Benefit Component	Kaiser Plan 415	PacifiCare HMO	PacifiCare Plus In-Network	PacifiCare Plus Out-of-Network
PCP Required?	Yes	Yes	Yes	No
Hospitals & Pharmacies Available	Network Only	Network Only	Network Only	Any
Deductible	N/A	N/A	N/A	$500 / $1,000
Out of Pocket Maximum	$2,000 individual $4,500 family	$2,500 individual $7,500 family	$3,500 individual $7,500 family	$5,000 individual $10,000 family (excludes deductibles & co-pays)
Coinsurance	N/A	N/A	N/A	30%
PCP Office Visit Co-pay	$15	$15 includes OB/GYN	$20 includes OB/GYN	30% after deductible
Specialist Office Visit Co-pay	$15	$30	$40	30% after deductible
Health Risk Appraisal	$0	Not covered	Not covered	Not covered
Preventive Care Office Visit Co-pay	$5	$15	$20	Not covered, except for well baby & well child to age 13
Emergency Room Visit	$50 (waived if admitted)	$50 (waived if admitted)	$50 (waived if admitted)	50% after deductible
Hospital Inpatient	$100 per admit	$200 per admit	$500 per admit	30% after deductible
Outpatient Surgery	$50 per visit	$100 per admit	$250 per visit	30% after deductible (Must be pre-authorized)
Urgent Care Office Visit (Out-of-Network Area)	$15	$25 ($400 contract year maximum)	$25 ($400 contract year maximum)	50% after deductible
Maternity Care	$5	$15	$20	30% after deductible
Chiropractic	$15 20 visits per calendar year	$15 20 visits per calendar year as medically necessary	Not Covered	30% after deductible Maximum benefit: $500 per contract year. Chrio & physical therapy combined
Mental Health Outpatient	$15 for visits 1 to 10 $25 thereafter	$0 for visits 1 to 5 $30 thereafter	$0 visits 1 to 5 $40 thereafter	30% after deductible (20 visits max per contract year)
Prescription Drugs	$10 per prescription 60 day supply	$8 generic / formulary $15 brand name / formulary $30 non-formulary / formulary 30 day supply 2 x co-pay for 90 day supply of maintenance drugs	$10 generic / formulary $20 brand name / formulary $30 non-formulary / formulary 30 day supply 2 x co-pay for 90 day	Applicable co-payment plus 20% of remaining cost
Oxygen; Durable Medical Equipment (DME)	Oxygen covered in full DME covered at 80% up to $2,000	$1,500 per year for oxygen and DME (separate $500 per year for podiatric shoe inserts & orthopedic braces)	$1,500 per year for oxygen and DME (separate $500 per year for podiatric shoe inserts & orthopedic braces)	30% after deductible Maximum Benefit: $1,000 per year
Vision Benefit	$15 Annual Eye exam	Not covered	Not covered	Not covered
Hearing Benefit	Not covered	Not covered	Not covered	Not covered
Dental Benefit	Not covered	Not covered	Not covered	Not covered
Lifetime Maximum (specific benefits limits may apply)	Unlimited (see also specific limits)	Unlimited (see also specific limits)	Unlimited (see also specific limits)	$1,000,000 (see also specific limits)