2021 Comparison Of Statewide Plans - Effective July 1, 2021 or October 1, 2021 - Manassas City Public ...
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2021 Comparison Of Statewide Plans Effective July 1, 2021 or October 1, 2021
The Local Choice 2021 Comparison of Statewide Plans
Key Advantage Expanded Key Advantage 250
Plan Year Deductible In-Network: In-Network:
(Key Advantage: Applies to Certain Medical Services One Person Two People Family One Person Two People Family
as Indicated on Chart) $100 See Family $200 $250 See Family $500
(HDHP: Applies to Medical, Behavioral Health, Out-of-Network: Out-of-Network:
and Prescription Drug Services) $200 See Family $400 $500 See Family $1,000
Plan Year Out-of-pocket Expense Limit In-Network: In-Network:
One Person Two People Family One Person Two People Family
$2,000 See Family $4,000 $3,000 See Family $6,000
Out-of-Network: Out-of-Network:
$3,000 See Family $6,000 $5,000 See Family $10,000
Out-of-Network Benefits Yes. Once you meet the out-of-network deductible, Yes. Once you meet the out-of-network deductible,
you pay 30% coinsurance for medical and behavioral you pay 30% coinsurance for medical and behavioral
health services. Copayments do not apply to medical health services. Copayments do not apply to medical
and behavioral health services. Copayments and and behavioral health services. Copayments and
coinsurance for routine vision, outpatient prescription coinsurance for routine vision, outpatient prescription
drugs and dental services will still apply. drugs and dental services will still apply.
Medical Care When Traveling (BlueCard) Included Included
Lifetime Maximum Unlimited Unlimited
Covered Services In-Network You Pay In-Network You Pay
Ambulance Travel 20% coinsurance after deductible 20% coinsurance after deductible
Autism Spectrum Disorder Copayment/coinsurance determined by Copayment/coinsurance determined by
service received service received
Behavioral Health and EAP
Inpatient treatment
• Facility Services $300 copayment per stay $400 copayment per stay
• Professional Provider Services $0 $0
Outpatient Professional Provider Visits $15 copayment $20 copayment
Employee Assistance Program (EAP) $0 $0
4 visits per issue (per plan year)
Dental Care
Preventive Dental Option (diagnostic and preventive $0 $0
services only for lower premium)
Comprehensive Dental Option
(for higher premium) One Person Two People Family One Person Two People Family
Dental Plan Year Deductible $25 $50 $75 $25 $50 $75
Plan Year Maximum (Except Orthodontics) $1,500 $1,500
• Preventive Dental Care $0 $0
• Primary Dental Care 20% coinsurance after dental deductible 20% coinsurance after dental deductible
• Major Dental Care 50% coinsurance after dental deductible 50% coinsurance after dental deductible
• Orthodontic Services (Includes Adult Ortho) 50% coinsurance, no dental deductible, 50% coinsurance, no dental deductible,
with $1,500 lifetime maximum with $1,500 lifetime maximum
2
Key Advantage 500 Key Advantage 1000 High Deductible Health Plan
In-Network: In-Network:
One Person Two People Family One Person Two People Family One Person Two People Family
$500 See Family $1,000 $1,000 See Family $2,000 $2,800 See Family $5,600
Out-of-Network: Out-of-Network: Deductible is combined for In-Network and
$1,000 See Family $2,000 $2,000 See Family $4,000 Out-of-Network services.
In-Network: In-Network: In-Network:
One Person Two People Family One Person Two People Family One Person Two People Family
$4,000 See Family $8,000 $5,000 See Family $10,000 $5,000 See Family $10,000
Out-of-Network: Out-of-Network: Out-of-Network:
$7,000 See Family $14,000 $9,000 See Family $18,000 $10,000 See Family $20,000
Yes. Once you meet the out-of-network deductible, Yes. Once you meet the out-of-network deductible, Yes. Once you meet the combined deductible
you pay 30% coinsurance for medical and behavioral you pay 30% coinsurance for medical and behavioral you pay 40% coinsurance for medical, behavioral
health services. Copayments do not apply to medical health services. Copayments do not apply to medical health and prescription drug services from
and behavioral health services. Copayments and and behavioral health services. Copayments and Out-of-Network providers.
coinsurance for routine vision, outpatient prescription coinsurance for routine vision, outpatient prescription
drugs and dental services will still apply. drugs and dental services will still apply.
Included Included Included
Unlimited Unlimited Unlimited
In-Network You Pay In-Network You Pay In-Network You Pay
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
Copayment/coinsurance determined by Copayment/coinsurance determined by 20% coinsurance after deductible
service received service received
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
$0 $0 20% coinsurance after deductible
$25 copayment $25 copayment 20% coinsurance after deductible
$0 $0 $0
$0 $0 $0
One Person Two People Family One Person Two People Family One Person Two People Family
$25 $50 $75 $25 $50 $75 $25 $50 $75
$1,500 $1,500 $1,500
$0 $0 $0
20% coinsurance after dental deductible 20% coinsurance after dental deductible 20% coinsurance after dental deductible
50% coinsurance after dental deductible 50% coinsurance after dental deductible 50% coinsurance after dental deductible
50% coinsurance, no dental deductible, 50% coinsurance, no dental deductible, 50% coinsurance, no dental deductible,
with $1,500 lifetime maximum with $1,500 lifetime maximum with $1,500 lifetime maximum
3
The Local Choice 2021 Comparison of Statewide Plans (continued)
Key Advantage Expanded Key Advantage 250
Covered Services In-Network You Pay In-Network You Pay
Diabetic Education $0 $0
Diabetic Equipment 20% coinsurance after deductible 20% coinsurance after deductible
Diabetic Supplies - See Outpatient Prescription Drugs
Diagnostic Tests and X-rays 20% coinsurance, no deductible 20% coinsurance after deductible
(for specific conditions or diseases at a doctor’s office,
emergency room or outpatient hospital department)
Doctor Visits – on an Outpatient Basis
Primary Care Physicians $15 copayment $20 copayment
Specialty Care Providers $25 copayment $35 copayment
Early Intervention Services Copayment/coinsurance determined by Copayment/coinsurance determined by
service received service received
Emergency Room Visits
Facility Services $250 copayment per visit $350 copayment per visit
(waived if admitted to hospital) (waived if admitted to hospital)
Professional Provider Services
– Primary Care Physicians $15 copayment $20 copayment
– Specialty Care Providers $25 copayment $35 copayment
Diagnostic Tests and X-rays 20% coinsurance, no deductible 20% coinsurance after deductible
Home Health Services $0 $0
(90 visit plan year limit per member)
Home Private Duty Nurse’s Services 20% coinsurance after deductible 20% coinsurance after deductible
Hospice Care Services $0 $0
Hospital Services
Inpatient Treatment
• Facility Services $300 copayment per stay $400 copayment per stay
• Professional Provider Services
– Primary Care Physicians $0 $0
– Specialty Care Providers $0 $0
Outpatient Treatment
• Facility Services $100 copayment $150 copayment
• Professional Provider Services
– Primary Care Physicians $15 copayment $20 copayment
– Specialty Care Providers $25 copayment $35 copayment
Diagnostic Tests and X-Rays 20% coinsurance, no deductible 20% coinsurance after deductible
LiveHealth Online $0 $0
(Online doctor’s visits)
4Key Advantage 500 Key Advantage 1000 High Deductible Health Plan
In-Network You Pay In-Network You Pay In-Network You Pay
$0 $0 20% coinsurance after deductible
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
$25 copayment $25 copayment 20% coinsurance after deductible
$40 copayment $40 copayment 20% coinsurance after deductible
Copayment/coinsurance determined by Copayment/coinsurance determined by 20% coinsurance after deductible
service received service received
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
$25 copayment $25 copayment 20% coinsurance after deductible
$40 copayment $40 copayment 20% coinsurance after deductible
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
$0 $0 20% coinsurance after deductible
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
$0 $0 20% coinsurance after deductible
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
$0 $0 20% coinsurance after deductible
$0 $0 20% coinsurance after deductible
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
$25 copayment $25 copayment 20% coinsurance after deductible
$40 copayment $40 copayment 20% coinsurance after deductible
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
$0 $0 Determined by services received
$
5The Local Choice 2021 Comparison of Statewide Plans (continued)
Key Advantage Expanded Key Advantage 250
Covered Services In-Network You Pay In-Network You Pay
Maternity
Professional Provider Services (Prenatal &
Postnatal Care)
– Primary Care Physicians $15 copayment $20 copayment
– Specialty Care Providers $25 copayment $35 copayment
If your doctor submits one bill for delivery, prenatal and postnatal care services, there is no
copayment required for physician care. If your doctor bills for these services separately, your
payment responsibility will be determined by the services received.
