%PDF-1.6
%
158 0 obj
<>stream
hެj1_e^$ds B/ һŋPlVo$imP
Mor @P2ЀT`:X+AP3G vz~\FƉ=[qS8=712={axx<o>.K--M&t [BO9`Y&O22~oJ8H)?Ϲuݝp~n$lc8O>%a7ɿ@\+ɫ@$6u 隁:ffuf̪̪Ue֫ X|%
endstream
endobj
159 0 obj
<>stream
hތϱ
1W7H6p\Xy zAID-da+l09p!#\E ӵ@\+3ܦqlpʳ.<>î{CQLV]ʃL> K7
endstream
endobj
160 0 obj
<>stream
hތM@#f?B(J`a[ѿonzygFDXQ׳UE,x%CvienZ KYݤ\z:<b!{
/$ϫy?$`HbqӇ/%/t.OH:Z6c3tֵ>4@O7,w:2# Y
endstream
endobj
161 0 obj
<>stream
hIn0EOpY]u@ot'Nh((JD9':łV"&)TpH/AI
!XtJPKQ@
,"!hFYF#ffJ@6F9oPcJz||x/_@S`>g"bzB]caJsdתdmu&*sTg4c<2;&URuFPv {O'tssLEX&^hFxkX,vC-{J`=Oz(6E}.jdlH$`ekߡ=_ V$
endstream
endobj
1 0 obj
<>
endobj
4 0 obj
<>
endobj
5 0 obj
<>stream
SBCGRP_00101
$100 copayment/visit
0
Not Covered
Not Applicable Individual / Not Applicable Family
$0 copayment/admission
93303-1847
None
20
---
Not Covered
No
No
Not Applicable Individual / Not Applicable Family
No
Not Applicable Individual / Not Applicable Family
01/09/2013
Not Covered
Not Covered
PO BOX 1847
Not Covered
Not Covered
healthy.kaiserpermanente.org/health/care/consumer/locate-our-services/doctors-and-locations
en
$0 copayment/pair
None
Acupuncture with limits^Bariatric Surgery^Chiropractic Care^Infertility Treatment^Routine Eye Exam (Adult)^Routine Foot Care^Routine Hearing Tests
Not Covered
Kaiser Permanente
Premiums, payments for health care this plan doesn't cover and cost sharing for certain services listed in plan documents.
Yes
No
//cnndcsbdm002/pspNASPROD/psp/mapperinput/SBC_GRP_MIDLG_CA/SBC_GRP_MIDLG_CAL_20130109084501.txt
January 09, 2013
RQR_REQUEST
Not Covered
68000
$0 copayment/visit
No
$0 copayment/admission
$30 copayment/visit
Covered
Not Covered
None
$30 copayment/visit
Not Covered
Covered
Nick Kouklis
Not Covered
Not Covered
None
$0 copayment/encounter
Not Covered
None
1-800-777-1370
5
None
Not Applicable Individual / Not Applicable Family
$1500 Individual / $3000 Family
healthhelp.ca.gov/
Not Covered
A179444
Not Covered
No
SBC_GRP_MIDLG_CA
$0 copayment/service
Not Applicable Individual / Not Applicable Family
TRADITIONAL PLAN
Not Applicable Individual / Not Applicable Family
$30 copayment/day
888-466-2219
Not Covered
600115
$150 Allowance per 24 Month(S)
$0 copayment/admission
Not Covered
700
80
en
Yes
Family
Covered
HMO
None
$10 copayment/prescription
No
CA
09/30/2013
800-777-7902
None
No
Yes
Not Covered
Yes
Not Applicable Individual / Not Applicable Family
N
$50 copayment/trip
Not Covered
BATCH
$0 copayment/procedure
Bi-Fold
None
Deductible + Coinsurance/Co-pay for Prescription Drugs, Office Viisits, and other services count towards the deductible. Does not apply to Preventive care and Generic drugs.
www.kp.org/formulary
Yes
Services related to Infertility covered at 50% coinsurance/visit
Cosmetic Surgery^Hearing Aids^Long-Term Care^Non-Emergency Care when Travelling Outside the U.S.^Private-Duty Nursing^Routine Dental Services (Adult)^Weight Loss Programs
Limited to diagnoses of a terminal illness with a life expectancy of twelve months or less
Yes
None
1847
200
Not Covered
Yes
Not Covered
None
$30 copayment/prescription for 1 to 100 day(s). Certain drugs may be covered at a higher cost share.
