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Kaiser Foundation Health Plan, Inc.Kaiser PermanenteHawaii’s Guide toYour Health PlanKP Gold I - 20JANUARY 2021
Benefit Summary Benefit and Payment ChartAnnual Copayment MaximumAnnual DeductibleRoutine and PreventiveSpecial Services for WomenSpecial Services for MenOnline CareMedical Office VisitsLaboratory, Imaging, and TestingSurgeryTotal Care Serviceso Inpatient Hospitalo Outpatient Surgery and Procedures in a Hospital-Based Setting or AmbulatorySurgery Center (ASC)o Emergency Serviceso Observationo Skilled Nursing Facilityo Dialysiso Radiation TherapyAmbulancePhysical, Occupational and Speech TherapyHome Health Care and Hospice CareChemotherapyInternal, External Prosthetics Devices and BracesMedical Equipment and SuppliesBehavioral Health - Mental Health and Substance AbuseTransplantsPrescription DrugsMiscellaneous Medical Treatments2021 Kaiser Permanente Hawaii’s Guide - GP‐1‐Benefit Summary
Benefit and Payment ChartAbout this ChartThis benefit and payment chart: Is a summary of covered services and other benefits. It is not a complete description of yourbenefits. For coverage criteria, description and limitations of covered Services, and excludedServices, be sure to read Chapter 1: Important Information, Chapter 3: Benefit Description, andChapter 4: Services Not Covered. Tells you if a covered service or supply is subject to limits or referrals. Gives you the page number where you can find the description of your services and otherbenefits. Tells you what your Cost Share is for covered services and supplies.Note: Special limits may apply to services or other benefits listed in this benefit and payment chart.Please read the benefit description found on the page referenced by this chart.You only pay a single Cost Share for covered benefits you receive in the Total Care Service settings. Ifyour care is not received in a Total Care setting, you pay the Cost Share for each medical service or itemin accord with its relevant benefit section.If a benefit in the Benefit and Payment Chart is not listed, or is listed as “Not covered” the descriptionsrelated to that benefit in Chapter 1, 3, and 4 are not applicable.Remember, services and other benefits are available only for care you receive when provided,prescribed, or directed by your KP Hawaii Care Team except for care for Emergency Services and out-ofstate Urgent Care. To find a Medical Office near you visit our website at www.kp.org. For moreinformation on these services see Chapter 3: Benefit Description. You are encouraged to choose aPersonal Care Physician (PCP). You may choose any PCP that is available to accept you. Parents maychoose a pediatrician as the PCP for their child.You do not need a referral or prior authorization to obstetrical or gynecological care from a health careprofessional who specializes in obstetrics or gynecology. Your Physician, however, may have to get priorauthorization for certain Services. Additionally, in accord with state law, you do not need a referral orprior authorization to obtain access to physical therapy from a physical therapist or Physician whospecialized in physical therapy.Members age 65 and over (excluding Tax Equity and Fiscal Responsibility Act of 1982 “TEFRA” members)must meet the required eligibility requirements to receive the benefit of either 1) those listed in thisBenefit Summary, or 2) benefits covered under Original Medicare. See Chapter 9: Coordination ofBenefits. Senior Advantage Members, please refer to your Senior Advantage Evidence of Coverage.2021 Kaiser Permanente Hawaii’s Guide - GP‐2‐Benefit Summary
DescriptionCost ShareAnnual Copayment MaximumMemberFamily Unit 2,500 per calendar year 5,000 per calendar year(for 2 or more members)Annual DeductibleMemberFamily UnitNoneNoneRoutine and PreventiveHealth Education and Disease Management Medical Office Visitso Primary Careo Specialty Care Tobacco Cessation and CounselingSessions Health education publications Healthy Living ClassesImmunizations (endorsed by the Centers forDisease Control and Prevention (CDC)) Office Visit for (CDC) Immunizations Office visit for Travel Immunizationo Primary Careo Specialty CareMedical Office Visits Well-Child Care Annual Preventive Care (physicalexam) Hearing Exam (for correction)o Primary Careo Specialty Care Vision Exam (for glasses)o Primary Careo Specialty CarePreventive Screenings and CareTotal Health Assessment (www.kp.org) 20 per visit 20 per visitNoneNoneApplicable class feesNoneNone 20 per visit 20 per visitNoneNone 20 per visit 20 per visit 20 per visit 20 per visitNoneNoneSpecial Services for WomenPreventive Care Annual Gynecological Exam Mammography (screening) Pap Smears (cervical cancerscreening)Family Planning Visits Primary Care Specialty Care2021 Kaiser Permanente Hawaii’s Guide - GPNoneNoneNone 20 per visit 20 per visit‐3‐Benefit Summary