Delivery
– Primary Care Physicians $0 $0
– Specialty Care Providers $0 $0
Hospital Services for Delivery (Delivery Room, $300 copayment per stay* $400 copayment per stay*
Anesthesia, Routine Nursing Care for Newborn)
Outpatient Diagnostic Tests 20% coinsurance, no deductible 20% coinsurance after deductible
Medical Equipment, Appliances, 20% coinsurance after deductible 20% coinsurance after deductible
Formulas, Prosthetics and Supplies
Outpatient Prescription Drugs -
Mandatory Generic
Retail up to 34-day supply* Tier 1 – $10 copayment Tier 1 – $10 copayment
*You may purchase up to a 90-day supply at a Tier 2 – $30 copayment Tier 2 – $30 copayment
retail pharmacy by paying multiple copayments, Tier 3 – $45 copayment Tier 3 – $45 copayment
or the coinsurance after the deductible Tier 4 - $55 copayment Tier 4 - $55 copayment
Home Delivery Services (Mail Order) Tier 1 – $20 copayment Tier 1 – $20 copayment
Covered Drugs for up to a 90-Day Supply Tier 2 – $60 copayment Tier 2 – $60 copayment
Tier 3 – $90 copayment Tier 3 – $90 copayment
Tier 4 - $110 copayment Tier 4 - $110 copayment
Diabetic Supplies 20% coinsurance, no deductible 20% coinsurance, no deductible
Routine vision - Blue View Vision Network
(Once Every Plan Year)
Routine Eye Exam $25 copayment $35 copayment
Eyeglass Lenses $20 copayment $20 copayment
Eyeglass Frames Up to $100 retail allowance** Up to $100 retail allowance**
Contact Lenses (In Lieu of Eyeglass Lenses)
• Elective Up to $100 retail allowance Up to $100 retail allowance
• Non-Elective Up to $250 retail allowance Up to $250 retail allowance
Upgrade Eyeglass Lenses (Available for Additional Cost)
• UV Coating, Tints, Standard Scratch-Resistant $15 $15
•Standard Polycarbonate $40 $40
• Standard Progressive $65 $65
• Standard Anti-Reflective $45 $45
• Other Add-Ons 20% off retail 20% off retail
Shots – Allergy & Therapeutic Injections 20% coinsurance, no deductible 20% coinsurance after deductible
(At Doctor’s Office, Emergency Room or
Outpatient Hospital Department)
*This plan will waive the hospital copayment if the member enrolls in the maternity management pre-natal program within the first 16 weeks of pregnancy,
has a dental cleaning during pregnancy and satisfactorily completes the program.
**You may select a frame greater than the covered allowance and receive a 20% discount for any additional cost over the allowance.
6Key Advantage 500 Key Advantage 1000 High Deductible Health Plan
In-Network You Pay In-Network You Pay In-Network You Pay
$25 copayment $25 copayment 20% coinsurance after deductible
$40 copayment $40 copayment 20% coinsurance after deductible
If your doctor submits one bill for delivery, prenatal and postnatal care services, there is no
copayment required for physician care. If your doctor bills for these services separately, your
payment responsibility will be determined by the services received.
$0 $0 20% coinsurance after deductible
$0 $0 20% coinsurance after deductible
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
Tier 1 – $10 copayment Tier 1 – $10 copayment 20% coinsurance after deductible
Tier 2 – $30 copayment Tier 2 – $30 copayment
Tier 3 – $45 copayment Tier 3 – $45 copayment
Tier 4 - $55 copayment Tier 4 - $55 copayment
Tier 1 – $20 copayment Tier 1 – $20 copayment 20% coinsurance after deductible
Tier 2 – $60 copayment Tier 2 – $60 copayment
Tier 3 – $90 copayment Tier 3 – $90 copayment
Tier 4 - $110 copayment Tier 4 - $110 copayment
20% coinsurance, no deductible 20% coinsurance, no deductible 20% coinsurance after deductible
$40 copayment $40 copayment $15 copayment
$20 copayment $20 copayment $20 copayment
Up to $100 retail allowance** Up to $100 retail allowance** Up to $100 retail allowance**
Up to $100 retail allowance Up to $100 retail allowance Up to $100 retail allowance
Up to $250 retail allowance Up to $250 retail allowance Up to $250 retail allowance
$15 $15 $15
$40 $40 $40
$65 $65 $65
$45 $45 $45
20% off retail 20% off retail 20% off retail
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
7The Local Choice 2021 Comparison of Statewide Plans (continued)
Key Advantage Expanded Key Advantage 250
Covered Services In-Network You Pay In-Network You Pay
Skilled Nursing Facility Stays
(180-Day Per Stay Limit Per Member)
Facility Services $0 $0
Professional Provider Services $0 $0
Spinal Manipulations and Other
Manual Medical Interventions
(30 Visits Per Plan Year Limit Per Member)
Primary Care Physicians $15 copayment $20 copayment
Specialty Care Providers $25 copayment $35 copayment
Surgery – See Hospital Services
Therapy Services
Infusion Services, Cardiac Rehabilitation Therapy,
Chemotherapy, Radiation Therapy,
Respiratory Therapy, Occupational Therapy,
Physical Therapy, and Speech Therapy
Facility Services 20% coinsurance after deductible 20% coinsurance after deductible
Professional Provider Services
– Primary Care Physicians 20% coinsurance after deductible 20% coinsurance after deductible
– Specialty Care Providers 20% coinsurance after deductible 20% coinsurance after deductible
Wellness services
Well Child (Office Visits at Specified Intervals
Through Age 6)
– Primary Care Physicians; No copayment, coinsurance, or deductible No copayment, coinsurance, or deductible
– Specialty Care Providers;
– Immunizations and Screening Tests
Routine Wellness – Age 7 & Older
• Annual Check-Up Visit (One Per Plan Year) No copayment, coinsurance, or deductible No copayment, coinsurance, or deductible
– Primary Care Physicians
– Specialty Care Providers
– Immunizations, Lab and X-Ray Services
• Routine Screenings, Immunizations, Lab No copayment, coinsurance, or deductible No copayment, coinsurance, or deductible
and X-Ray Services (Outside of Annual
Check-Up Visit)
Preventive Care (One of Each Per Plan Year) No copayment, coinsurance, or deductible No copayment, coinsurance, or deductible
• Gynecological Exam
• Pap Test
• Mammography Screening
• Prostate Exam (Digital Rectal Exam)
• Prostate Specific Antigen Test
• Colorectal Cancer Screenings
8Key Advantage 500 Key Advantage 1000 High Deductible Health Plan
In-Network You Pay In-Network You Pay In-Network You Pay
$0 $0 20% coinsurance after deductible
$0 $0 20% coinsurance after deductible
$25 copayment $25 copayment 20% coinsurance after deductible
$40 copayment $40 copayment 20% coinsurance after deductible
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
20% coinsurance after deductible 20% coinsurance after deductible 20% coinsurance after deductible
No copayment, coinsurance, or deductible No copayment, coinsurance, or deductible No copayment, coinsurance, or deductible
No copayment, coinsurance, or deductible No copayment, coinsurance, or deductible No copayment, coinsurance, or deductible
No copayment, coinsurance, or deductible No copayment, coinsurance, or deductible No copayment, coinsurance, or deductible
No copayment, coinsurance, or deductible No copayment, coinsurance, or deductible No copayment, coinsurance, or deductible
9Health & Wellness Programs
Be your healthy best! The TLC plans include access to a host of health and wellness programs to help you manage
your health issues.
