MMC Benefits Handbook
The Medical Plan Options at a Glance
The chart below outlines some important Plan features and coverage information that distinguish the four medical plan options available only to residents of California (CA), Colorado (CO), Georgia (GA), Maryland (MD), Virginia (VA), Oregon (OR), Washington (WA) and Washington D.C. (DC). Additional information is provided throughout this section of the Benefits Handbook, as well as in the Kaiser Permanente Evidence of Coverage available on Colleague Connect (https://mmcglobal.sharepoint.com/sites/home). Select Pay & Benefits, under Find a document, select Search all documents.
Please note: The Evidence of Coverage is the binding document between Kaiser Permanente and its members. A Plan physician must determine that the services and supplies are medically necessary to prevent, diagnose, or treat your medical condition. The services and supplies must be provided, prescribed, authorized, or directed by a Plan physician. You must receive the services and supplies at a Plan facility or skilled nursing facility inside our Service Area, except where specifically noted to the contrary in the Evidence of Coverage. For details on the benefit and claims review and adjudication procedures, please refer to Kaiser Permanente's Evidence of Coverage. If there are any discrepancies between benefits included in this Benefits Handbook section and the Evidence of Coverage (EOC), the EOC will govern.
For example: If you are enrolled with family coverage in the $1,500 Deductible Plan in California, your individual deductible will be limited to $2,800 ($3,000 for other regions) and your individual out-of-pocket maximum will be limited to $3,000 ($6,000 in other locations). Please refer to Kaiser Permanente's Evidence of Coverage available on Colleague Connect, for additional details.
Plan feature
$400 Deductible Plan1,7
$900 Deductible Plan1,7
$1,500 Deductible Plan1,7
$2,850 Deductible Plan1,7
Deductible
Employee: $400
Family2: $8003
Employee: $900
Family2: $1,8003
Employee: $1,500
Family2: $3,0004
Employee: $2,850
Family2: $5,7003
Out-of-pocket maximum
(including deductible)
Employee: $2,200
Family2: $4,4003
Employee: $3,000
Family2: $6,0003
Employee: $3,000
Family2: $6,0004
Employee: $5,500
Family2: $11,0003
Coverage levels
80% coinsurance after deductible
70% coinsurance after deductible
Physician office visits
Primary Care Physician (PCP)/Specialist Visit
$20 copay5
80% coinsurance after deductible
80% coinsurance after deductible
70% coinsurance after deductible
Specialist Visit
$40 copay5
80% coinsurance after deductible
80% coinsurance after deductible
70% coinsurance after deductible
Hospital Facility
Inpatient
80% coinsurance after deductible
80% coinsurance after deductible
80% coinsurance after deductible
70% coinsurance after deductible
Outpatient
80% coinsurance after deductible
80% coinsurance after deductible
80% coinsurance after deductible
70% coinsurance after deductible
Emergency Room (waived if admitted)
$150 copay, then 80% coinsurance after deductible
80% coinsurance after deductible
80% coinsurance after deductible
70% coinsurance after deductible
Prescription drugs
There is a pharmacy network for retail and mail order Prescription drugs. Prescriptions are purchased through Kaiser Permanente. There is a pharmacy located in every Kaiser medical center.
Retail Prescriptions6
(30-day supply)
  • Generic
$10 copay5 (these amounts do not apply to the deductible)
70% coinsurance5 (these amounts do not apply to the deductible; minimum $10/maximum $20)
80% coinsurance after deductible
70% coinsurance after deductible
  • Formulary Brand
$30 copay5 (these amounts do not apply to the deductible)
70% coinsurance5 (these amounts do not apply to the deductible; minimum $25/maximum $50)
80% coinsurance after deductible
70% coinsurance after deductible
  • Non-Formulary Brand
$60 copay5 (these amounts do not apply to the deductible)
55% coinsurance5 (these amounts do not apply to the deductible; minimum $40/maximum $80)
80% coinsurance after deductible
70% coinsurance after deductible
Mail-order Prescriptions6
(90-day supply)
  • Generic
$25 copay5 (these amounts do not apply to the deductible)
70% coinsurance5 (these amounts do not apply to the deductible; minimum $25/maximum $50)
80% coinsurance after deductible
70% coinsurance after deductible
  • Formulary Brand
$75 copay5 (these amounts do not apply to the deductible)
70% coinsurance5 (these amounts do not apply to the deductible; minimum $62.50/maximum $125)
80% coinsurance after deductible
70% coinsurance after deductible
  • Non-Formulary Brand
$150 copay5 (these amounts do not apply to the deductible)
55% coinsurance5 (these amounts do not apply to the deductible; minimum $100/maximum $200)
80% coinsurance after deductible
70% coinsurance after deductible
Contact Information
Contact for Medical and Prescription Drug Services:
Kaiser Permanente (Claims Administrator)
See the Kaiser Claims Administrator chart for address information.
