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BENEFITs

KaIsER

INdEmNITy

alCoHol & CHEmICal dEPENdENCy TREaTmENT PRovIdEd By PaCIFICaRE BEHavIoRal HEalTH (PBH)

All levels of Chemical Dependency Care

In-Network Only - $0 copay, covered at

(including detoxification)

100%. Requires prior authorization.

In-Network

  • -

    100%, no deductible

Out-of-Network -

50%, no deductible

All services must be pre-authorized or no benefits are payable.

Annual Maximum

$25,000

$25,000

Lifetime Maximum

$35,000

$35,000

mEmBER assIsTaNCE PRogRam (maP) - PRovIdEd By PaCIFICaRE BEHavIoRal HEalTH (PBH)

Counseling Sessions with a PBH net-

3 visits per incident at $0 copay (In-Net-

3 visits per incident at $0 copay (In-Net-

work counselor

work) counseling and community re-

work) counseling, community resources

sources referrals (No Deductible)

referrals (No Deductible)

oTHER mEdICal sERvICEs

Home Health Care

No Charge, up to 100 visits per calendar year

Subject to deductibles and annual out of pocket limits. PPO: paid at 90% Non-PPO: paid at 70%

Skilled Nursing Facilities

No Charge; Limited to 100 days per ben- efit period.

Subject to deductibles and annual out of pocket limits. PPO: paid at 90% Non-PPO: paid at 70% Limited to 70 days per period of confine- ment. Utilization review recommended.

Short Term Therapy (Physical, Speech, Occupational)

$20 per visit

Subject to deductibles and annual out of pocket limits. PPO: paid at 90% Non-PPO: paid at 70%

Chiropractic

Self-referral; must use network provid- ers; $10 per visit, limited to 30 visits per year. $50 allowance per calendar year on Chiropratic appliances.

Benefit for Participant and Spouse only. Maximum payment of $25 per visit and 20 visits per calendar year. Subject to deductibles. Out of pocket limits do not apply to charges over plan maximums.

Acupuncture

Available with referral

Maximum payment of $35 per visit and 20 visits per calendar year. Subject to deductibles. Out of pocket limits do not apply to charges over plan maximums.

Podiatry

$20 per visit

Subject to deductibles and annual out of pocket limits. PPO: paid at 90% Non-PPO: paid at 70%

Durable Medical Equipment

No Charge

Subject to deductibles and annual out of pocket limits. PPO: paid at 90% Non-PPO: paid at 70%

Plan A & R Comparison

5

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