• Sydney: The Sydney mobile app acts like a personal health • MyHealth Advantage: Receive personalized health-related
guide, answering your questions and connecting you to the suggestions, tips, and reminders via mail or email to alert you
right resources at the right time. And you can use the chatbot of potential health risks, care gaps or cost-saving opportunities.
to get answers quickly. Download from the App Store (iOS) or • Staying Healthy Reminders: Receive yearly reminders of
Google Play (Android). important checkups, tests, screenings, immunizations, and
– Find care and check costs other preventive care needs for you and your family.
– View and use digital ID cards
– Check all benefits and view claims • 24/7 NurseLine & Audio Health Tape Library:
Sometimes you need health questions answered right away
• ConditionCare: Take advantage of free and confidential – even in the middle of the night. Call 24/7 NurseLine
support to manage these conditions: (800-337-4770) to speak with a nurse. Or use the Audio Health
– Asthma – High cholesterol Library if you want to learn about a health topic on your own.
– Heart failure – Coronary artery disease (CAD) Your call is always free and completely confidential.
– Diabetes – Metabolic syndrome
– Hypertension – Obesity • CommonHealth is the employee wellness program for
–C hronic obstructive The Local Choice. The main objective of CommonHealth is
pulmonary disease (COPD) to promote wellness in the workplace. Yearly programs
You may receive a call from ConditionCare if your claims cover a variety of health and wellness subjects and are
indicate you or an enrolled family member may be dealing presented in a variety of formats - including onsite programs
with one or more of these conditions. While you’re encouraged and video presentations that make it easy to participate.
to enroll and take advantage of help from registered nurses Not only are the programs educational and fun, they help
and other healthcare professionals, you may also opt out of you stay fit and healthy. For more information, visit
the program when they call. www.commonhealth.virginia.gov/tlc.
• Future Moms: Enroll and receive pre- and post-natal support.
Access a nurse coach and other maternity support specially
See more information on Health & Wellness
designed to help women have healthy pregnancies and
healthy babies. programs at www.anthem.com/tlc.
LiveHealthOnline.com Employee Assistance
LiveHealth Online lets you have a face-to-face doctor visit from
your mobile device or computer with a webcam at no cost. Go to Program (EAP)
livehealthonline.com or download the app so you’ll be ready
whenever you need these LiveHealth Online services. Your EAP gives you, your covered dependents and members of your
household up to four free confidential counseling sessions per
• LiveHealth Online Medical – Use your smartphone, tablet or issue each plan year.
computer to see a board-certified doctor in minutes, any
Turn to your EAP for information and resources about:
time, day or night. It’s a fast, easy way to get care for common
medical conditions like the flu, colds, allergies, pink eye, sinus • Emotional well-being
infections, and more. • Addiction and recovery
• Work and career
• LiveHealth Online Psychology – Use your device to make an
appointment to see a therapist or psychologist online. • Childcare and parenting
• Helping aging parents
• LiveHealth Online Psychiatry – Unlike therapists who provide • Financial issues
counseling support, psychiatrists can also provide medication (including free credit monitoring and identity theft recovery)
management. Use your device to set up a visit online. • Legal concerns
• LiveHealth Online EAP – You can access your free EAP • Smoking cessation
counseling sessions from your device. Contact your EAP to
learn more.
102021
KAISER PERMANENTE
BENEFITS SUMMARY
Effective July 1, 2021 or October 1, 2021This guide is only an overview. For a complete description of benefits, exclusions, limitations, and
reductions, please see the Kaiser Permanente Group Evidence of Coverage.
BENEFIT HIGHLIGHTS The Local Choice is a unique health benefits program managed by
the Commonwealth of Virginia Department of Human Resource
Management (DHRM). Your employer has selected the Kaiser
How The Plan Works . . . . . . . . . . . . . . . . . . . . . . . 2
Permanente plan from The Local Choice Health Benefits Program to
Summary of Benefits . . . . . . . . . . . . . . . . . . . . . . . 3 offer you and your eligible family members.
Using Your Benefits To Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.
(KFHP-MAS), is a federally qualified HMO. Health care services
The Best Advantage . . . . . . . . . . . . . . . . . . . . . . . . 5 are provided or arranged by the Mid-Atlantic Permanente Medical
Get Help in Your Language . . . . . . . . . . . . . . . . . 6 Group, P.C. (MAPMG) at one of Kaiser Permanente’s 38 medical
centers located in the Washington metropolitan area.
If You Need Assistance . . . . . . . . . . . . . . . . . . . . . 8
Access to your KP microsite:
https://my.kp.org/commonwealthofvirginia/
SERVICE AREA
Kaiser Permanente’s service area includes the District of Columbia and the following cities and counties in Virginia and Maryland:
Virginia Counties: Arlington, Caroline, Culpeper, Fairfax, Fauquier, Hanover, King George, Louisa, Loudoun, Orange, Prince William,
Stafford, Spotsylvania, Westmoreland
Cities: Alexandria, Fairfax, Falls Church, Fredericksburg, Manassas, Manassas Park
Maryland Counties: Anne Arundel, Baltimore, Calvert (partial), Carroll, Charles (partial), Frederick (partial), Harford, Howard,
Montgomery, Prince Georges
Cities: Baltimore
HOW THE PLAN WORKS
n Use your Directory of Providers to choose a convenient Kaiser Permanente medical center.
Then select a primary care physician for you and for each enrolled family member.
n Your Kaiser Permanente physician provides or arranges all services.
n Specialty care is provided on a referral basis by a MAPMG physician.
n Members make appointments directly with the Kaiser Permanente medical center by calling:
Metropolitan Washington, D.C. (703) 359-7878 or toll free at 1-800-777-7904 (TTY 711)
Outside Washington Area 1-800-777-7902
If you are registered on kp.org, you are able to make or cancel appointments.
EAP Services through Beacon Health Options (866) 517-7042 www.achievesolutions.net/kaiser
Dental Services through Dominion National 1-855-733-7524
n Outside the service area, you are covered for emergency and urgent care anywhere in the world. For information or assistance while
traveling, call the 24/7 Away from Home Travel Line at 951-268-3900 or visit kp.org/travel.
Email your doctor’s office with nonurgent questions, have a phone/video visit with your primary care physician, or connect with a
licensed care provider 24/7 for medical advice.
