House Staff Medical Plan Comparison Chart
Services
PPO with HIA
Kaiser
Permanente HMO
Domestic In-Network
(SHC/LPCHProvider/
Facility)
Non-Domestic
In-Network
(UMR Provider/Facility)
Out-of-Network*
(Non-UMR Provider/
Facility)
Annual Deductible
(Applies to medical and
mental health/ substance
abuse)
$0/employee only coverage
$300/employee only coverage
$750/employee only coverage
$400/per person
$0/employee + one or more
covered dependents
$750/employee + one or more
covered dependents
$1,875/employee + one or
more covered dependents
$1,000/family limit
Wellness Incentive
Based on participation in the Healthy Steps to Wellness Program
Annual Out-of-Pocket
Maximum – includes
deductible (Applies to
medical and mental health/
substance abuse)
$0/employee only coverage
$3,250/employee only coverage
$9,375/employee + one or
more covered dependents
$1,800/individual
Maximum Lifetime Benefit
Unlimited
Unlimited
Unlimited
Unlimited
Choice of Physicians
You must use SHC/LPCH
providers and facilities for
domestic in-network benefits
You must use UnitedHealthcare
Options PPO network providers
for non-domestic in-network
benefits
You may use any licensed
provider
You must use Kaiser facilities;
all care and covered services
must be approved by a Kaiser
physician
Claim Forms
No, except for out-of-network
emergency services
No, except for out-of-network
emergency services
Yes
No, except for non-Kaiser
emergency services
Hospital Care
Room and Board,
Surgeon, Physician Visit
and Anesthesiologist
No charge; precertification
required
80% after deductible;
precertification required
60% after deductible;
precertification required or
$300/ admission penalty applies
(waived if emergency admission)
90% after deductible
Physician Visit
No charge
$20/visit
60% after deductible
$20/visit
Routine Physical
No charge
No charge
60% after deductible
No charge
Adult Preventive Services
No charge
No charge
60% after deductible
No charge
Child Preventive Services
No charge
No charge
60% after deductible
No charge
Specialist Visit
No charge
$35/visit
60% after deductible
$35/visit
Allergy Tests and Injections
No charge
80% after deductible
60% after deductible
$3/visit/injection;
$20/testing
Immunizations
No charge
No charge
60% after deductible
No charge
Lab and X-ray (nonpreventive)
No charge
80% after deductible
60% after deductible
90%
Outpatient Surgery
No charge
80% after deductible
60% after deductible
90% after deductible
Chiropractic Care
No charge; 30-visit maximum
per calendar year (combined
domestic, in- and out-ofnetwork maximum)
80% after deductible; 30-visit
maximum per calendar year
(combined domestic, in- and
out-of-network maximum)
60% after deductible; 30-visit
maximum per calendar year
(combined domestic, in- and
out-of-network maximum)
Discounts apply through
Kaiser Permanente’s
Healthyroads program
Acupuncture
No charge; 12-visit maximum
per calendar year (combined
domestic, in- and out-ofnetwork maximum)
80% after deductible; $30/
visit benefit maximum; 12-visit
maximum per calendar year
(combined domestic, in- and
out-of-network maximum)
60% after deductible; $30/
visit benefit maximum; 12-visit
maximum per calendar year
(combined domestic, in- and
out-of-network maximum)
Discounts apply through
Kaiser Permanente’s
Healthyroads program
$0/employee + one or more
covered dependents
$1,300/employee only
coverage
$3,250/employee + one or
more covered dependents
$3,600/family
Office Care
*Usual Customary and Reasonable (UCR) charges are the fees normally charged for medical services or supplies in a particular geographic location.
Services
PPO with HIA
Kaiser
Permanente HMO
Domestic In-Network
(SHC/LPCH Provider/
Facility)
Non-Domestic
In-Network
(UMR Provider/Facility)
Out-of-Network*
(Non-UMR Provider/
Facility)
No charge; covered expenses
include counseling and
consultation, infertility studies
and tests
80% after deductible; covered
expenses include counseling
and consultation, infertility
studies and tests
60% after deductible; covered
expenses include counseling
and consultation, infertility
studies and tests
50% for all services related to
covered infertility treatment
Outpatient Hospital
No charge; 60-visit maximum
per calendar year (combined
with physical, occupational or
speech therapy for outpatient
hospital and office visits)
(combined domestic, in- and
out-of-network maximum)
80% after deductible; limited
to a 60-visit maximum per
calendar year (combined with
physical, occupational or
speech therapy for outpatient
hospital and office visits)
(combined domestic, in- and
out-of-network maximum)
60% after deductible; limited
to a 60-visit maximum per
calendar year (combined with
physical, occupational or speech
therapy for outpatient hospital
and office visits) (combined
domestic, in- and out-ofnetwork maximum)
$20/visit
Office Visit
No charge; 60-visit maximum
per calendar year (combined
with physical, occupational or
speech therapy for outpatient
hospital and office visits)
(combined domestic, in- and
out-of-network maximum)
$35/visit; limited to a 60-visit
maximum per calendar year
(combined with physical,
occupational or speech
therapy for outpatient hospital
and office visits) (combined
domestic, in- and out-ofnetwork maximum)
60% after deductible; limited
to a 60-visit maximum per
calendar year (combined with
physical, occupational or speech
therapy for outpatient hospital
and office visits) (combined
domestic, in- and out-ofnetwork maximum)
Emergency in Area
No charge
$50/visit
$50/visit
90% after deductible
Emergency Out-of-Network
No charge
$50/visit
$50/visit
90% after deductible
Urgent Care
No charge
$20/visit
$20/visit
$20/visit at Kaiser facilities
Ambulance
No charge
No charge after deductible
No charge after deductible
No charge when medically
indicated and authorized by
plan physician
Skilled Nursing Facility
Not applicable
80% after deductible; 100-visit
maximum per calendar year
(combined domestic, in- and
out-of-network maximum)
60% after deductible; 100-visit
maximum per calendar year
(combined domestic, in- and
out-of-network maximum)
90% up to 100 days per
benefit period
Home Health Care
Not applicable
80% after deductible; 100-visit
maximum per calendar year;
one visit equals 4 hours or
less (combined in- and out-ofnetwork maximum)
60% after deductible; 100-visit
maximum per calendar year
(combined in- and out-ofnetwork maximum)
100% with Kaiser approval;
part-time or intermittent
only; 100-visit maximum per
calendar year (must live within
the service area)
Vision Screening
No charge
80% after deductible
60% after deductible
No charge
Hearing Exams
No charge
80% after deductible
60% after deductible
No charge
Dental Benefits
Not applicable
Not covered, except for
emergency treatment; 80%
after deductible
Not covered, except for
emergency treatment; 60%
after deductible
Not covered
Infertility Diagnosis
Physical, Speech and
Occupational Therapy
(Restorative services only)
Emergency and Urgent Care
*Usual Customary and Reasonable (UCR) charges are the fees normally charged for medical services or supplies in a particular geographic location.
