INSURANCE RATES & COVERAGE

Here your current 2011-2012 Health Insurance Rates & Coverage Information

Age	EE only		EE+S		EE+C		EE+S+C
up to 29	$263	$30.58	$735	$139.73	$723	$136.73	$1023	$206.65
30-39	$291	$33.81	$790	$149.19	$744	$138.35	$1131	$228.35
40-49	$375	$43.5	$863	$156.35	$713	$121.5	$1139	$220.50
50-54	$488	$56.54	$1015	$178.38	$805	$129.69	$1297	$244.38
55-59	$617	$71.42	$1296	$228.35	$922	$141.81	$1491	$273.81
60-64	$761	$88.04	$1446	$246.35	$1018	$147.35	$1688	$302.65
65+	$863	$99.81	$1865	$331.27	$1298	$200.19	$2050	$374.4

247 Delivers pays 50% of the eligible employee only. Total Monthly Rate Employee wkly portion

EE only = eligible employee only EE+S = eligible employee plus spouse EE+C = eligible employee plus children without spouse EE+S+C = eligible employee plus spouse and children

Current employees can only enroll or make changes in the month of September. Changes will take affect October 1st. Please do not let this opportunity pass by. We do try to keep this page up to date, but please check with Kaiser for your Features, Co-Pays, Deductibles, ect.

FEATURES
MEDICAL CALENDAR-YEAR DEDUCTIBLE	$0
PHARMACY CALENDAR-YEAR DEDUCTIBLE	$250 for brand prescriptions
ANNUAL OUT-OF-POCKET MAXIMUM1 Individual/Family	$3,000/$6,000
IN THE MEDICAL OFFICE
Office visits	$30
Preventive exams	$30
Maternity/prenatal care2	$0
Well-child preventive care visits3	$0
Vaccines (immunizations)	$0
Allergy injections	$5
Infertility services	Not covered
Occupational, physical, and speech therapy	$30
Most labs and imaging	$10
MRI/CT/PET	$50
Outpatient surgery	$200
Chiropractic care	$15 20-visits per year
EMERGENCY SERVICES
Emergency Department visits (waived if admitted directly to hospital)	$100
Ambulance	$75
PRESCRIPTIONS4	(up to a 100-day supply)
Generic	$10
Brand	$35 (after pharmacy deductible)
HOSPITAL CARE
Physicians services, room and board, test, medications, supplies, therapies	$400 per day
Skilled nursing facility care (up to 100 days per benefit period)	$0
MENTAL HEALTH SERVICES6
In the medical office (up to 20 visits per calendar year)	$30 individual $15 group
In the hospital (up to 30 days per calendar year)	$400 per day
CHEMICAL DEPENDENCY SERVICES
In the medical office	$30 individual
In the hospital (detoxification only)	$400 per day
OTHER
Certain durable medical equipment (DME) DME used in the home in accord with our DME formulary	Not covered7
Optical (eyewear)	Not covered
Vision exam	$30
Home health care (up to 100 two-hour visits per calendar year)	$0
Hospice care	$0

1The annual out-of-pocket maximum is the limit to the total amount that an individual or family must pay for certain services in a calendar year (as discussed int the Evidence of Coverage).

2Scheduled prenatal visits and the first postpartum visit.

323 months or younger.

4Prescription drugs are covered in accord with our formulary when prescribed by a plan physician and obtained at Plan pharmacies. A few drugs have different copayments; please refer to the Evidence of Coverage for detailed information about prescription drug copayments.

5This service is not subject to a deductible.

6Visit or day limits do not apply to serious emotional disturbances of children and severe mental illnesses as described in the Evidence of Coverage.

7Please refer to the Evidence of Coverage for more information; most DME is not covered.