DescriptionInfertility Consultation Primary Care Specialty CareIn Vitro FertilizationMaternity Maternity Care – routine prenatalvisits in Medical Office Maternity Care – delivery Maternity Care – one postpartumvisit in Medical Office Maternity and Newborn InpatientStay Breast PumpContraceptive Drugs and DevicesCost Share 20 per visit 20 per visit20% of Applicable ChargesNone20% of Applicable ChargesNone20% of Applicable ChargesNoneSee prescription drugs in this BenefitSummaryPregnancy Termination Primary Care Specialty Care Total Care SettingsVoluntary sterilization (including tuballigation) Medical Office Total Care Settings 20 per visit 20 per visitIncluded in Total Care ServicesNoneNoneSpecial Services for MenProstate Specific Antigen (screening)Vasectomy Primary Care Specialty Care Total Care Settings 20 per day 20 per visit 20 per visitIncluded in Total Care ServicesOnline CareMy Health Manager (www.kp.org)NoneMedical Office VisitsMedical Office Visits Primary Care Specialty Care Routine pre-surgical and post-surgicalUrgent Care Visits Within Service Area Outside Service AreaDependent Child Outside of Service Area Routine Primary Care Basic laboratory and general imaging Testing2021 Kaiser Permanente Hawaii’s Guide - GP 20 per visit 20 per visitNone 20 per visit20% of Applicable Charges 20 per visit 10 per visit20% of Applicable Charges‐4‐Benefit Summary
Description Immunizations Contraceptive drugs and devices Self-administered drug prescriptionsHouse Calls Primary Care Specialty CareTelehealthCost ShareNoneNone20% of Applicable Charges 20 per visit 20 per visitCost Share, if applicable, will varydepending on ServiceLaboratory, Imaging, and TestingLaboratory Basic SpecialtyImaging General SpecialtyTesting Allergy Testingo Primary Careo Specialty Care Skilled-Administered Drugs Diagnostic Testing 20 per day20% of Applicable Charges 20 per day20% of Applicable Charges 20 per visit 20 per visit20% of Applicable Charges20% of Applicable ChargesSurgeryOutpatient Surgery and Procedures Primary Care Specialty Care Total Care SettingsReconstructive Surgery Primary Care Specialty Care Covered Mastectomy Total Care Settings2021 Kaiser Permanente Hawaii’s Guide - GP 20 per visit 20 per visitIncluded in Total Care Services 20 per visit 20 per visit20% of Applicable ChargesIncluded in Total Care Services‐5‐Benefit Summary
DescriptionCost ShareTotal Care ServicesYou may only pay a single Cost Share forcovered benefits you receive in Total CareService settings. Here are examples:Inpatient Hospital ServicesOutpatient Surgery and Procedures in aHospital-Based Setting or Ambulatory SurgeryCenter (ASC)Emergency ServicesObservationSkilled Nursing Facility20% of Applicable Charges20% of Applicable Charges20% of Applicable Charges20% of Applicable Charges20% of Applicable Charges for up to120 days per Accumulation PeriodDialysis20% of Applicable ChargesNone DialysisEquipment, Training and MedicalSupplies for home DialysisRadiation Therapy20% of Applicable ChargesAmbulanceAir AmbulanceGround Ambulance20% of Applicable Charges20% of Applicable ChargesPhysical, Occupational, and SpeechTherapyPhysical and Occupational Therapy Medical Office Home Health Care Total Care SettingsSpeech Therapy Medical Office Home Health Care Total Care Settings 20 per visitNoneIncluded in Total Care Services 20 per visitNoneIncluded in Total Care ServicesHome Health Care and Hospice CareHome Health CareHospice CarePhysician Visits Primary Care Specialty CareNoneNone 20 per visit 20 per visitChemotherapy Primary Care Specialty Care Total Care Settings2021 Kaiser Permanente Hawaii’s Guide - GP 20 per visit 20 per visitIncluded in Total Care Services‐6‐Benefit Summary