If you need urgent care in a state without Kaiser Permanente, go to the nearest MinuteClinic or urgent care facility. If you need
urgent care while traveling internationally, go to the nearest urgent care facility or hospital.
2 KAISER PERMANENTEKAISER PERMANENTE 2021 BENEFITS
Remember, your primary care physician must coordinate all your health care services. Your primary care physician will
refer you to a specialist if necessary. There are no benefits for services received out of your plan’s network, except for
emergency services in a life-threatening situation, and urgent care when traveling out of the area.
Covered Services You Pay
Outpatient Primary Care n Physician, x-ray, and other diagnostic services $25 copayment
Physician (PCP) Visits n Immunizations
n Pre-admission testing
n Voluntary family planning
n Laboratory, pathology, radiology, and diagnostic testing $0 copayment
Preventive Services n Periodic checkups $0
n Routine gynecological exam (Pap smear, pelvic exam, and breast exam — no referral needed)
n Well baby care and primary care services for children up to age 5 $0
n Women’s Preventive Care $0
Specialty Care Physician Visits Includes physician and outpatient facility services $40 copayment
Outpatient Surgery Free-standing ambulatory surgery center or hospital outpatient facility $75 Copayment
Inpatient Hospital Services n Includes semi-private room, intensive or coronary care unit $300 per admission
(For admissions arranged (no maximum number of days)
through your PCP and n Private room–if ordered by participating physician and
authorized by the HMO) approved by the HMO as medically necessary
n Physician services
n Surgery
n Anesthesia
n Diagnostic services such as lab and x-ray
n Blood transfusion procedures, drugs
n Physical therapy, chemotherapy, radiation therapy
Maternity Care n All routine outpatient pre- and postnatal care of the mother rendered by the OB/GYN $0
n Hospital care of mother and child $300 per admission
n Diagnostic testing (such as ultrasounds and fetal monitor procedures) $0
Emergency Services For n Hospital emergency room $75 copayment per visit
Life-Threatening Conditions (waived if admitted)
(Such as heart attacks, $40 copayment for urgent
hemorrhaging, poisoning, care center
loss of consciousness, or
convulsions — no referral needed)
Mental Health And n Outpatient visits when medically necessary Group visits - $12 copayment per visit
Substance Abuse Services Individual visits - $25 copayment
(A primary care physician per visit
referral is not needed. Instead, n Inpatient treatment when medically necessary $300 per admission
you must contact the plan n Detoxification $300 per admission
to coordinate care except in a
life-threatening situation.)
Complementary Alternative n Includes chiropractic and acupuncture services when $40 copayment per visit
Medicine medically necessary up to 30 visits
KAISER PERMANENTE 3Covered Services You Pay
Family Planning And n Sperm count 50% of allowable charges
Infertility Services n Hysterosalpinography
n Endometrial biopsy
n Vasectomy (male sterilization) $75 copayment
n IUD insertion (No charge, part of women’s health)
n Oral contraceptives (subject to prescription drug copayments)
No charge, part of women’s health
Therapy Services n Physical therapy (up to 30 visits per incident) $40 copayment
n Chemotherapy and radiation therapy $40 copayment
Skilled Care n Home health care, nursing, and other services in your home $0
n Skilled nursing facility (up to 100 days maximum per member $300 per admission
per calendar year)
Durable Medical Equipment n Rental or purchase of plan approved durable medical equipment $0
Diabetic Supplies n Diabetic Equipment and Supplies 20% of allowable charges
Prescription Drugs
Generic program (up to 30-day supply). Brand name drugs are Per prescription at a Kaiser Permanente
covered when prescribed by a physician. on-site pharmacy:
$15 generic/$25 brand formulary/
$40 non-brand formulary
When prescriptions are filled at a network pharmacy, your program Per prescription at a participating
covers the following: community pharmacy:
n Medically necessary drugs and medications prescribed by a participating physician $20 generic/$45 brand formulary/
n Any medication which by law requires a prescription, including birth control pills $60 non-brand formulary
Per prescription:
Maximum copay per 30-day supply of
insulin is $50
Specialty drugs 50% up to $75 Maximum
Mail Service Benefit n Maintenance drug prescription (up to 90-day supply for $13 generic/$23 brand formulary/
medications prescribed for 6 months or more) filled through $38 non-brand formulary
the mail service pharmacy for 2x copay.
Out-Of-Area Urgent Care n Physician’s office visit $40 copayment
(For unexpected conditions n Kaiser Permanente urgent care center/after hours care center $40 copayment
requiring immediate attention n Emergency room $75, waived if admitted
such as high fever, vomiting, or
sprains — no referral needed)
Additional Information
Lifetime maximum n None
Annual deductibles n None
n Benefits administered Per contract year
n Annual maximum out-of-pocket expense (does not include $1500 per individual
adult dental benefits, only pediatric dental benefits) $3000 per family
DENTAL
PLAN (Provided by Dominion National) You Pay
The plan pays an annual maximum of $1,000 per person for in-network services and
$500 for out-of-network services
Annual Deductible n PPO (in-network) $25 individual / $75 family
n Out-of-network $50 individual / $150 family
Diagnostic and n PPO (in-network) 0%
Preventive Services n Out-of-network 40%
Basic Services n PP0 (in-network) 20%
n Out-of-network 50%
Major Services n PP0 (in-network) 50%
n Out-of-network 65%
Orthodontics n PP0 (in-network) 50%
(age 19 and under) n Out-of-network Not covered
4 KAISER PERMANENTEUSING YOUR BENEFITS TO THE BEST ADVANTAGE
You have responsibilities to make sure that your health benefits plan works to your advantage. By following the
directions outlined below you can make sure you and enrolled family members receive the highest level of benefits.
PRIMARY CARE PHYSICIAN n You do not need a referral from your primary care physician
to receive services within the Kaiser Permanente program
You will receive comprehensive medical care primarily within for the following: OB/GYN, Optical, and Mental Health and
the Kaiser Permanente medical centers. Always contact Substance Abuse services.
your primary care physician when you or an enrolled family n If you see a provider outside of Kaiser Permanente without a
member needs care. Your primary care physician will provide referral, you will be responsible for the total cost.
or coordinate all medical services, including specialty and
inpatient care. To schedule a routine or urgent appointment
FOR LIFE-THREATENING
in metropolitan Washington, D.C., Maryland, or Virginia, call
(703) 359-7878 or toll free at 1-800-477-7904 (TTY 711).
EMERGENCIES
Outside the metropolitan Washington, D.C. area, call (such as heart attacks, hemorrhaging, poisoning, loss of
1-800-777-7902. consciousness, or convulsions)
However, there are exceptions: n Call 911 and go to the nearest emergency room for treatment.
n Contact your primary care physician as soon as possible.
n For a life-threatening emergency, call 911 and go to the nearest
emergency room for treatment. Contact your primary care
physician as soon as possible. MENTAL HEALTH AND
n For mental health or substance abuse treatment, call the SUBSTANCE ABUSE CARE
number shown on page 6 to schedule an appointment.
Before you or an enrolled family member receives inpatient,
Always remember, you pay the total cost of care when partial day, or outpatient services, you must call
services are not coordinated by your primary care Kaiser Permanente to coordinate your care:
physician or approved by the health plan.
n Behavioral Health Access Unit: 1-866-530-8778
n For Medical Emergencies (Washington, D.C.,
FOR MEDICAL, SURGICAL, OR
Maryland, and Virginia): 1-800-677-1112
HOSPITAL CARE
kp.org/selfcareapps
Always contact your primary care physician to receive medical
care. In urgent situations such as high fever, vomiting, sprains, or OUTPATIENT
broken bones, call:
PRESCRIPTION DRUGS
For appointments:
Always ask that your prescription be filled with a generic drug.
