Page 1 Page 2 Page 3 Page 4 Page 5 Page 6 Page 7 Page 8 Page 9 Page 10 Page 11 Page 12 Page 13 Page 14 Page 15 Page 16 Page 17 Page 18 Page 19 Page 20 Page 21 Page 22 Page 23 Page 24 Page 25 Page 26 Page 27 Page 28 Page 29 Page 30 Page 31 Page 32 Page 33 Page 34 Page 35 Page 36 Page 37 Page 388 Copays: PCP Specialists Deductibles Out-of-Pocket Maximum Child Preventive Visits Adult Preventive Visits Physician Office Visit (PCP) Sickness and Injury Specialist Office Visit Sickness and Injury Routine Gynecological Exam Mammogram Screening Cancer Screenings, Prostate, PAP, Colorectal Allergy – Office Visit Allergy Testing Allergy Injections Inpatient Hospital/ Facility Hospital Services Skilled Nursing Facility Inpatient Professional Services–Medical Physician Services Surgery, Anesthesia Diagnostic Radiology & Pathology Physical Therapist Services Plan Benefits $25 $30 N/A $2,500 Individual $5,000 Family Covered at 100%. Covered at 100%. Covered at 100% after PCP copay. Covered at 100% after Special- ist copay (non-routine care). Covered at 100%. Covered at 100% for routine screenings. Covered at 100% for routine screenings. Diagnostic Lab covered at 100%. Covered at 100% after applicable PCP or Specialist copay. Covered at 100% after applicable PCP or Specialist copay. Covered at 100% after applicable PCP or Specialist copay. Covered at 100%. Covered at 100%; (Limited to 60 combined days per benefit year). Covered at 100%. Covered at 100%. Covered at 100%. Please see Outpatient Rehabilitation Services. UnitedHealthcare Choice Plus POS In-Network N/A $300 Individual $600 Family $2,500 Individual $5,000 Family Covered at 70% of Plan Allowance through age 18. Not subject to deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance. Not Subject to deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible; (Limited to 60 combined days per benefit year). Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Covered at 70% of Plan Allowance after deductible. Please see Outpatient Rehabilitation Services. UnitedHealthcare Choice Plus POS Out-of-Network $20 $25 N/A $2,000 Individual $4,500 Family Covered at 100%. Covered at 100%. Covered at 100% after PCP copay. Covered at 100% after Special- ist copay (non-routine care). Covered at 100%. Covered at 100% for routine screenings. Covered at 100% for rou- tine screenings. Diagnostic Lab covered at 100%. Covered at 100% after applicable PCP or Specialist copay. Covered at 100% after applicable PCP or Specialist copay. Covered at 100% after applicable PCP or Specialist copay. Covered at 100%. Covered at 100%; (Limited to 60 days per benefit year). Covered at 100%. Covered at 100%. Covered at 100%. Please see Outpatient Rehabilitation Services. UnitedHealthcare Select EPO In-Network Only $20 $25 Requires PCP & referrals. N/A $3,500 Individual $9,400 Family $0 Well Child Exams / Immunizations. $0 copay for exam / Immunizations. PCP copay; waived for children under age 5. Specialist copay. Covered at 100%. Covered at 100%. Covered at 100%. $20 copay PCP/ $25 copay Specialist. $20 copay PCP/ $25 copay Specialist. $20 copay. Covered at 100%. Covered at 100% when deemed medically neces- sary; (Limited to 100 days per contract year). Covered at 100%. Covered at 100%. Covered at 100%. Covered at 100%. Kaiser Permanente HMO In-Network Only 2017 Non-Medicare Medical Summary of Services This is a summary of health care benefits. In the event of a difference between this summary and the plan brochure, the plan brochure will govern. PLEASE NOTE: Copay (copayment) charges are PER VISIT unless specified otherwise. This chart does not apply to Medicare Eligible members. Please see pages 19–23 for Medicare Supplement Plan details. ———­ ——————— No PCP or referrals required. ———­ ———————