Maryland - Retired Employees

"Bold" print identifies plan changes effective 1/1/2003
Plan Name	Kaiser HMO of Maryland	Sparrows Point Plan PPO In- Network	Sparrows Point Plan PPO Out-of-Network
Web Site	www.kaiserpermanente.org	www.fidelityig.com	www.fidelityig.com
Member Service Number	1-800-777-7902 (Also the Pre-Enrollee Number) Group No. 6456	410-329-1800	410-329-1800
Individual Lifetime Maximum Benefits	None	None	$1 Million
Annual Deductible
Individual	None	None	None
Family	None	None	None
Coinsurance	None	None	25%
Annual Out-of-Pocket Maximum
Individual	None	None	$2,000
Family	None	None	$4,000
Inpatient Hospital	100% covered	100%	100% of maximum allowed charge
Physician Services: PCP Office Visit	$15 copay	$15 copay	100% of maximum allowed charge (less $15 copay)
Emergency Care: In-area Hospital	$35 copay - waived if admitted	100%	100% of maximum allowed charge
Outpatient X-Ray and Lab	100% covered	100%	100% of maximum allowed charge
Durable Medical Equipment	100% covered	100%	100% of maximum allowed charge
Retail Prescription Coverage
Generic	$10 copay for 60-day supply at Kaiser Pharmacies;$20 copay for a 60-day supply at community pharmacies	15% (Represented) 20% (Salaried)	15% (Represented) 20% (Salaried)
Brand Name	$15 surcharge for a 60-day supply when not required by physician	25% if generic unavailable; 30% if Generic available and medically necessary (Represented) 30% if generic unavailable; 50% if Generic available and medically necessary (Salaried)	25% if generic unavailable; 30% if Generic available and medically necessary (Represented) 30% if generic unavailable; 50% if Generic available and medically necessary (Salaried)
Mail-Order Prescription Coverage
Generic	$10 copay for 60-day supply	10% Generic; 20% Brand if Generic unavailable; 25% if Generic available and medically necessary (Represented) 10% Generic; 20% Brand if Generic unavailable; 40% if Generic available and medically necessary (Salaried)	10% Generic; 20% Brand if Generic unavailable; 25% if Generic available and medically necessary (Represented) 10% Generic; 20% Brand if Generic unavailable; 40% if Generic available and medically necessary (Salaried)
Brand Name	Available only if there is no generic equivalent	See Above	See Above
Diabetic Benefits
Insulin	$10 copay for 60-day supply at Kaiser Pharmacies	Covered Under Pharmacy Benefit	Covered Under Pharmacy Benefit
Chem. Strips/Lancets	$10 copay for 60-day supply at Kaiser Pharmacies	Covered Under Pharmacy Benefit	Covered Under Pharmacy Benefit
Home Health Care	100% covered	100% up to 100 visits per calendar year	100% of allowed charges up to 100 visits per calendar year
Mental Health
Inpatient	100% covered, no maximum	100% up to 60 days per calendar year (OP days count towards maximum)	Not Covered
Outpatient	$20 individual, $10 group, unlimited visits	100% up to 80 days per calendar year (IP days count towards maximum)	Not Covered
Substance Abuse
Inpatient	100% covered, no maximum	100% up to 60 days per calendar year (Combined with OP days)	Not Covered
Outpatient	$20 individual, $10 group, unlimited visits	100% up to 60 days per calendar year (Combined with IP days)	Not Covered
Vision Care
Routine Eye Exam	$15 copay	Not Covered	Not Covered
Eyeglasses and Contact Lenses	25% discount lenses and frames; $15 discount contacts	Not Covered	Not Covered
Hearing Care
Exam	100% covered	Provided by National Ear Care Plan (NECP) - 1-800-999-1458	Not Covered
Hearing Aids	One hearing aid every 36 months	Provided by National Ear Care Plan (NECP) - 1-800-999-1458	Not Covered
Dental Care
Basic Services	Not Covered	Not Covered	Not Covered
Major Services	Not Covered	Not Covered	Not Covered
Preventive Services	Not Covered	Not Covered	Not Covered
Wellness Benefits	$15 copay	$15 Copay	Not Covered