(703) 359-7878 or toll free at 1-800-777-7904 (TTY 711) —
Remember, the Kaiser Permanente plan primarily covers generic
5:30 a.m.-7:30 p.m., Monday through Friday
drugs unless your doctor requests a brand name, or a generic
7:30 a.m.-11:30 a.m., weekends and holidays
substitution is not permitted by law.
1-800-777-7902 — outside the metropolitan Washington, D.C. area.
2020 Prescription Drug Benefit:
Emergency hotline: 1-800-677-1112
n Kaiser Permanente Medical Center Pharmacy (Up to 30-Day
When your medical center is closed, call the evening and
supply)
weekend medical advice lines at:
$15 Generic/$25 Brand formulary/$40 Brand Non-formulary
(703) 359-7878 or toll free at 1-800-777-7904 (TTY 711) —
n Community Participation Pharmacy (Up to 30-Day supply)
metropolitan Washington, D.C. area
$20 Generic/$45 Brand formulary/$60 Brand Non-formulary
1-800-777-7902 — outside the metropolitan Washington, D.C. area
n Mail Order (Up to a 90-Day Supply 2x copay)
$13 Generic/$23 Brand formulary/$38 Brand Non-formulary
FOR SPECIALTY CARE
n Specialty Drug 50% up to $75 Max
Your primary care physician will refer you to a specialist as
needed. Most specialty services are provided by members of the
Kaiser Permanente medical group.
Additional Benefits include discount gym membership as well as free ClassPass, MyStrength, Calm. kp.org/selfcareapps KAISER PERMANENTE 5Get help in your language Get help in your language
Curious to know what all this says? We would be too. Here’s the English version:
Curious to know what all this says? We
This notice has important information about your application or benefits. Look for important dates. You might need to take
This notice has important information ab
action by certain dates to keep your benefits or manage costs. You have the right to get this information and help in your
action by certain dates to keep your ben
language for free. Call the Member Services number on your ID card for help. (TTY/TDD: 711)
language for free. Call the Member Serv
Spanish
Spanish
Este aviso contiene información importante acerca de su solicitud o sus beneficios. Busque fechas importantes. Podría
Este aviso contiene información importa
ser necesario que actúe para ciertas fechas, a fin de mantener sus beneficios o administrar sus costos. Tiene el derecho
ser necesario que actúe para ciertas fec
de obtener esta información y ayuda en su idioma en forma gratuita. Llame al número de Servicios para Miembros que
de obtener esta información y ayuda en
figura en su tarjeta de identificación para obtener ayuda. (TTY/TDD: 711)
figura en su tarjeta de identificación par
Amharic
ይህ ማስታወቂያ ሰለማመልከቻዎ ወይም ጥቅማ ጥቅሞችዎ ጠቃሚ መረጃ አለው። አስፈላጊ ቀኖችን ይፈልጉ። ጥቅማ ጥቅሞችዎን Amharic
ለማቆየት ወይም ክፍያዎችን
ይህ ማስታወቂያ
ለመቆጣጠር በሆነ ቀን አንድ እርምጃ መውሰድ ያስፈልግዎ ይሆናል። ይህንን መረጃ እና እገዛ በቋንቋዎ በነጻ የማግኘት መብት አልዎት። ሰለማመልከቻዎ
ለእገዛ በመታወቂያዎ ላይ ወይም
ያለውንጥቅማ ጥቅሞች
ለመቆጣጠር በሆነ ቀን አንድ እርምጃ መውሰድ ያስፈልግ
የአባል አገልግሎቶች ቁጥር ይደውሉ። (TTY/TDD: 711)
የአባል አገልግሎቶች ቁጥር ይደውሉ። (TTY/TDD: 7
Arabic
Arabic
ﻗد ﺗﺣﺗﺎج إﻟﻰ اﺗﺧﺎذ إﺟراء ﻗﺑل ﻣواﻋﯾد ﻣﺣددة ﻟﻼﺣﺗﻔﺎظ ﺑﺎﻟﻣزاﯾﺎ. اﺣرص ﻋﻠﻰ ﺗﺗﺑﻊ اﻟﻣواﻋﯾد اﻟﻣﮭﻣﺔ.ﯾﺣﺗوي ھذا اﻹﺷﻌﺎر ﻋﻠﻰ ﻣﻌﻠوﻣﺎت ﻣﮭﻣﺔ ﺣول طﻠﺑك أو اﻟﻣزاﯾﺎ اﻟﻣﻘدﻣﺔ ﻟك
ج إﻟﻰ اﺗﺧﺎذ إﺟراء ﻗﺑل ﻣواﻋﯾد ﻣﺣددة ﻟﻼﺣﺗﻔﺎظ ﺑﺎﻟﻣزاﯾﺎ
ﯾُرﺟﻰ اﻻﺗﺻﺎل ﺑرﻗم ﺧدﻣﺎت اﻷﻋﺿﺎء اﻟﻣوﺟود ﻋﻠﻰ ﺑطﺎﻗﺔ اﻟﺗﻌرﯾف اﻟﺧﺎﺻﺔ ﺑك. ﯾﺣق ﻟك اﻟﺣﺻول ﻋﻠﻰ ھذه اﻟﻣﻌﻠوﻣﺎت واﻟﻣﺳﺎﻋدة ﺑﻠﻐﺗك ﻣﺟﺎ ًﻧﺎ.أو ﻹدارة اﻟﺗﻛﻠﻔﺔ
ﺎء اﻟﻣوﺟود ﻋﻠﻰ ﺑطﺎﻗﺔ اﻟﺗﻌرﯾف اﻟﺧﺎﺻﺔ ﺑك
.(TTY/TDD:711)ﻟﻠﻣﺳﺎﻋدة
Bassa
Bassa
Bɔ̃̌ i-po-po nìà kɛ ɓéɖé bɔ̃̌ kpaɖɛ ɓá nì ɖɛ-mɔ́ -ɖìfèɖè mɔɔ kpáná-ɖɛ̀ ɓě m̀ ké dyéɛ dyí. M� mɛ mɔ́ wé kpaɖɛ ɓě dyi. Ɓɛ́ nì kpáná-ɖɛ̀
Bɔ̃̌ i-po-po nìà kɛ ɓéɖé bɔ̃̌ kpaɖɛ ɓá nì ɖɛ-m
ɓě ké m̀ xwa se mɔɔ ɓɛ́ m̀ ké píɔ́ xwa ɓɛ́ ìn nyɛɛ, ɔ mu wɛ̃̀ ìn ɓɛ́ m̀ kéɔ́ ɖɛ ɓě ti kɔ̃ nyùìn. M� ɓéɖé dyí-ɓɛ̀ ɖɛ̀ ìn-ɖɛ̀ ɔ̀ ɓɛ́ m̀ ké bɔ̃̌ nìà kɛ
ɓě ké m̀ xwa se mɔɔ ɓɛ́ m̀ ké píɔ́ xwa ɓɛ́ ìn
kè gbo-kpá-kpá dyé ɖé m̀ ɓíɖí-wùɖùǔn ɓó pídyi. Ɖá Mɛ́ ɓà jè gbo-gmɔ̀ Kpòɛ̀ nɔ̀ ɓà nìà nì Dyí-dyoìn-bɛ̃̀ ɔ̃ kɔ̃ ɛ, ɓó gbo-kpá-kpá dyé
kè gbo-kpá-kpá dyé ɖé m̀ ɓíɖí-wùɖùǔn ɓó
jè. (TTY/TDD: 711)
jè. (TTY/TDD: 711)
