Santa Clara University

Department of Human Resources

Kaiser Permanente HMO Standard Option Medical Plan

 

Phone no: 1-800-464-4000 (English)
Phone no: 1-800-788-0616 (Spanish)
Group no: 979
ID no: Medical Record # (on ID card)
Website: www.kaiserpermanente.org
Note: This plan is for non-union members.

Description: Members enrolled in the Kaiser Permanente HMO, receive all medical treatment from Kaiser physicians, facilities and pharmacies. The Plan does not cover services rendered by providers outside of Kaiser unless participants require immediate medical care for an urgent medical condition and are outside the Kaiser service area. There are no deductibles or claim forms. Kaiser Permanente covers most services at 100% after participants pay a copayment. In exchange for lower per pay period premiums, you pay more money out-of-pocket when you receive services.

Benefit Coverage/Copay
Deductible None
Inpatient Hospital
$500 copay per day
Physician Office Visits
$30 copay
Routine Physical Exams No copay
Routine GYN Exams
No copay
Maternity Care Office Visits Prenatal and 1st postpartum - no copay; all other visits $20 copay
Well-Baby Care No copay
Prescription Drugs
$10 copay generic;$25 copay for non-generic formulary
Emergency Room (waived if admitted) $150 copay, waived if hospitalized
Chiropractic
$15 copay;limited to 30 visits per year
Mental Health (Outpatient)*
 
$30 copay
 
Mental Health (Inpatient Hospital)
$500 copay per day
Vision Benefit (Exam)
$30 copay, no maximum
Vision Benefit (Lenses, Frames, and Contacts) $175 allowance every 24 months

*SCU provides additional mental health benefits through its Employee Assisitance Program (EAP) and Mental Health Benefits Program with United Behavioral Health (UBH).

This is a summary of the benefits provided. Once enrolled, members will receive a Combined Evidence of Coverage and Disclosure Form. See also Chiropractic Care and Principal Benefits - for non-union members only (PDF) for plan details, exclusions and limitations.

 
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Established 1851