DescriptionCost ShareInternal, External Prosthetics Devices andBracesImplanted Internal Prosthetics, Devices andAids Medical Office Total Care SettingsExternal Prosthetics Devices Outpatient NoneIncluded in Total Care Services10% of Applicable ChargesTotal Care SettingsIncluded in Total Care ServicesOutpatientTotal Care Settings10% of Applicable ChargesIncluded in Total Care ServicesBraces Durable Medical EquipmentDurable Medical Equipment Outpatient Total Care SettingsOxygen (for use with DME)10% of Applicable ChargesIncluded in Total Care Services10% of Applicable ChargesIncluded in Total Care Services OutpatientTotal Care SettingsRepair or Replacement Outpatient Total Care SettingsDiabetes EquipmentHome Phototherapy Equipment10% of Applicable ChargesIncluded in Total Care Services50% of Applicable ChargesNoneBehavioral Health – Mental Health andSubstance AbuseMental Health Care Medical Office Total Care SettingsChemical Dependency Care Medical Office Total Care SettingsAutism Care Primary Care Specialty Care 20 per visitIncluded in Total Care Services 20 per visitIncluded in Total Care Services 20 per visit 20 per visitTransplantsTransplant Care for Transplant Recipients Primary Care Specialty Care Total Care Settings2021 Kaiser Permanente Hawaii’s Guide - GP 20 per visit 20 per visitIncluded in Total Care Services‐7‐Benefit Summary
DescriptionTransplant Services for Transplant Donors(based on health plan approval) Primary Care Specialty Care Total Care SettingsRelated Prescription DrugsCost Share 20 per visit 20 per visitIncluded in Total Care ServicesSee prescription drugs in this BenefitSummaryTransplant Evaluations Primary Care Specialty Care 20 per visit 20 per visitPrescription DrugSkilled Administered Drugs20% of Applicable Charges;Included in Total Care ServicesIf your employer has purchased adrug rider, coverage will be asspecified in your drug rider followingthis Benefit SummarySelf-Administered DrugsChemotherapy Drugs Chemotherapy Infusion or Injections(Skilled Administered Drugs) Chemotherapy – Oral Drugs (SelfAdministered DrugsContraceptive Drugs and DevicesDiabetic SuppliesTobacco Cessation Drugs and Products20% of Applicable Charges20% of Applicable Charges; oras specified in applicable drug rider50% of Applicable Charges or None50% of Applicable ChargesNone (up to 30-day supply)Drug Therapy CareGrowth Hormone Therapy Primary Care Specialty Care Skilled-Administered Drug Total Care SettingsHome IV/Infusion therapy Therapy and IV drugs Self-administered injections 20 per visit 20 per visit20% of Applicable ChargesIncluded in Total Care ServicesNoneSee prescription drugs in this BenefitSummaryInhalation Therapy Primary Care Specialty Care Total Care Settings2021 Kaiser Permanente Hawaii’s Guide - GP 20 per visit 20 per visitIncluded in Total Care Services‐8‐Benefit Summary
DescriptionCost ShareMiscellaneous Medical TreatmentsBlood and Blood Products Medical Office Rh Immune Globulin Total Care SettingsDental Procedures for Children Primary Care Specialty Care Total Care SettingsHearing Aids Hearing Testo Primary Careo Specialty Care AppliancesHyperbaric Oxygen Therapy Primary Care Specialty Care Total Care SettingMaterials for Dressings and CastsNone20% of Applicable ChargesIncluded in Total Care Services 20 per visit 20 per visitIncluded in Total Care Services 20 per visit 20 per visit60% of Applicable Charges 20 per visit 20 per visitIncluded in Total Care ServicesCost Share will vary upon place ofserviceIncluded in Total Care Services20% of Applicable ChargesNone Total Care SettingMedical FoodsMedical Social ServicesOrthodontic Care for the Treatment ofOrofacial Anomalies (from birth) Primary Care Specialty CarePulmonary Rehabilitation Primary Care Specialty Care Total Care Setting 20 per visit 20 per visit 20 per visit 20 per visitIncluded in Total Care Servicesver. KP Gold I - 20 Plan6/3/20202021 Kaiser Permanente Hawaii’s Guide - GP‐9‐Benefit Summary