Bengali
Bengali
আপনার আেবদন বা সুিবধার িবষেয় এই িব�ি�িটেত গর�পূণর্ তথয্ রেয়েছ। গর�পূণর্ তািরখগিলর জনয্ েদখুন। আপনার সুিবধাগিল
আপনার আেবদন বা সুিবধার িবষেয় এই িব�
বজায় রাখার জনয্ বা খরচ িনয়�ণ করার জনয্ িনিদর্ � তািরেখ আপনােক কাজ করেত হেত পাের। িবনামূেলয্ এই তথয্ পাওয়ার ও
বজায় রাখার জনয্ বা খরচ িনয়�ণ করার জ
আপনার ভাষায় সাহাযয্ করার অিধকার আপনার আেছ। সাহােযয্র জনয্ আপনার আইিড কােডর্ থাকা সদসয্ পিরেষবা ন�ের কল করন।
আপনার ভাষায় সাহাযয্ করার অিধকার আপ
(TTY/TDD: 711)
(TTY/TDD: 711)
Chinese
Chinese
本通知有與您的申請或利益相關的重要資訊。請留意重要日期。您可能需要在特定日期前採取行動以維護您的利益或管理費
本通知有與您的申請或利益相關的重要資
用。您有權使用您的語言免費獲得該資訊和協助。請撥打您的 ID 卡上的成員服務號碼尋求協助。(TTY/TDD: 711)
用。您有權使用您的語言免費獲得該資訊
Farsi
Farsi
. ﺑﮫ ﺗﺎرﯾﺨﮭﺎی ﻣﮭﻢ دﻗﺖ ﮐﻨﯿﺪ.اﯾﻦ اﻃﻼﻋﯿﮫ ﺣﺎوی اﻃﻼﻋﺎت ﻣﮭﻢ در ﻣﻮرد درﺧﻮاﺳﺖ ﯾﺎ ﻣﺰاﯾﺎی ﺷﻤﺎ اﺳﺖ
.ﺑﮫ ﺗﺎرﯾﺨﮭﺎی ﻣﮭﻢ دﻗﺖ ﮐﻨﯿﺪ
ﻣﻤﮑﻦ اﺳﺖ ﻻزم ﺑﺎﺷﺪ در ﺑﺮﺧﯽ ﺗﺎرﯾﺨﮭﺎی ﺧﺎص اﻗﺪاﻣﯽ اﻧﺠﺎم دھﯿﺪ ﺗﺎ ﻣﺰاﯾﺎی ﺧﻮد را ﺣﻔﻆ ﮐﻨﯿﺪ ﯾﺎ
ﺰاﯾﺎی ﺧﻮد را ﺣﻔﻆ ﮐﻨﯿﺪ ﯾﺎ
ﺷﻤﺎ اﯾﻦ ﺣﻖ را دارﯾﺪ ﮐﮫ اﯾﻦ اﻃﻼﻋﺎت و ﮐﻤﮑﮭﺎ را ﺑﮫ ﺻﻮرت راﯾﮕﺎن ﺑﮫ.ھﺰﯾﻨﮫھﺎ را ﻣﺪﯾﺮﯾﺖ ﮐﻨﯿﺪ
ﻤﮑﮭﺎ را ﺑﮫ ﺻﻮرت راﯾﮕﺎن ﺑﮫ
ﺑﺮای درﯾﺎﻓﺖ ﮐﻤﮏ ﺑﮫ ﺷﻤﺎره ﻣﺮﮐﺰ ﺧﺪﻣﺎت اﻋﻀﺎء ﮐﮫ ﺑﺮ روی ﮐﺎرت.زﺑﺎن ﺧﻮدﺗﺎن درﯾﺎﻓﺖ ﮐﻨﯿﺪ
اﻋﻀﺎء ﮐﮫ ﺑﺮ روی ﮐﺎرت
.(TTY/TDD:711) ﺗﻤﺎس ﺑﮕﯿﺮﯾﺪ،ﺷﻨﺎﺳﺎﯾﯽﺗﺎن درج ﺷﺪه اﺳﺖ
French
French
Cette notice contient des informations importantes sur votre demande ou votre couverture. Vous y trouverez également
Cette notice contient des informations im
des dates à ne pas manquer. Il se peut que vous deviez respecter certains délais pour conserver votre couverture santé
des dates à ne pas manquer. Il se peut
ou vos remboursements. Vous avez le droit d’accéder gratuitement à ces informations et à une aide dans votre langue.
ou vos remboursements. Vous avez le d
Pour cela, veuillez appeler le numéro des Services destinés aux membres qui figure sur votre carte d’identification.
Pour cela, veuillez appeler le numéro de
(TTY/TDD: 711)
(TTY/TDD: 711)
German
German
Diese Mitteilung enthält wichtige Informationen zu Ihrem Antrag oder Ihren Beihilfeleistungen. Prüfen Sie die Mitteilung
Diese Mitteilung enthält wichtige Inform
auf wichtige Termine. Möglicherweise müssen Sie bis zu einem bestimmten Datum Maßnahmen ergreifen, um Ihre
auf wichtige Termine. Möglicherweise m
Beihilfeleistungen oder Kostenzuschüsse aufrechtzuerhalten. Sie haben das Recht, diese Informationen und
Beihilfeleistungen oder Kostenzuschüss
Unterstützung kostenlos in Ihrer Sprache zu erhalten. Rufen Sie die auf Ihrer ID-Karte angegebene Servicenummer für
Unterstützung kostenlos in Ihrer Sprach
Mitglieder an, um Hilfe anzufordern. (TTY/TDD: 711)
Mitglieder an, um Hilfe anzufordern. (TT
05179VAMENMUB 06/16 Notice
6 KAISER PERMANENTE 05179VAMENMUB 06/16 NoticeHindi
इस सूचना म� आपके आवेदन या लाभ� के बारे म� महत्वपूणर् जानकार� है । महत्वपूणर् �त�थयाँ दे ख�। अपने लाभ बनाए रखने या लागत
का प्रबंध करने के �लए, आपको �निश्चत �त�थय� तक कारर् वाई करने क� ज़रूरत हो सकती है । आपके पास यह जानकार� और मदद
अपनी भाषा म� मुफ़्त म� प्राप्त करने का अ�धकार है । मदद के �लए अपने ID काडर् पर सदस्य सेवाएँ नंबर पर कॉल कर� ।
(TTY/TDD: 711)
Igbo
Ọkwa a nwere ozi dị mkpa gbasara akwụkwọ anamachọihe ma ọ bụ elele gị. Chọgharịa ụbọchị ndi dị mkpa. Ị nwere ike
ịme ihe n’ụfọdụ ụbọchị iji dowe elele gị ma ọ bụ jikwaa ọnụego. Ị nwere ikike ịnweta ozi a yana enyemaka n’asụsụ gị
n’efu. Kpọọ nọmba Ọrụ Onye Otu dị na kaadị NJ gị maka enyemaka. (TTY/TDD: 711)
Korean
이 공지사항에는 귀하의 신청서 또는 혜택에 대한 중요한 정보가 있습니다. 중요 날짜를 살펴 보십시오. 혜택을 유지하거나
비용을 관리하기 위해 특정 마감일까지 조치를 취해야 할 수 있습니다. 귀하에게는 무료로 이 정보를 얻고 귀하의 언어로
도움을 받을 권리가 있습니다. 도움을 얻으려면 귀하의 ID 카드에 있는 회원 서비스 번호로 전화하십시오. (TTY/TDD: 711)
Russian
Настоящее уведомление содержит важную информацию о вашем заявлении или выплатах. Обратите внимание
на контрольные даты. Для сохранения права на получение выплат или помощи с расходами от вас может
потребоваться выполнение определенных действий в указанные сроки. Вы имеете право получить данную
информацию и помощь на вашем языке бесплатно. Для получения помощи звоните в отдел обслуживания
участников по номеру, указанному на вашей идентификационной карте.
