8/3/2019 2010-2011KaiserBenefitSummary

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Kaiser Permanente HMO for LMI AEROSPACEPurchaser ID: 107243

Proposed Renewal Option 1

Annual Deductible: Individual / Family per calendar year(s) None / None None / None

Maximum Out-Of-Pocket $1,500 per member, $3,000 per family $1,500 per member, $3,000 per family

Maximum Lifetime Benefit None / None None / None

Hospital Inpatient (all services rendered while hospitalized) $250 per admit $500 per admit

Outpatient (specialty, routine, eye/hearing exams, and urgent care) $15 per visit $25 per visit

Well-child preventive care visits (23 months or younger) $15 per visit $15 per visitScheduled prenatal care and first postpartum visit $15 per visit $15 per visit

Outpatient surgery $15 per procedure $25 per procedureAllergy Injections / Immunizations $5 per visit $5 per visit

X-rays and Lab tests $5 per encounter No chargeAmbulance services $75 per trip $75 per trip

Emergency department visits $75 per visit $100 per visit

Outpatient Prescription Drugs (pharmacy and mail order)$10 gen / $30 brand

$10 gen / $30 brand, $20 gen / $60brand MOI

Days supply 100 days 30 days, 100 days MOI

Mental Health Services

Inpatient psychiatric care / days per calendar year $250 per admit $500 per admit

Outpatient individual therapy visits $15 per visit $25 per visitOutpatient group therapy visits $7 per visit $12 per visit

Chemical Dependency Services

Inpatient detoxification $250 per admit $500 per admit

Outpatient individual therapy visits $15 per visit $25 per visitOutpatient group therapy visits $5 per visit $5 per visit

Transitional Residential Recovery Services $100 per admit $100 per admit

Infertility Services

Covered services related to the diagnosis and treatment of infertility 50% per visit 50% per visit

Additional Benefits

Supplemental Durable Medical Equipment 20% per item 20% per itemSkilled Nursing, Home and Hospice Care No charge No charge

Optical eyewear (frames, lenses, contact lenses) $175 per 24 months $175 per 24 monthsHearing aids Not covered Not covered

Chiropractic $10 per visit to 20 visits $10 per visit to 20 visitsDental Not covered Not covered

Proposed Monthly Dues Effective 07/01/2010 to 06/30/2011Including commissions of 3.0%.

Subscriber Only $378.04 $366.07Subscriber and Spouse $756.08 $732.14Subscriber and Child / Children $718.27 $695.54Family $1,096.30 $1,061.60

The information presented in this chart is a summary only. For a complete understanding of benefits, please read this chart in conjunction with the Evidence of Coverage (EOC). The EOCcontains a detailed explanation of benefits, exclusions, and limitations.