2017 Rates and Benefits

Kaiser Foundation Health Plan of Washington Options, Inc. FEHB Rates

High Deductible Health Plan (HDHP)

Enrollment TypeCode Non-Postal Biweekly PremiumPostal Category 1 Biweekly PremiumPostal Category 2 Biweekly PremiumAnnuitant Premium
Self OnlyL14$59.16$51.47$49.10$128.18
Self Plus One L16$123.41$107.36$102.43$267.38
Self and FamilyL15$138.64$120.61$115.07$300.38

Standard Option

Enrollment TypeCode Non-Postal Biweekly PremiumPostal Category 1 Biweekly PremiumPostal Category 2 Biweekly PremiumAnnuitant Premium
Self OnlyL11$73.64$64.07$61.12$159.56
Self Plus One L13$154.65$134.55$128.36$335.08
Self and FamilyL12$201.76$180.70$173.69$437.15

High Option

Enrollment TypeCode Non-Postal Biweekly PremiumPostal Category 1 Biweekly PremiumPostal Category 2 Biweekly PremiumAnnuitant Premium
Self OnlyVT1$203.48$194.25$191.17$440.87
Self Plus One VT3$417.01$397.18$390.58$903.52
Self and FamilyVT2$515.13$494.07$487.06$1,116.12

Non-Postal rates apply to most non-Postal employees. If you are in a special enrollment category, contact the agency that maintains your health benefits enrollment.

Postal rates apply to Postal Service employees.

Postal Category 1 rates apply to career bargaining unit employees who are represented by the APWU (including IT/ASC, MDC, OS and NPPN employees) and NRLCA.

Postal Category 2 rates apply to career bargaining unit employees who are represented by the NALC, NPMHU and PPO.

Non-Postal rates apply to all career non-bargaining unit Postal Service employees.

For further assistance, Postal Service employees should call:

Human Resources Shared Service Center, 877-477-3273, option 5, TTY: 866-260-7507

Postal rates do not apply to non-career Postal employees, Postal retirees, or associate members of any Postal employee organization who are not career postal employees.

Kaiser Foundation Health Plan of Washington Options, Inc. FEHB Benefits

CoverageHigh Option Plan You Pay


Deductible Applies, Except Where Indicated
Standard Option Plan You Pay

Deductible applies, except where indicated
High Deductible Health Plan You Pay

Deductible must be met before benefits apply, except where indicated
Annual Deductible$100 individual / $200 family
$350 individual / $700 family

Plan providers: $1,500 individual / $3,000 family

Non-Plan Providers: $1,500 Individual/$3,000 Family

Annual Out-of-Pocket Maximum

Plan Providers: $5,000 Individual/$10,000 Family (Includes copays, RX copays, and coinsurance)

Non-Plan Providers: Unlimited

Plan Providers: $5,000 Individual/$10,000 Family (Includes deductible, copays, RX copays, and coinsurance)

Non-Plan Providers: Unlimited

Plan Providers: $5,000 Individual/$10,000 Family (Includes deductible, RX copays, and coinsurance)

Non-Plan Providers: Non-Plan Providers: $5,000 Individual/$10,000 Family (Includes deductible, RX copays, and coinsurance)

Preventive Care Visit

Adult routine physical exams & screenings, mammograms, PSA testing, immunizations, routine screening eye exams.

Child routine physical exams & immunizations, routine eye and hearing exams.

Nothing, no deductible

 

 

 

Nothing, no deductible

Nothing, no deductible

 

 

 

Nothing, no deductible

Nothing, no deductible

 

 

 

Nothing, no deductible

Professional Services
Office, Home, Naturopath or Urgent Care Visits

$30 copay per office visitNo deductible, $25 primary / $35 specialty copay per office visit20% coinsurance
Lab and X-ray20% coinsurance20% coinsurance20% coinsurance

Facility/Hospital
Inpatient & Outpatient
Inpatient requires preauthorization

20% coinsurance20% coinsurance20% coinsurance
Emergency Room & Supplies$150 copay per visit (waived if admitted)20% coinsurance20% coinsurance
MaternityNothing, no decuctibleNothing, no deductible20% coinsurance
(Prenatal care covered at 100%, no deductible)

Ambulance
Ground & Air

20% coinsurance20% coinsurance20% coinsurance

Alternative Care - Acupuncture, Chiropractic, Massage Therapy
20 treatments max per provider type per year

$30 copay per office visitNo deductible
$25 primary / $35 specialty copay per office visit
20% coinsurance
Mental Health

Inpatient requires preauthorization

Outpatient: No deductible
$30 copay per office visit
Inpatient 20% coinsurance

Outpatient: No deductible $25 primary / $35 specialty copay per office visit
Inpatient 20% coinsurance

Outpatient: 20% coinsurance
Inpatient 20% coinsurance

Prescription Drugs
90-day supply of any Tier 1, Tier 2, or Tier 3 medications with two copays (some exceptions)

No deductible
Tier 1 - $10 copay
Tier 2 - $35 copay
Tier 3 - $60 copay
Tier 4 - 25% up to $200 per 30 day supply
Tier 5 - 35% up to $300 per 30 day supply

No deductible
Tier 1 - $20 copay
Tier 2 - $40 copay
Tier 3 - $60 copay
Tier 4 - 25% up to $200 per 30 day supply
Tier 5 - 35% up to $300 per 30 day supply

Tier 1 - $20 copay
Tier 2 - $40 copay
Tier 3 - $60 copay
Tier 4 - 25% up to $200 per 30 day supply
Tier 5 - 35% up to $300 per 30 day supply

Worldwide Travel Benefit
(Outside WA State)

Applicable Benefit Cost Shares

Applicable Benefit Cost Shares

Applicable Benefit Cost Shares

Compare Your Plan Options PDFHigh OptionStandard OptionHigh Deductible Health Plan
Summary of Benefits and Coverage PDFHigh OptionStandard OptionHigh Deductible Health Plan

Dental Benefits (Included in Medical Premium)

CoverageHigh Option Plan You Pay
Standard Option Plan You Pay
High Deductible Health Plan You Pay

Preventive
No Deductible

All charges in excess of scheduled allowanceAll charges in excess of scheduled allowanceAll charges in excess of scheduled allowance

Basic and Major
No annual maximum for children through age 17.*

All charges in excess of scheduled allowance after $25 individual/$50 family deductibleAll chargesAll charges

*$1,000 annual maximum applies for adults age 18 and older.

Vision Benefits (Included in Medical Premium)

CoverageHigh Option Plan You Pay
Standard Option Plan You Pay
High Deductible Health Plan You Pay

Annual routine eye exam

Nothing. No deductibleNothing. No deductibleNothing. No deductible

Diagnostic exams

$30 copay per exam
No deductible
$25 primary / $35 specialty copay per exam
No deductible
Deductible and 20% coinsurance

Eyeglasses or contact lenses
(Accident or surgery related)

Deductible and 20% coinsuranceDeductible and 20% coinsuranceDeductible and 20% coinsurance

Other services & hardware

All charges less 20% discountAll charges less 20% discountAll charges less 20% discount

Note: The above information is a summary of benefits. It is not a contract. For complete information, and before making a final decision, please read the Federal brochure (RI 73-051). All benefits are subject to the definitions, limitations and exclusions set forth in the brochure.