Kaiser Foundation Health Plan, Inc. – HawaiiACA Small Group AmendmentThis amendment is included in the Benefit Summary in the front of the Guide to Your Health Plan(Guide). The provisions of this Guide and the Evidence of Coverage (EOC) apply to this amendment.For Senior Advantage members, this amendment is included in the Medical Benefits Chart in the front ofthe Evidence of Coverage (EOC).Benefit SummaryDescriptionCost SharePhysical, Occupational and SpeechTherapyHabilitative Services Medical OfficeSame physical, occupational, andspeech therapy Medical Office CostShares listed in the Benefit Summaryin front of this Guide Home Health CareSame home health care Cost Sharelisted in the Benefit Summary in frontof this Guide Total Care SettingsIncluded in Total Care ServicesPrescription DrugsSelf-Administered Drugs in accord withUSPSTF and PPACANoneSpecial Services for WomenFamily Planning Visits in accord with PPACANoneBehavioral Health – Mental Health andSubstance AbuseConditions listed in current DSMSame behavioral health Cost Shareslisted in the Benefit Summary in frontof this GuideEmergency ServicesEmergency services from dentistsACA Amendment 21r.DocxSame emergency services CostShares listed in the Benefit Summaryin front of this GuideACA-1rev. 4/2020
DescriptionCost ShareMiscellaneous Medical TreatmentsErectile Dysfunction Primary Care Same primary care Cost Share listedin the Benefit Summary in front ofthis GuideSame specialty care Cost Share listedin the Benefit Summary in front ofthis GuideSpecialty Care Total Care SettingsTemporomandibular Joint Dysfunction Primary Care Included in Total Care ServicesSame primary care Cost Share listedin the Benefit Summary in front ofthis GuideSame specialty care Cost Share listedin the Benefit Summary in front ofthis GuideSpecialty Care Total Care SettingsVision appliances and proceduresIncluded in Total Care ServicesCost Share will vary depending onservicePediatric Vision Care One eye exam One pair of eyeglasses (lenses andframe) One pair of non-disposable contactlenses (in lieu of eyeglasses) Medically necessary contact lens One low vision hand-held or pagemagnifier deviceNoneNoneNoneNoneNoneNot coveredPediatric Oral Care services are onlycovered under this Kaiser Permanente EOC ifspecifically provided by a separate dentalrider bundled with this plan.Benefit DescriptionPhysical, Occupational and Speech TherapyHabilitative ServicesWe cover habilitative services and devices to develop, improve, or maintain skills and functioning fordaily living that were never learned or acquired to a developmentally appropriate level. Skills andACA Amendment 21r.DocxACA-2rev. 4/2020
functioning for daily living, such as basic activities of daily living, are typically learned or acquired duringchildhood development.Habilitative services and devices include: Audiology services,Occupational therapy,Physical therapy,Speech-language therapy,Vision services, andDevices associated with these services including augmentative communication devices, readingdevices, and visual aids.Prescription DrugsSelf-Administered Drugs in accordance with USPSTFWe cover U.S. Preventive Services Task Force (USPSTF) recommended drugs, including mail order, inaccordance with the Patient Protection and Affordable Care Act provided the drug quantity prescribeddoes not exceed (i) a 30-consecutive-day supply, or (ii) an amount as determined by the Health Planformulary. Mail order is provided up to a 90-consecutive-day supply to your home. The mail orderprogram does not apply to certain pharmaceuticals (such as controlled substances as determined bystate and/or federal regulations, bulky items, medication affected by temperature, injectables, andother products and dosage forms as identified by the Kaiser Permanente Pharmacy and TherapeuticsCommittee). Mail order drugs will not be sent to addresses outside of the Service Area.Special Services for WomenFamily Planning VisitsWe cover family planning services in accordance with the Patient Protection and Affordable Care Act.Behavioral Health – Mental Health and Substance AbuseWe cover conditions listed in the current Diagnostic and Statistical Manual of the American PsychiatricAssociation that meet the standards of Medical Necessity.Emergency Services from DentistsWe cover services of dentists only when the dentist performs emergency or surgical services that couldalso be performed by a Physician.Miscellaneous Medical TreatmentsErectile DysfunctionWe cover services approved by Health Plan for the treatment of erectile dysfunction due to an organiccause.Temporomandibular Joint Dysfunction (TMJ)We cover services for the treatment of temporomandibular joint dysfunction (TMJ).ACA Amendment 21r.DocxACA-3rev. 4/2020