(TTY/TDD: 711)
Tagalog
May mahalagang impormasyon ang abisong ito tungkol sa inyong aplikasyon o mga benepisyo. Tukuyin ang
mahahalagang petsa. Maaaring may kailangan kayong gawin sa ilang partikular na petsa upang mapanatili ang inyong
mga benepisyo o mapamahalaan ang mga gastos. May karapatan kayong makuha ang impormasyon at tulong na ito sa
ginagamit ninyong wika nang walang bayad. Tumawag sa numero ng Member Services na nasa inyong ID card para sa
tulong. (TTY/TDD: 711)
Urdu
ﯾہ ﻧوﮢس ٓاپ ﮐﯽ درﺧواﺳت ﯾﺎ ﻓﺎﺋدوں ﮐﮯ ﺑﺎرے ﻣﯾں اﮨم ﻣﻌﻠوﻣﺎت ﭘر ﻣﺷﺗﻣل ﮨﮯ۔ اﮨم ﺗﺎرﯾﺧﯾں دﯾﮑﮭﯾﮯ۔ اﭘﻧﮯ ﻓﺎﺋدوں ﯾﺎ ﻻﮔﺗوں ﮐو ﻣﻧظم ﮐرﻧﮯﮐﮯ ﻟﯾﮯ ٓاپ ﮐو ﺑﻌض
ﺗﺎرﯾﺧوں ﭘر اﻗدام ﮐرﻧﮯ ﮐﯽ ﺿرورت ﮨوﺳﮑﺗﯽ ﮨﮯ۔ آپ ﮐو اﭘﻧﯽ زﺑﺎن ﻣﯾں ﻣﻔت ان ﻣﻌﻠوﻣﺎت اور ﻣدد ﮐﮯﺣﺻول ﮐﺎ ﺣق ﮨﮯ۔ ﻣدد ﮐﮯ ﻟﯾﮯ اﭘﻧﮯ آﺋﯽ ڈی ﮐﺎرڈ ﭘر ﻣوﺟود
(TTY/TDD:711) ﻣﻣﺑر ﺳروس ﻧﻣﺑر ﮐو ﮐﺎل ﮐرﯾں۔
Vietnamese
Thông báo này có thông tin quan trọng về đơn đang ký hoặc quyền lợi bảo hiểm của quý vị. Hãy tìm các ngày quan trọng.
Quý vị có thể cần phải có hành động trước những ngày nhất định để duy trì quyền lợi bảo hiểm hoặc quản lý chi phí của
mình. Quý vị có quyền nhận miễn phí thông tin này và sự trợ giúp bằng ngôn ngữ của quý vị. Hãy gọi cho Dịch Vụ Thành
Viên trên thẻ ID của quý vị để được giúp đỡ. (TTY/TDD: 711)
Yoruba
Àkíyèsí yìí ní ìwífún pàtàkì nípa ìbéèrè tàbí àwọn ànfàní rẹ. Wá déètì pàtàkì. O le ní láti gbé ìgbésẹ̀ ní déètì kan pàtó láti
tọ́jú àwọn ànfàní tàbí ṣàkóso iye owó rẹ. O ní ẹ̀tọ́ láti gba ìwífún yìí kí o sì ṣèrànwọ́ ní èdè rẹ lọ́fẹ̀ẹ́. Pe Nọ́mbà àwọn ìpèsè
ọmọ-ẹgbẹ́ lórí káàdì ìdánimọ̀ rẹ fún ìrànwọ́. (TTY/TDD: 711)
It’s important we treat you fairly
That’s why we follow federal civil rights laws in our health programs and activities. We don’t discriminate, exclude people,
or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we
offer free aids and services. For people whose primary language isn’t English, we offer free language assistance services
through interpreters and other written languages. Interested in these services? Call the Member Services number on your
ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color,
national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with
our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond,
VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at
200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019
(TDD: 1- 800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf. Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
05179VAMENMUB 06/16 Notice KAISER PERMANENTE 7NOTE: This is a brief summary of benefits. For
a complete description of the plan, refer
IF YOU NEED ASSISTANCE
to your Kaiser Permanente Member Member Services (301) 468-6000
Handbook. These handbooks are available 1-800-777-7902 outside Washington, D.C. area
from your Benefits Administrator, or may
be obtained by calling Kaiser Permanente Appointments and (703) 359-7878
directly. or toll free at 1-800-777-7904 (TTY 711)
Medical Advice 1-800-777-7902 outside Washington, D.C. area
Dental Benefit Provider Dominion National: 1-855-733-7524
Mental Health And
Substance Abuse Care 1-866-530-8778
Employee Assistance Beacon Health Options: (866) 517-7042
Program (EAP) www.achievesolutions.net/kaiser
A10511 (12/2020)Your Advantage 65
Dental/Vision Benefits
Medical, Dental and Vision administered by
Anthem Blue Cross and Blue Shield
Effective January 1, 2021 - December 31, 2021The Local Choice is a unique health benefits program managed by the Commonwealth
of Virginia Department of Human Resource Management (DHRM). The Advantage 65 with
Dental/Vision plan may be offered to you if you are eligible for Medicare and to your
Medicare-eligible family members by your group. Benefits are administered on a calendar
year basis to coincide with your Medicare coverage. Changes in your monthly premium
are effective July 1 (or October 1 for certain school groups) to coincide with your former
employer’s The Local Choice (TLC) health plan renewal.
The Advantage 65 with Dental/Vision plan provides medical benefits that work with Medicare
Part A and Part B. It does not provide prescription drug coverage.
This guide is only an overview. For a complete description of the benefits, exclusions,
limitations, and reductions, please see the TLC Medicare Coordinating Plans Member
Handbook.
Service Area
Wherever retirees live.
Medical Benefits
To receive full benefits you must be enrolled under both Part A and Part B of Medicare.
Always show both your Medicare card and your Anthem identification card when you
receive care.
Advantage 65 covers the Medicare Part A hospital deductible (after you pay $100) and
copayment amounts, and the Part B coinsurance for Medicare-approved charges. It also
covers out-of-country Major Medical services.
Choose Healthcare Providers Carefully
Physicians
Ask your doctor if he or she is a Medicare participating physician. A
doctor who participates in Medicare agrees to:
n File claims on your behalf
n Accept Medicare’s payment for covered services
This means your coinsurance is limited to a percentage of the
Medicare-approved charge. Go to Medicare.gov for additional
information about Medicare-participating physicians.
This brochure describes benefits based on Medicare-approved charges. Doctors who
do not accept assignments may not charge you any more than 15% above what Medicare
considers a reasonable fee. This applies to all doctors and all services.
Hospitals
Hospitals that participate in the Medicare program are covered.
Admissions not approved by Medicare are not covered.