Covered
01/09/2013
10/01/2012
No
NCR
$30 copayment/visit Individual, $5 copayment/visit Group
1.0
Not Covered
Inpatient:$0 copayment/admission; Outpatient:$30 copayment/day
200
1,500
None
SBC_GRP_MIDLG_CA_1117582_2
800-278-3296
Mid/Large
$0 copayment/visit
Not Covered
01/01/2002
Must be in accordance with formulary guidelines
1-800-464-4000
No
$30 copayment/visit
No
Not Applicable Individual / Not Applicable Family
$30 copayment/prescription
Not Covered
Covered
SISC - SELF-INSURED SCHOOLS OF CALIFORNIA NCR
Not Covered
No
www.kp.org
No
Not Covered
Not Covered
None
Up to 100 day maximum per benefit period.
www.kp.org
220
None
3,000
true
For exclusions to the Out-of-Network Annual Out-of-Pocket Limit, please refer to the contract
Not Covered
Not Covered
Covered with Limitations
93303
$30 copayment/visit
39228393
No
NO_SIGNIFICANT_CHANGES(0)
Up to 30 visit(s) / Calendar Year for chiropractic services, Physician referred acupuncture.
12/31/4000
Not Applicable Individual / Not Applicable Family
Yes
$0 copayment/visit
$10 copayment/visit for chiropractic services,$30 copayment/visit for acupuncture.
DUPLEX
SBC_GRP_MIDLG_CA
Non plan providers covered when outside a service area.
Not Covered
980
01/09/2013
4,420
None
None
Cost sharing for prenatal care is for routine preventive care only. Cost sharing for postnatal care is for the first postnatal visit only.
Same as Preferred brand drugs.
Nick Kouklis
No
Not Covered
Covered
$0 copayment/admission
$30 copayment/prescription
Not Covered
0
$100 copayment/visit
Nick Kouklis
Not Covered
$30 copayment/procedure
$0 copayment/admission
0
$30 copayment/visit
Yes
1-888-466-2219
10/1/2012 Renewal - Final TRADITIONAL HMO NCR
Not Covered
Not Applicable Individual / Not Applicable Family
1696
Not Covered
written referral required but you may self-refer to certain specialists.
20% coinsurance/item
Up to 2 hour(s) Maximum/ Visit ,Up to 3 visit(s) Maximum/ Day ,Up to 100 visit(s) Maximum/ Calendar Year
-1
None
BATCH
None
None
$50 copayment/trip
N
$30 copayment/visit Individual, $15 copayment/visit Group
None
None
Not Covered
BAKERSFIELD
$30 copayment/prescription
CA
Limited to services to maintain/improve skills or functioning at risk due to medical deficits.
:933031847471:
Not Covered
Not Covered
Yes
Y
Prenatal care: $0 copayment/visit, Postnatal care: $0 copayment/visit
Some preventive screenings ( such as lab and imaging ) may be at a different cost share.
$10 copayment/prescription for 1 to 100 day(s). Certain drugs may be covered at a higher cost share.
NCR
Not Covered
No
Same as Preferred brand drug when approved through exception process.
Not Covered
$0 copayment/admission
None
LAMMERSVILLE ELEMENTARY TRADITIONAL HMO NCR - 1 -S
7,320
$0 copayment/procedure
None
2013-01-09T13:10:24-08:00
XSL Formatter V4.3 MR6e (4,3,2009,0317) for Windows
2013-01-14T16:23:33-08:00
2013-01-14T16:23:33-08:00
Antenna House PDF Output Library 2.6.0 (Windows)
False
application/pdf
id="SBC_GRP_MIDLG_CA_1117582_2"
SBC_GRP_MIDLG_CA_1117582_2
uuid:6856ec21-de8e-4b8e-8eb0-4da566d1ed4f
uuid:970ba3d8-47da-4cc0-93ab-f9737cd5d0c6
endstream
endobj
6 0 obj
<>
endobj
10 0 obj
<>
endobj
22 0 obj
<>
endobj
27 0 obj
<>stream
x]K丑W<@iħHP@Uvn>|`Qe|G!j4S~ud(ʦ~,mr4_%}gflfV}NLlԲ0
ej[_e^*+Uebӿ|+BjāU̚%l\]fUb\̶%Kg9NbVVW:}e~搆l!A?˗W:Q1}#@٬%j,|]b]EZ^~j^"fHm-៣KQD%Wƕ<&_[\ >kmO#Llysl&H[bArb
]WdIr zP[._VE3j+#p'k_&W>?|+]A,FD~}9Ǵ_v.$ev:]eyVՔK۶Do"
'ջLU&sd-xwXkDVpB܀z,<Ohrwjy/'Uv>#Iulꑪg+i(Y2g^
8
@}n-q(?~r?bD\OΕBbdHM<@|ЕTrx
Qi`ju
,
*PQ)_rBrNē<<9r&N?iFoB\;sE