Vision Appliances and ProceduresWe cover vision appliances, including eyeglasses and contact lenses and vision procedures for certainmedical conditions when prescribed by a Physician.Pediatric Vision CareWe cover pediatric vision care services for Members up to age 19, as follows: One eye examination per Accumulation Period.Please note: Additional eye exams are covered at the usual office visit Cost Share.When prescribed by a Kaiser Permanente Optometrist or Physician, one pair of polycarbonatesingle vision, lined bifocal or lined trifocal lenses per Accumulation Period.One frame every Accumulation Period. Covered frames must be from the “value collectionframes” available at Vision Essentials by Kaiser Permanente clinic locations.(in lieu of frames and lenses) One pair of non-disposable contact lenses (including fitting anddispensing) or an initial supply of disposable contact lenses (including fitting and dispensing) notmore than once every 12 months is provided at no charge. Covered contact lenses include:o Standard (one pair annually): one contact lens per eye (total of two lenses), oro Monthly (six-month supply): six lenses per eye (total of 12 lenses), oro Bi-weekly (three-month supply): six lenses per eye (total of 12 lenses), oro Dailies (one-month supply): 30 lenses per eye (total of 60 lenses).Medically necessary contact lenses, when determined by a Physician. Contact lenses may be medicallynecessary and appropriate in the treatment of certain conditions such as Keratoconus, PathologicalMyopia, Aphakia, Anisometropia, Aniseikonia, Aniridia, Corneal Disorders, Post-traumatic Disorders,Irregular, and Astigmatism.One low vision hand-held or page magnifier device (including fitting and dispensing) is provided every 24months.Services Not CoveredMiscellaneous ExclusionsHabilitative Services: You are not covered for: Rehabilitation Programs, unless referred by a Physician;Unskilled therapy;Routine vision services; andDuplicate services provided by another therapy or available through schools and/or governmentprogramsErectile Dysfunction: You are not covered for drugs, injections, equipment, supplies, prosthetics,devices and aids related to treatment of erectile (sexual) dysfunction, except as described in this Rider.ACA Amendment 21r.DocxACA-4rev. 4/2020
Additional ProvisionsMiscellaneous ProvisionsEssential Health Benefits (EHBs)Essential Health Benefits (EHBs) are benefits that the U.S. Department of Health and Human Services(HHS) Secretary defines as essential health benefits. EHBs include ambulatory services, emergencyservices, hospitalization, maternity and newborn care, mental health and substance abuse disorderservices (including behavioral health treatment), prescription drugs, rehabilitative and habilitativeservices and devices, laboratory services, preventive and wellness services and chronic diseasemanagement, and pediatric services to the extent required by HHS and the EHB-benchmark plan. TheseEHBs are subject to change at any time to conform to applicable laws and regulations. This list isavailable through our Member Services department.Health Plan certifies that this EOC covers Essential Health Benefits to the full extent required by law,except pediatric oral care services are not covered. Coverage for pediatric oral care should either beobtained via a stand-alone (independent) dental plan or via a “bundled” qualified health plan (QHP)purchased from Kaiser Permanente Hawaii Region (if purchased through us, the benefit will be describedin the Benefit Summary in the front of this Guide), in accordance with applicable law. “Bundled” qualifiedhealth plans are medical plans that have been certified and approved as a QHP, in accordance with thePatient Protection and Affordable Care Act, and are bundled with a stand-alone exchange-certifiedpediatric dental plan from Hawaii Dental Service (HDS). Information regarding dental benefits should beobtained directly from HDS.All other terms of coverage in this EOC applicable to Essential Health Benefits remain effective, includingbut not limited to the Exclusions and Limitations section of this EOC and the requirement that coveredservices be provided by or arranged by a Physician and be provided at a