Kaiser Customer Service: See the phone numbers listed by region below.
Website: www.kp.org (for regions outside of WA)
Website: www.kp.org/wa (WA area outside of Southwest WA)
Marsh McLennan does not administer claims under this plan. For medical and prescription drug claims, Kaiser's decisions are final and binding.
1 These plans are named for the deductible applicable to the "individual" for in-network service providers. The deductibles applicable to any other coverage level (for example, "Family coverage") or for services provided by out-of-network service providers will be significantly higher than (in many instances, double) the amounts captured in the names of the plans.
2 "Family" applies to all coverage levels except, Employee-Only.
3 Not "True" Family: For the $400, $900 and $2,850 Deductible Plans, if more than one person in a family is covered under this plan, there are two ways the plan will begin to pay benefits for a covered family member. When a family member meets his or her individual deductible, benefits begin for that family member only, but not for the other family members. When the family deductible is met, benefits begin for every covered family member whether or not they have met their own individual deductibles. The family deductible can only be met by one family member or a combination of family members, as amounts counted toward individual deductibles count toward the larger family deductible. The out-of-pocket maximum functions in the same way. When a family member meets his or her individual out-of-pocket maximum, the out-of-pocket maximum is satisfied for that family member only, but not for the other family members. When the family out-of-pocket maximum is met, the out-of-pocket maximum is satisfied for every covered family member whether or not they have met their own individual out-of-pocket maximums. The family out-of-pocket maximum can only be met by one family member or a combination of family members, as amounts counted toward individual out-of-pocket maximums count toward the larger family out-of-pocket maximum.
4 "True" Family: The $1,500 Deductible Plan does not require that you or a covered eligible family member meet the "individual" deductible in order to satisfy the family deductible. If more than one person in a family is covered under this plan, benefits begin for any one covered family member only after the family deductible is satisfied. The family deductible may be met by one family member or a combination of family members. The out-of-pocket maximum functions in the same way. If more than one person in a family is covered under this plan, the out-of-pocket maximum is satisfied for any one covered family member when the family out-of-pocket maximum is satisfied. The family out-of-pocket maximum may be met by one family member or a combination of family members.
5 Office visit copays and prescriptions do not apply toward the annual deductible.
6 Please note your Rx benefits may vary from what is shown depending on your state of residence. Please refer to the Kaiser Permanente Evidence of Coverage for more detail.
7 Kaiser does not provide out-of-network coverage except in an emergency.
Kaiser Claims Administrator Address Information
Kaiser Permanente- Northern CA
P.O. Box 12923
Oakland, CA 94612
Kaiser Permanente- Southern CA
P.O. Box 7004
Downey, CA 90242-0361
Kaiser Permanente- CO
P.O. Box 373150
Denver, CO 80237-9998
Kaiser Permanente- GA
P.O. Box 370010
Denver, CO 80237-9998
Kaiser Permanente- Mid-Atlantic (MD, VA, DC)
P.O. Box 371860
Denver, CO 80237-9998
Kaiser Permanente- Northwest (Oregon and Southwest WA)
P.O. Box 370050
Denver, CO 80237-9998
Kaiser Permanente- Washington (Western Washington and Spokane area)
P.O. Box 34585
Seattle, WA 98124-1585
Kaiser Customer Service Phone Numbers
Region
Toll Free
TTY
Georgia
+1 888 865 5813
711
Northern California
+1 800 464 4000
711
Southern California
+1 800 464 4000
711
Northwest (Oregon and Southwest WA)
+1 800 813 2000
711
Colorado
+1 800 632 9700
711
Mid-Atlantic (MAS)
+1 800 777 7902
711
Washington (Western Washington and Spokane area)
+1 888 901 4636
711