC $40/$80 $1000/day (max 4) $200
KP 0/45/Rx SBC $45/$90 $1000/day (max 4) $200
KP 0/50/Rx SBC $50/$100 $1000/day (max 4) $200
Deductible Plans Office Visit Copay Deductible Coinsurance
KP 500/40/Rx SBC $40/$60 $500 30% to $2400
KP 1200/40/Rx SBC $40/$60 $1,200 30% to $2700
KP 1600/40/Rx SBC $40/$60 $1,600 30% to $3300
KP 2300/40/Rx SBC $40/$60 $2,300 30% to $3600
KP 3600/40/Rx SBC $40/$60 $3,600 30% to $3300
KP 5000/40/Rx SBC $40/$60 $5,000 30% to $2900
H.S.A. Plans Individual Ded. Family Deductible
KP 3500/HSA/Rx SBC $3,500 $7,000
KP 4500/HSA/Rx SBC $4,500 $9,000
KP HSA 5950 SBC $5,950 $11,900
POS Plans Office Visit Copays Deductible In/Out Coinsurance In/Out
KP+1 1400/40/Rx SBC $40/$60 – $60/$100 $1400/$2800 30% $3100/50% $6200
KP+1 2000/40/Rx SBC $40/$60 – $60/$100 $2000/$4000 30% $3500/50% $7000
KP+1 3200/40/Rx SBC $40/$60 – $60/$100 $3200/$6400 30% $3300/50% $6600
Basic HMO SBC $40/$60 Copays $10,000
Standard HMO SBC $30/$50 Copays $4500
Old HMO Plans
Health Plan Name Office Visit Copay Hospital Copay Outpatient Copay
Classic 30 SBC $30/$40 $1,000 $150
Classic 35A SBC $30/$50 20% to $4k max $200
Classic 40 SBC $40/$75 $1000/day, $4K max $200
Old Deductible Plans
Plan Name Office Visit Copay Deductible Coinsurance
HMO 500D SBC $30/$50 $500 20% to $2,500 max
HMO 1000D SBC $30/$50 $1,000 20% to $3,000 max
HMO 1200D SBC $30/$50 $1,200 20% to $2,500 max
HMO 2000D SBC $30/$50 $2,000 20% to $4,000 max
HMO 2500D SBC $30/$50 $2,500 20% to $5,000 max
HMO 3000D SBC $30/$50 $3,000 20% to $6,000 max
HMO 4000D SBC $30/$50 $4,000 20% to $8,000 max
HMO 5000D SBC $30/$50 $5,000 20% to $10,000 max
Health Savings Account Plans
HSA 1500 SBC Deductible $1,500 0%
HSA 2000 SBC Deductible $2,000 0%
HSA 3000 SBC Deductible $3,000 0%
HSA 5000 SBC Deductible $5,000 0%