Retiree Health Summary Plan Description
As of February 1, 2018
En Español (PDF)

2.2 Summary of Benefits

2.2.1 Early Retirees (Under Age 62 and not eligible or enrolled in Medicare)

Summary of Benefits for Early Retirees (Under Age 62 and not eligible or enrolled in Medicare)
Kaiser Permanente HMO
(In Network Only)		 UnitedHealthcare HMO
(In Network Only)		 Out-of-Area Plan UnitedHealthcare
(In Network Benefits)
Member Customer Service Number (800) 464-4000 (800) 624-8822 Northern California (800) 624-8822
Out-of-state
(866)633-2446
Website www.kp.org www.myuhc.com www.myuhc.com
General Features  
Calendar Year Deductible None None $500 per Individual
$1,000 per Family
Maximum Benefits Unlimited Unlimited Unlimited
Annual Co-payment Maximum $1,500 per Individual
$3,000 per Family		 $1,000 per Individual
$3,000 per Family		 $4,500 per Individual
$9,000 per Family
Hospital Benefits No charge No charge 80% after deductible has been met
Emergency Services
Co-payment waived if admitted		 $5 co-payment $50 co-payment $100 co-payment; deductible does not apply
Urgently Needed Services
Medically Necessary services required outside geographic area service by Primary Medical Group		 $5 co-payment $50 co-payment $50 co-payment; deductible does not apply
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 No charge 80% after deductible
Mental Health Services
As required by law, coverage includes treatment for Severe Mental Illness of adults and the treatment of Serious Emotional Disturbance.		 No charge No charge 80% after deductible
Physician Care No charge No charge No charge
Reconstructive Surgery No charge No charge 80% after deductible
Rehabilitative Care
Including physical, occupational and speech therapy		 No charge No charge $20 co-payment
Skilled Nursing Facility
Up to 100 Consecutive Days from the first treatment per disability		 No charge No charge 80% after deductible
Outpatient Benefits  
Alcohol, Drug or Other Substance Abuse Detoxification $5 per visit No charge $20 co-payment
Ambulance No charge No charge 80% after deductible
Durable Medical Equipment No charge No charge 80% after deductible
Voluntary Termination of Pregnancy (medical, medication, surgical):
1st Trimester		 $5 co-payment $75 co-payment The amount you pay is based on where the covered service is provided.
Laboratory Services
When available through or authorized by PCP		 No charge No charge No charge
Maternity Care, Tests Procedures No charge No charge The amount you pay is based on where the covered service is provided.
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)		 $5 co-payment $5 co-payment $20 co-payment
Oral Surgery Services
No dental		 No charge No charge $40 co-payment
Outpatient Medical Rehabilitation Therapy at a Participating Free-Standing or Outpatient Surgery Facility $5 co-payment $5 co-payment $20 co-payment
Outpatient Surgery at a Participating Free-Standing or Outpatient Surgery Facility $5 co-payment No charge 80% after deductible
Preventative Care
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 provider		 $5 co-payment No charge No charge
Physician Office Visit $5 co-payment $5 co-payment $20 co-payment for Primary Care Physician;
$40 co-payment for Specialist
Well-Woman Care
Includes PAP smear by PCP or an OB/GYN in PMG and a referral by the PMG for screening mammography as recommended by the U.S. Preventive Services Task Force		 $5 co-payment No charge No charge

2.2.2 Medicare Eligible Retirees (Enrolled in Medicare Parts A and B)

Summary of Benefits for Medicare Eligible Retirees (Enrolled in Medicare Parts A & B)
Kaiser Permanente
Senior Advantage
HMO		 UnitedHealthcare® Group Medicare Advantage HMO Out-of-Area Plan UnitedHealthcare® Group Medicare Advantage
Member Customer Service Number (800) 464-4000 (800) 457-8506 (800) 457-8506
Website www.kp.org www.uhcretiree.com www.uhcretiree.com
General Features  
Calendar Year Deductible None None None
Maximum Benefits Unlimited Unlimited Unlimited
Annual Co-Payment Maximum $1,500 per Individual
$3,000 per Family		 $6,700 $6,700
Hospital Benefits No charge No charge No charge
Emergency Services
Co-payment waived if admitted		 $5 co-payment $20 co-payment $20 co-payment
Urgently Needed Services
Medically Necessary services required outside geographic area service by Primary Medical Group		 $5 co-payment $15 co-payment $15 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 No charge 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 No charge No charge
Physician Care No charge No charge No charge
Reconstructive Surgery No charge No charge No charge
Rehabilitative Care
Including physical, occupational and speech therapy		 No charge No charge No charge
Skilled Nursing Facility
Up to 100 Consecutive Days from the first treatment per disability		 No charge No charge up to 100 days No charge up to 100 days
Outpatient Benefits  
Alcohol, Drug or Other Substance Abuse Detoxification $5 per individual visit
co-payment
$2 per group visit
co-payment		 $5 co-payment $5 co-payment
Ambulance No charge No charge No charge
Durable Medical Equipment No charge No charge 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		 $5 co-payment $5 co-payment
Oral Surgery Services
No dental		 No charge No charge No charge
Outpatient Medical Rehabilitation Therapy at a Participating Free-Standing or Outpatient Surgery Facility $5 co-payment No charge No charge
Outpatient Surgery at a Participating Free-Standing or Outpatient Surgery Facility $5 co-payment No charge No charge
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 No charge No charge
Physician Office Visit $5 co-payment $5 co-payment $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 No charge No charge
Prescription Drugs  
Retail Pharmacy: Generic Drugs $5 co-payment
Up to a 100-day supply		 $5 co-payment
Up to a 30-day supply		 $10 co-payment
Up to a 30-day supply
Retail Pharmacy: Brand Retail Drugs $15 co-payment
Up to a 100-day supply		 $15 co-payment
Up to a 30-day supply		 $20 co-payment
Up to a 30-day supply
Mail Order: Generic Drugs $5 co-payment
Up to a 100-day supply		 $10 co-payment
Up to a 30-day supply		 $20 co-payment
Up to a 90-day supply
Mail Order: Brand Name Drugs $15 co-payment
Up to a 100-day supply		 $30 co-payment
Up to a 30-day supply		 $40 co-payment
Up to a 90-day supply
 

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