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SBC_GRP_14349424_9
747095695
SBC_GRP
SBCGRP_00101
en
DUPLEX
2.11
Covered
Not Applicable Individual / Not Applicable Family
Not Applicable Individual / Not Applicable Family
No Maximum Individual / No Maximum Family
None
$2500 person/$7500 family (3 or more members)
Not Applicable Individual / Not Applicable Family
No
No
Covered
false
NO_INPUT_ZIP_NO_INPUT_STATE_AND_NO_INPUT_CITY(111)
Covered
Not Covered
Not Covered
01/01/2022
12/31/2022
Not Covered
Individual / Family
Not Applicable
1-808-432-5955 (Oahu) or 1-800-966-5955 (Neighbor Islands)
www.kp.org
10/22/2021
none
None
Delivery: No Charge.
Not Covered
10% coinsurance, newborn inpatient
Delivery: No Charge.
Not Covered
10% coinsurance, newborn inpatient
No coverage for Dental Check-up
Not Covered
Not Covered
300
900
No
0
0
No
6200
1,200
coinsurance
10%
copayment
$15
$0
copayment
$15
Lab: 20% coinsurance (specialty); Inpatient fee included in Hospital stay;
Lab: $15/day (basic); Xray: $15/day
Not Covered
No
20% for all other equipment
50% coinsurance diabetes equipment
Not Covered
Covered under HMO benefit
Must notify KP within 48 hours if admitted to a non plan provider; Limited to initial emergency only
$100/visit
Covered under HMO benefit
Covered under HMO benefit
None
20% coinsurance
Covered under HMO benefit
Premiums, health care this plan doesn't cover, and services indicated in chart starting on page 2.
None
\\cs.msds.kp.org\KPCTINAS\NA\DMSNASProd\psp\mapperinput\SBC_GRP\SBC_GRP_HAW_20211023034810.txt
Only 1 annual visit for eye exam covered at no charge. Hardware limited to 1 frame and lenses (selected styles), or 1 set of contacts per contract period.
No Charge
Not Covered
7,500
pdf
200
200
No
0
coinsurance
10%
0
No
copayment
$15
$0
1,500
copayment
$15
400
$3 Maintenance Generic. Up to 30-day retail or 90-day mail order. No charge contraceptives in accordance with formulary guidelines. Certain drugs may be covered at a different cost share.
$10 retail; $20 mail order/prescription
Not Covered
1-808-432-5955 (Oahu) or 1-800-966-5955 (Neighbor Islands)
4595
ASSOCIATION OF UNIVERSITIES
No coverage for habilitation
Not covered
Not Covered
No
TRUE
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
No
Yes
No
Yes
Covered
Physician visit covered at primary care visit copay
No Charge
Not Covered
Includes two 90-day periods, followed by unlimited number of 60-day periods
No Charge
Not Covered
No
None
20% coinsurance
Not Covered
Covered
10% coinsurance
Not Covered
None
Not Covered
None
10% coinsurance
Yes
No
Yes
No
Kaiser Permanente
en
BATCH
Small
Not Covered
10/22/2021
October 22, 2021
SBC_GRP
-
letter_en1
0
10
No
0
coinsurance
10%
0
No
copayment
$15
$0
12790
copayment
$15
10
10% coinsurance
Not Covered
None
$15/visit
Not Covered
None
No
None
Not Covered
Up to 30-day retail or 90-day mail order. No charge contraceptives in accordance with formulary guidelines. Certain drugs may be covered at a different cost share.
$45 retail; $90 mail order/prescription
Not Covered
BETS
embedded
None
Not Applicable Individual / Not Applicable Family
Not Applicable Individual / Not Applicable Family
None
Not Applicable Individual / Not Applicable Family
Not Applicable Individual / Not Applicable Family
None
Not Applicable Individual / Not Applicable Family
Not Applicable Individual / Not Applicable Family
$20/visit for chiro, acupuncture & massage
Not Covered
Limited to 12 combined visits/calendar year from American Specialty Health Network
10% coinsurance
Not Covered
None
10% coinsurance
Not Covered
None
Not Covered
Not Covered
2,500
R.A.S. -- 2021 KPLG PACKAGE KP HAWAII 320 CALENDAR YEAR
01/01/2022
12/31/2022
5567760
HMO Group Plan
Up to 30-day retail or 90-day mail order. No charge contraceptives in accordance with formulary guidelines. Certain drugs may be covered at a different cost share.
$45 retail; $90 mail order/prescription
Not Covered
Depending on the type of services, a copayment, coinsurance, or deductible may apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound.)
No Charge/Confirmed pregnancy
Not Covered
www.kp.org/formulary
No charge for immunizations; No Charge
Not Covered
You may have to pay for services that aren't preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.
Not Covered
None
$15/visit
N
Not Covered
HMO
1-808-432-5955 (Oahu) or 1-800-966-5955 (Neighbor Islands)
www.kp.org
BATCH
Bi-Fold
1992281
HAW
HAW
None
10% coinsurance (inpatient); $15/visit (outpatient)
Not Covered
HAW
1-866-444-3272 or 1-877-267-2323 x61565
Not Covered
Covered
None
No Charge
Not Covered
Not Covered
Not Covered
No
4595/001 1992281 5567760
HI:NPP:20211022204752
3
Renewal
0
Acupuncture (Limited to 12 combined visits/calendar year from American Specialty Health Network)^Bariatric Surgery^Chiropractic Care (Limited to 12 combined visits/calendar year from American Specialty Health Network)^Hearing Aids (Every 3 years)^Infertility Treatment^Routine eye care (Adult)
Children’s dental check-up^Cosmetic Surgery^Dental care (Adult)^Habilitation services^Long-Term/Custodial Nursing Home Care^Non-Emergency Care when Travelling Outside the U.S.^Private-Duty Nursing^Routine Foot Care^Weight Loss Programs
Limited to 120 days/benefit period
10% coinsurance
Not Covered
SBC_GRP_HAW_20211023034810.txt
None
$15/visit
Not Covered
Up to 30-day retail. No charge contraceptives in accordance with formulary guidelines. Certain drugs may be covered at a different cost share.
$200 retail prescription
Not Covered
HI
1-866-444-3272
www.dol.gov/ebsa
001
10% coinsurance
Not Covered
None
$15/visit
Not Covered
None
Y
10/21/2021
Quote
1-877-447-5990
Written approval is required to see most specialists.
Covered under HMO benefit
None
$15/visit; $15 IN-AREA / 20% coinsurance (out of area)
Covered under HMO benefit
Yes
N
Not Covered
2021-10-22T21:00:50-08:00
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