Medical Office, Hospital orSkilled Nursing Facility, except where such terms of coverage are specifically limited in this EOC (such asfor emergency services) or would violate applicable law.EHBs are provided upon payment of any applicable Deductible and Cost Shares listed in the Benefit Summaryin the front of this Guide.This section describes EHBs that are not described in other parts of this Guide. These EHBs are subject to allcoverage requirements described in other parts of this EOC.Payments toward EHBs count toward your Annual Copayment Maximum described in the Benefit Summaryfound in the front of this Guide and Chapter 2: Payment Definitions and Information.ACA Amendment 21r.DocxACA-5rev. 4/2020
Kaiser Foundation Health Plan, Inc. – HawaiiPrescription Drug RiderThis rider is included in the Benefit Summary in the front of the Guide to Your Health Plan (Guide). Theprovisions of this Guide and the Evidence of Coverage (EOC) apply to this rider.Note: We also cover some outpatient drugs and supplies in the Prescription Drugs section in Chapter 3:Benefit Description of this Guide.For Senior Advantage members, this rider is included in the Medical Benefits Chart in the front of theEvidence of Coverage (EOC).Benefit SummaryDescriptionCost ShareSelf-administered Prescription Drugs(at Kaiser Permanente Pharmacies)Generic maintenance drugs * 5Other Generic drugs * 30Brand-name drugs *50% of Applicable Charges afterdeductibleSpecialty drugs *50% of Applicable Charges afterdeductibleRefills through Mail-Order Program(for up to a 90-consecutive-day supply)Two times above-listed copayInsulin - other generic 30Insulin - brand name50% of Applicable Charges afterdeductibleAnnual Prescription Drug CopaymentMaximum (on Pharmacy Dispensed Drugs) Member 6,050 Family Unit 12,100(2 or more members)Annual Prescription Drug Deductible Applies only to these types of drugsBrand-name and Specialty drugs Member 3,000 Family Unit 6,000 (2 or more members)Drug 5d 30d 50p 50p 6050drxmoop 3000drxdedbrandspecialty EOC 21rDrug-1rev. 04/2020
DescriptionWell Rx Program drugs*Cost ShareNot applicable* For up to a 30-consecutive-day supply per prescription, or an amount as determined by the KaiserPermanente formulary.Benefit DescriptionSelf-administered Prescription Drugs(at Kaiser Permanente Pharmacies)Covered Drugs and SuppliesWe cover self-administered prescription drugs and supplies only if all of the following conditions aremet: prescribed by a KP physician or licensed Prescriber, is a drug for which a prescription is required by law, except for insulin, obtained at pharmacies in the Service Area that are operated by Kaiser Foundation Hospital, KaiserFoundation Health Plan, Inc. or a pharmacy we designate, listed on the Kaiser Permanente formulary and used in accordance with formulary guidelines orrestrictions. Senior Advantage members with Medicare Part D are entitled to drugs on the KaiserPermanente formulary and Kaiser Permanente Hawaii Medicare drug formulary, and is a drug which does not require administration by nor observation by medical personnel,Notes: Immunizations are described in Chapter 3: Benefit Description under Routine and Preventive.Contraceptive drugs and devices are described in Chapter 3: Benefit Description under Routine andPreventive. Diabetic equipment and supplies are described in Chapter 3: Benefit Description under theDurable Medical Equipment (DME) and Prescription Drug.Cost Share for Covered Drugs and SuppliesWhen you get a prescription from a Kaiser Permanente Pharmacy, pharmacy we designate, or order aprescription from our Kaiser Permanente Mail-Order Pharmacy, you pay the Cost Share as shown in theabove Benefit Summary. A reasonable charge is made for prescribed quantities in excess of theamounts described in the Benefit Summary. Each refill of the same prescription will also be provided atthe same charge.The Cost Share amounts count toward the Annual Copayment Maximum, or the Annual PrescriptionDrug Copayment Maximum if you have one listed in the above Benefit Summary. This applies for eachcovered prescription, except Cost Share for sexual dysfunction and testosterone drugs do not counttoward any annual maximum.If you get a prescription from a non-Kaiser Permanente pharmacy, you will be responsible for 100% ofthe charges because it is not covered under this Prescription Drug Rider.Day Supply LimitDrug 5d 30d 50p 50p 6050drxmoop 3000drxdedbrandspecialty EOC 21rDrug-2rev. 04/2020
