Retiree Health Plan Benefit Tabs™

This is a summary of benefits and not a substitute for the Southern California IBEW-NECA Retiree Health Plan Summary Plan Description, and to the extent it differs from the SPD, the terms of the SPD will govern.


Overview
 

Early Retirees who elect Kaiser have the same hospital and medical benefits as active participants. (See the Active Health BenefitTab for Kaiser.) Prescription drugs must be obtained only from Kaiser pharmacies. Please refer to the description provided below.

Participants on Medicare Parts A & B who elect the Kaiser Senior Advantage program have benefits, including prescription coverage, as described below.

General Features
 
Calendar Year Deductible None
Maximum Benefits Unlimited
Annual Co-Payment Maximum $1,500 per Individual
$3,000 per Family
Hospital Benefits No charge
Emergency Services
Co-payment waived if admitted
$5 co-payment
Urgently Needed Services
Medically Necessary services required outside geographic area service by Primary Medical Group
$5 co-payment
Pre-existing Conditions All Medically Necessary conditions are covered provided they are a covered benefit.
Inpatient Hospital Benefits
 
Alcohol, Drug or Other Substance Abuse Detoxification No charge
Mental Health Services
As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and the treatment of Serious Emotional Disturbance (SED)
No charge
Physician Care No charge
Reconstructive Surgery No charge
Rehabilitative Care
Including physical, occupational and speech therapy
No charge
Skilled Nursing Facility
Up to 100 Consecutive Days from the first treatment per disability
No charge
Outpatient Benefits
 
Alcohol, Drug or Other Substance Abuse Detoxification $5 per individual visit
co-payment
$2 per group visit
co-payment
Ambulance No charge
Durable Medical Equipment No charge
Mental Health Services
As required by law, coverage includes treatment for Severe Mental Illness of adults and the treatment of Serious Emotional Disturbance
$5 per individual visit
co-payment
$2 per group visit
co-payment
Oral Surgery Services
No dental
No charge
Outpatient Medical Rehabilitation Therapy at a Participating Free-Standing or Outpatient Surgery Facility $5 co-payment
Outpatient Surgery at a Participating Free-Standing or Outpatient Surgery Facility $5 co-payment
Periodic Health Evaluations
Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics, Advisory Committee on Immunization Practices and U.S. Preventive Services Task Force and authorized through the patient's primary care physician
$5 co-payment
Physician Office Visit $5 co-payment
Well-Woman Care Office Visit
Includes PAP smear by PCP or an OB/GYN in Primary Medical Group and a referral by the Primary Medical Group for screening mammography as recommended by the U.S. Preventive Services Task Force
$5 co-payment
Prescription Drugs
 
Retail Pharmacy: Generic Drugs $5 co-payment
Up to a 100-day supply
Retail Pharmacy: Brand Retail Drugs $15 co-payment
Up to a 100-day supply
Mail Order: Generic Drugs $5 co-payment
Up to a 100-day supply
Mail Order: Brand Name Drugs $15 co-payment
Up to a 100-day supply
Self-Pay Rates - 2020
(1/1/20-12/31/20)
 

Plan

Early Retiree
(No Medicare Coverage)

Medicare Eligible
(Enrolled in Medicare Parts A & B)

 

One Early Retiree & One Medicare

Kaiser HMO
     
Retiree Only $170 Not Applicable Not Applicable

Retiree and Spouse

$339
Senior Advantage
     
Retiree Only Not Applicable $78 Not Applicable

Retiree and Spouse

$156

Retiree & Spouse

Not Applicable Not Applicable $247
Additional Information
 
Member Customer Service Number (800) 464-4000
Website www.kp.org
Evidence of Coverage (EOC)
Early Retiree Kaiser Permanente Health Plan – Evidence of Coverage – Early Retirees
Medicare Eligible Retirees (Enrolled in Medicare Parts A & B)

Kaiser Permanente Health Plan – Evidence of Coverage – Retiree

Kaiser Permanente Health Plan - Delta Care Senior Advantage - Evidence of Coverage (Retirees)