Medical Plan Comparison Chart

Kao America Inc. Medical Plans Comparison Chart

PLAN OPTION PPO HDHP

Coverage Limits/Plan Features

Calendar-Year Deductible

In-Network Out-of-Network In-Network Out-of-Network $500 Single $1,000 Family $1,000 Single $2,000 Family $3,000 Single $6,000 Family $6,000 Single $12,000 Family

Annual Out-of-Pocket Maximum $3,000 Single $5,500 Family $5,000 Single $10,000 Family $3,000 Single $6,000 Family $12,000 Single $24,000 Family

Lifetime Maximum

Unlimited Unlimited Unlimited Unlimited

Health Savings Account

Covered Services

Preventive Benefits

Not Applicable KAI will make a one time contribution of $500 for employees who enroll in the Orange Medical Plan for 2022. In addition, KAI provides a $1 for $1 match on payroll contributions to your account up to $1,000. Account rolls over each year. Can be used on in- or out-of-network coverage.

Copay/Coinsurance | Plan Pays

$0 Not Covered $0 Not Covered

In-Network Preventive Benefits: Includes annual physical exam, routine gynecological care, well baby/child care and immunizations, hearing screening, preventive lab/x-ray screenings.

Copay/Coinsurance | Plan Pays

Virtual Visit

$5 employee copay, then plan pays 100% Deductible then plan pays 60% Deductible then plan pays 100% Deductible then plan pays 60%

Physician Office Visits: Primary Care Type Physician

$25 employee copay, then plan pays 100% Deductible then plan pays 60% Deductible then plan pays 100% Deductible then plan pays 60%

Specialist Office Visits

(applies to services provided by a specialist)

$40 copay then plan pays 100% Deductible then plan pays 60% Deductible then plan pays 100% Deductible then plan pays 60%

Outpatient Surgery

Hospital: Inpatient Stay Professional Fees for Surgical & Medical Services

(Inpatient & Outpatient) Deductible then plan pays 80% Deductible then plan pays 60% Deductible then plan pays 100% Deductible then plan pays 60%

Deductible then plan pays 80% Deductible then plan pays 60% Deductible then plan pays 100% Deductible then plan pays 60%

Deductible then plan pays 80% Deductible then plan pays 60% Deductible then plan pays 100% Deductible then plan pays 60%

Emergency Room

Deductible then plan pays 80% Same as in-network

Advanced Imaging

(includes MRI, CT, MRA, PET and Nuclear Medicine)

Urgent Care Center

Deductible then plan pays 80% Deductible then plan pays 60% Deductible then plan pays 100% Deductible then plan pays 60%

$50 copay, then plan pays 100% Deductible then plan pays 60% Deductible then plan pays 100% Deductible then plan pays 60%

Mental Health/Substance Abuse: Inpatient

Mental Health/Substance Abuse: Outpatient

Deductible then plan pays 80% Deductible then plan pays 60% Deductible then plan pays 100% Deductible then plan pays 60%

$40 Individual; $25 Group then plan pays 100% Deductible then plan pays 60% Deductible then plan pays 100% Deductible then plan pays 60%

Prescription Drug1 Retail Drug (Participating pharmacy up to 30 day supply) Tier 1: $10 | Tier 2: $30 | Tier 3: $50

Mail-Order

(Participating pharmacy 90 day supply) Tier 1: $20 | Tier 2: $60 | Tier 3: $100 Deductible then plan pays 100% Same as in-network

Deductible then plan pays 100%

Deductible then plan pays 100%