The prescribing provider determines how much of a drug or supply to prescribe. For purposes of daysupply coverage limits, the prescribing provider determines the amount of a drug or supply thatconstitutes a Medically Necessary 30-consecutive-day (or any other number of days) supply for you.Dispensing limitations may apply within the 30-consecutive-day supply period for certain drugs. Whenyou pay the Cost Share shown in the Benefit Summary, you will receive the prescribed supply up to theday supply limit.How to Get Covered Drugs or SuppliesOur pharmacies are located in most Kaiser Permanente clinics. To find a pharmacy, please see yourCaring for You: Physicians and Locations Directory, visit kp.org, or contact Member Services. You mustpresent your KP membership ID card, which has your medical record number, and a photo ID to thepharmacist.Our mail-order pharmacy offers postage-paid delivery for refills of Maintenance drugs. Some drugs andsupplies are not available through our mail-order pharmacy, for example controlled substances asdetermined by state and/or federal regulations, bulky items, drugs that require special handling orrefrigeration, injectables, and other products and dosage forms as identified by the Kaiser PermanentePharmacy and Therapeutics Committee. Drugs and supplies available through our mail-order pharmacyare subject to change at any time without notice. We are not licensed to mail medications out of state,so mail order drugs will not be mailed to addresses outside of the Service Area.If you would like to use our mail-order pharmacy, use one of the methods below: For the quickest turnaround time, order online at kp.org. Order via our automated prescription refill service by calling (808) 643-7979, press 1. Order using our mail-order envelope, available at all Kaiser Permanente clinic locations. Order via our Pharmacy Refill Center at (808) 643-7979, press 3 then press 5, Monday to Friday,8:30 a.m. to 5 p.m. TTY users may call 1-877-447-5990.DefinitionsThe following terms, when capitalized and used in this Prescription Drug Rider mean: Brand-name Drug. The first U.S. Food and Drug Administration (FDA) approved version of a drug.Marketed and sold under a proprietary, trademark-protected name by the pharmaceutical companythat holds the original patent. Brand-name drugs include single source drugs (where there is only oneapproved product available for that active ingredient, dosage form, route of administration, andstrength). Generic Drug. A drug that contains the same active ingredient as a Brand-Name Drug and isapproved by the U.S. Food and Drug Administration (FDA) as being therapeutically equivalent andhaving the same active ingredients(s) as the Brand-name Drug. Generic Drugs are produced and soldunder their Generic names after the patent of the Brand-Name drug expires. Generally, GenericDrugs cost less than Brand-Name Drugs, and must be identical in strength, safety, purity, andeffectiveness. Generic Maintenance Drug. A specific Generic Drug to treat chronic conditions and is on Health Plan’sapproved list. Note: Not all Generic Drugs to treat chronic conditions are considered GenericMaintenance Drugs. Maintenance Drug. A drug to treat chronic conditions, such as asthma, high blood pressure, diabetes,high cholesterol, cardiovascular disease, and mental health. Specialty Drug. A very high-cost drug approved by the U.S. Food and Drug Administration (FDA).Drug 5d 30d 50p 50p 6050drxmoop 3000drxdedbrandspecialty EOC 21rDrug-3rev. 04/2020
Annual Prescription Drug Copayment Maximum. The Annual Prescription Drug Copayment Maximumis the maximum amount for Pharmacy Dispensed Drugs you pay out of your pocket in anAccumulation Period. Once you meet the Annual Prescription Drug Copayment Maximum, you areno longer responsible for Cost Share amou
2021 Kaiser Permanente Hawaii s Guide - GP rïr Benefit Summary Description Cost Share Annual Copayment Maximum Member 2,500 per calendar year Family Unit 5,000 per calendar year (for 2 or more members) Annual Deductible Member None Family Unit None Routine and Preventive Health Education and Disease Management