Services
Durable Medical Equipment
PPO with HIA
Kaiser
Permanente HMO
Domestic In-Network
(SHC/LPCH Provider/
Facility)
Non-Domestic
In-Network
(UMR Provider/Facility)
Out-of-Network*
(Non-UMR Provider/
Facility)
Not applicable
80% after deductible; includes
hearing aids (limited to one
hearing aid per ear every three
years)
60% after deductible; includes
hearing aids (limited to one
hearing aid per ear every three
years)
80% when prescribed by a
Kaiser physician (must live
within the service area)
50% for external sexual
dysfunction devices
Transplant Services
No charge
80% after deductible; must
be performed at a Center of
Excellence facility and subject
to utilization review program
Must use Center of Excellence
For covered transplant
services, you pay the same
cost sharing as other services
not related to a transplant
Mental or Nervous
Disorders
Mental Health Care Provided
through Optum
Mental Health Care Provided
through Optum
Mental Health Care Provided
through Optum
Mental Health Care Provided
through Kaiser Permanente
Employee
No charge
No charge
No charge
90% after deductible
Dependent
No charge
80% after deductible
60% after deductible
90% after deductible
Employee
No charge
No charge
No charge
Individual: $20/visit; Group:
$10/visit
Dependent
No charge
$20/visit
60% after deductible
Individual: $20/visit; Group:
$10/visit
Substance abuse care provided
through Optum
Substance abuse care provided
through Optum
Substance abuse care provided
through Optum
Substance abuse care
provided through Kaiser
Permanente
Employee
No charge
No charge
No charge
90% after deductible
Dependent
No charge
80% after deductible
60% after deductible
90% after deductible
Employee
No charge
No charge
No charge
Individual: $20/visit; Group:
$10/visit
Dependent
No charge
$20/visit
60% after deductible
Individual: $20/visit; Group:
$10/visit
Not applicable
Prescription Drugs provided
through Express Scripts
Prescription Drugs provided
through Express Scripts
Prescription Drugs provided
through Kaiser Permanente
Not applicable
Retail 30-day Supply**
Generic: $5/prescription
Brand: $20/prescription
Brand-Non Formulary:
$50/prescription
Retail**
60% after deductible
Retail 30-day Supply
Generic: $10/prescription
Brand: $25/prescription when
prescribed by a plan physician
Inpatient
Outpatient
Substance Abuse
Inpatient
Outpatient
Prescription Drugs
Mail Order 90-day Supply
Generic: $10/prescription
Brand: $40/prescription
Brand-Non Formulary:
$100/prescription
Mail Order
Not covered
Mail Order 100-day Supply
Generic: $20/prescription
Brand: $50/prescription
*Usual Customary and Reasonable (UCR) charges are the fees normally charged for medical services or supplies in a particular geographic location.
**Preventive generic and formulary prescription drugs are covered at no charge.
Services
PPO with HIA
Kaiser
Permanente HMO
Domestic In-Network
(SHC/LPCH Provider/
Facility)
Non-Domestic
In-Network
(UMR Provider/Facility)
Out-of-Network*
(Non-UMR Provider/
Facility)
Women’s Contraceptives
Not applicable
Provided through Express
Scripts
Provided through Express
Scripts
Provided through Kaiser
Permanente Pharmacy
Contraceptives examples
include: oral, patch,
emergency
Not applicable
Retail & Mail-order
Generic and Brand: 100%
Retail: 60% after deductible
No charge (see plan for
details)
Mail-order: Not covered
Brand-Non Formulary: $50/
prescription (retail); $100/
prescription (mail-order)
For a full list, visit the
HealthySteps website
Women’s Contraceptives
covered under the Medical
Plan
Not applicable
Services through UMR
Services through UMR
Services through Kaiser HMO
Contraceptive injections,
and contraceptive devices
such as, IUDs, implants,
(including the insertion and
removal)
Not applicable
No charge
60% after deductible
No charge
See medical plan for additional
details
*Usual Customary and Reasonable (UCR) charges are the fees normally charged for medical services or supplies in a particular geographic location.