KAI 2022 ENROLLMENT • PLANNING FOR YOUR BENEFITS
MEDICAL BENEFITS
Kao America Inc. Medical Plans Comparison Chart PLAN OPTION
Coverage Limits/Plan Features
PPO
HDHP
In-Network
Out-of-Network
In-Network
Out-of-Network
Calendar-Year Deductible
$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
Unlimited
Unlimited
Unlimited
Unlimited
Lifetime Maximum
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
Copay/Coinsurance | Plan Pays
Health Savings Account
Covered Services Preventive Benefits
$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. 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
$40 copay then plan pays 100%
Deductible then plan pays 60%
Deductible then plan pays 100%
Deductible then plan pays 60%
Outpatient Surgery
Deductible then plan pays 80%
Deductible then plan pays 60%
Deductible then plan pays 100%
Deductible then plan pays 60%
Hospital: Inpatient Stay
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%
Same as in-network
Deductible then plan pays 100%
Same as in-network
Deductible then plan pays 80%
Deductible then plan pays 60%
Deductible then plan pays 100%
Deductible then plan pays 60%
Urgent Care Center
$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
Deductible then plan pays 80%
Deductible then plan pays 60%
Deductible then plan pays 100%
Deductible then plan pays 60%
Mental Health/Substance Abuse: Outpatient
$40 Individual; $25 Group then plan pays 100%
Deductible then plan pays 60%
Deductible then plan pays 100%
Deductible then plan pays 60%
(applies to services provided by a specialist)
Professional Fees for Surgical & Medical Services (Inpatient & Outpatient)
Emergency Room Advanced Imaging
(includes MRI, CT, MRA, PET and Nuclear Medicine)
Prescription Drug1 Retail Drug
(Participating pharmacy up to 30 day supply)
Mail-Order
(Participating pharmacy 90 day supply) 1
Tier 1: $10 | Tier 2: $30 | Tier 3: $50
Deductible then plan pays 100%
Tier 1: $20 | Tier 2: $60 | Tier 3: $100
Deductible then plan pays 100%
Tier 1 Generic (your lowest cost option), Tier 2 Formulary Brand (your mid-cost option), Tier 3 Non-Preferred Brand (your highest cost option)
9 | Lea r n m o re a b o u t y o u r b en e fits by e ma ilin g b enef its @ Kao .com o r by cal l i ng 800-650-8180