2 Advantage 65 with Dental/VisionAdvantage 65
What The Plan Covers
Plan Pays
PART A SERVICES
Hospital Inpatient n Medicare Part A hospital deductible less $100 per benefit period, days 1-60 In full
nM
edicare Part A daily hospital copayment amount, days 61-90 In full
n 100% of the allowable charge*, for eligible expenses for an additional 365 days. In full
nC
opayment amount for Medicare Lifetime Reserve Days (60 days available) In full
Skilled Nursing Facility n Medicare Part A skilled nursing facility copayment, days 21-100 In full
(Medicare covers days 1-20 in full.)
nA
daily amount equal to Medicare skilled nursing home copayment, In full
days 101-180 (Medicare provides no coverage beyond 100 days.)
Plan Pays
PART B SERVICES
Physician And Other Services n Part B coinsurance of Medicare-approved charges for services such as: In full
(after you pay the Medicare • Doctor’s care
Part B calendar year • Surgical services
deductible) • Outpatient x-ray and lab services
• Professional ambulance service
AT HOME n At-home recovery care for an illness or injury approved under a Medicare Up to $40 per
RECOVERY SERVICES home health treatment plan. Benefits include: visit (limited
•H ome visits up to the number approved by Medicare, not to exceed to $1,600 per
7 visits per week (This benefit applies to home health services, certified calendar year)
by a physician, for personal care during the recovery period)
Plan Pays
OUT-OF-COUNTRY
MAJOR MEDICAL
SERVICES n Lifetime maximum $250,000
(after you pay $250
n Annual restoration of lifetime maximum (limited to the amount of benefits $2,000
calendar year deductible)
used in any one year)
Covered Services n Medically necessary services received in a foreign country 80% AC*
Out-Of-Pocket Expense Limit n In a calendar year when your out-of-pocket expenses for covered services
reach $1,200, the plan pays 100% of the allowable charge for the rest of the
calendar year.
*Allowable Charge (AC) — The term has two meanings, depending on whether the service is provided by a doctor (or
other healthcare professional) or a hospital. For care by a doctor or other healthcare professional, the allowable charge is
the lesser amount of your plan’s allowance for that service, or the provider’s charge for that service. For hospital services,
the allowable charge is the amount of the negotiated compensation to the facility for the covered service or the facility’s
charge for that service, whichever is less. For complete information about the allowable charge, please see the Medicare
Coordinating Plans Member Handbook.
Advantage 65 with Dental/Vision 3Dental/Vision Benefits
Dental Benefits
The plan pays up to $1,500 per member per calendar year. It also pays 100% of the
allowable charge for diagnostic and preventive services, such as oral examinations and
dental x-rays. It pays 80% of the allowable charge for basic services, such as fillings,
re-cementing of crowns, inlays and bridges, or repair of removable dentures. The
remaining 20% is your responsibility. The plan also pays 5% for major services such as
crowns, dentures, and implants.
When you need services, simply present your plan identification card to your dentist. If you go to an Anthem Dental
Complete network dentist, you will be responsible only for your coinsurance. If services are provided by a non-network
dentist, you pay your coinsurance, plus the difference, if any, between the plan’s allowable charge for a covered service
and the dentist’s charge. Network dentists are listed on the Web at www.anthem.com/tlc, or call Anthem Dental Complete
at 1-855-648-1411 to determine if a dentist is in the network.
Plan Pays $1,500 Maximum Per Person Per Calendar Year In-Network You Pay
Diagnostic And Twice-a-year visits to the dentist for oral examinations, $0
Preventive Services x-rays, and cleanings
Basic Dental Care Fillings, oral surgery, periodontal services, scaling, 20% AC**
repair of dentures, root canals and other endodontic services,
and recementing of existing crowns and bridges
Major Dental Care Crowns (single crowns, inlays and onlays), prosthodontics 95% AC**
(partial or complete dentures and fixed bridges) and dental implants.
Out-Of-Network Care For services by a non-network dentist, you pay the applicable coinsurance plus any amounts
above the allowable charge.
**Allowable Charge (AC) — The allowable charge is the lesser amount of the Anthem Dental Complete plan allowance for
that covered service, or the provider’s submitted charge for that covered service. Participating Anthem Dental Complete
dentists have agreed to accept Anthem’s payment, plus any required coinsurance (if applicable) as payment in full for
covered benefits..
Routine Vision Benefits
Your routine vision benefits are through the Anthem Blue View Vision network. Available once per calendar
year, your vision benefits include a routine eye exam, eyewear and special eye accessory discounts. You may
receive services from any ophthalmologist, optometrist, optician and/or retail location in the Anthem Blue
View Vision network.
To locate an Anthem Blue View Vision provider, select Find A Doctor at www.anthem.com/tlc, or contact Member
Services at 800-552-2682 for assistance. To receive vision services, simply present your Anthem identification card to
your Blue View Vision provider when you receive your eye exam or purchase covered eyewear. Your Blue View Vision
provider will verify eligibility and file your claims.
While some vision benefits are also covered out-of-network, you will receive the
most value when you choose a Blue View Vision provider. If you use an out-of-
network provider, your benefits will be covered at a lower payment level. You will
need to pay for covered services and purchases at the time of your visit and send
an out-of-network claim form to Blue View Vision. The claim form is available at
anthem.com/tlc under Forms.
Certain non-routine vision care such as eye surgery may be covered under your
primary medical coverage under your Medicare plan. Refer to your Medicare and
You Handbook or contact Medicare for more information.
4 Advantage 65 with Dental/VisionVision Benefits Highlights
Routine vision care services In-Network You Pay
Routine eye exam (once per calendar year) $20 copayment
Eyeglass frames
Once per calendar year you may select any eyeglass frame1 and receive the following $100 allowance then 20% off
allowance toward the purchase price: remaining balance
Standard Eyeglass Lenses
Polycarbonate lenses included for children under 19 years old.
Once per calendar year you may receive any one of the following lenses:
n Standard plastic single vision lenses (1 pair) $20 copay; then covered in full
n Standard plastic bifocal lenses (1 pair) $20 copay; then covered in full
n Standard plastic trifocal lenses (1 pair) $20 copay; then covered in full
n Standard progressive lenses (1 pair) $85 copay; then covered in full
Upgrade Eyeglass Lenses (available for additional cost) Lens options Member cost for upgrades
When receiving services from a Blue View Vision n UV coating $15
provider, you may choose to upgrade your new n Tint (solid and gradient) $15
eyeglass lenses at a discounted cost. Eyeglass lenses n Standard scratch resistance $15
copayment applies, plus the cost for the upgrade. n Standard polycarbonate $40
n Standard anti-reflective coating $45
n Other add-ons and services 20% off retail price
Contact lenses Lens options
Prefer contact lenses over glasses? You may choose n Elective conventional lenses2 $100 allowance then 15% off
to receive contact lenses instead of eyeglasses the remaining balance
(frames and lenses) and receive an allowance n Elective disposable lenses2 $100 allowance (no additional
toward the cost of a supply of contact lenses once discount)
per calendar year. n Non-elective contact lenses2 $250 allowance (no additional
discount)
1 Discount is not available on certain frame brands in which the manufacturer imposes a no-discount policy.
2 Elective
contact lenses are in lieu of eyeglass lenses. Non-elective lenses are covered when glasses are not an option for
vision correction.
Options For Prescription Drug Coverage—
Medicare Part D
If you want prescription drug coverage, you must enroll in a
separate Medicare Part D prescription drug plan.
Several Medicare Part D plan options are being offered. To determine
what drug coverage option best meets your needs, consult the
Medicare and You Handbook, call 1-800-MEDICARE (1-800-633-4227)
or visit the Medicare Web site at www.medicare.gov.
Advantage 65 with Dental/Vision 5You can also read
