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Must use Kaiser Optical. Maximum al- lowance of $125 for glasses or contact lenses. Benefit renews every 24 months.

Covered through Vision Service Sig- nature Choice Plan after $25 co-pay- ment for materials. Provides one pair of lenses every 12 months and frames every 24 months. Visually Necessary contact lenses paid in full if provided by a VSP doctor. For other elective contact lenses, Plan pays up to a $105 allowance for pro- fessional fees and materials.

PREsCRIPTIoN dRUgs

$10 for generic drug $30 for formulary brand drug Prescriptions from Non-Kaiser providers (other than Dentists) are NOT covered. Maximum 100-day supply.

Retail contract pharmacies only, unless there are none within 10 miles. $10 for formulary generic drug $10, PLUS cost difference between ge- neric and brand for multi-source brand. $40 for single source formulary brand. $60 for non-formulary - Certain non- formulary drugs are not covered without prior authorization. 30-day supply All prescription drug benefits limited to a maximum payment of $75,000 per eli- gible individual per calendar year.

$10 for generic drug $30 for formulary brand drug Maximum 100-day supply. Mail orders on reorder prescriptions only. Call your local Kaiser Pharmacy for fur- ther details or see Kaiser’s website at www. kaiserpermante.org Prescriptions from Non-Kaiser providers (other than Dentists) are NOT covered.

$20 for formulary generic drug. $20 PLUS cost difference between ge- neric and brand for multi-source brand. $80 for single source formulary brand. $100 for non-formulary. Certain non-formulary drugs are not covered without prior authorization. 90-day supply. All prescription drug benefits limited to a maximum payment of $75,000 per eli- gible individual per calendar year.

$20 per visit; $2,500 maximum for each hearing aid. Hearing aids are provided every 36 months.

Maximum benefit limits: 100%, up to $800 maximum for each ear, including the exam only if the hearing aid(s) is obtained. Hearing aids provided every 3 years. (Not subject to deductibles or out of pocket limits.)

See attached page for a zip code listing of covered areas.

PPO/Contract facilities available through- out California and the U.S. Call 1(888) 547-2054 to verify contract providers in California, or 1 (800) 810-2583 for con- tract providers outside California

Glasses and Contact Lenses

Retail Pharmacy

Mail Order

Hearing Exam & Hearing Aids

Coverage Areas

6

Plan A & R Comparison

Vision Exam

BENEFITs

KaIsER vIsIoN BENEFITs

INdEmNITy

$20 per visit, must use Kaiser Optical

Vision exam through Vision Service Sig- nature Choice Plan every 12 months after $10 co-payment for exam.

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