Page 2 - 2019 Micromenders - Brochure PHS

MEDICAL HMO| DENTAL

Individual Funding $7,550 Delta Dental PPO

Employee Only In Network Out of Network
Max Out Of Pocket $25
(includes deductible) Deductible Individual
Office Copay Deductible Family $75
(PC/Specialist) Preventive 100%

Lab & X-Ray $0 Cleanings 3x per year
Use Wex Card
Hospital Inpatient Deductible Waived Yes
Outpatient Surgery Basic Endo/Perio 80% 80%
Acupuncture Major 50% 50%
(Physician-referred)
Chiropractic Not Covered Annual Maximum $1,500
(Per Member)
Ambulance $150 per trip Pays out of network MAC

ER Charge $150 per visit Waiting Period 24 Months
$0 Ortho Not Covered
Rx Generic
(by reimbursement via EBA&M app) Ortho Maximum N/A

$20 Copay
Rx Brand
(by reimbursement via EBA&M app) WHEN AND HOW TO USE YOUR WEX CARD

•Employees will have a starting balance of $7,550 on their Wex Cards to be used for covered medical services
 Use the Wex Visa Card to make payments as requested by Kaiser Permanente in a number of
•Employees who add dependents: ways; at point of service, via phone call, mail, bill sent to your home after the appointment or
•Will NOT receive a Wex Card. online at :www.kp.org/paymedicalbills
•Will submit their own claims to Ebam for reimbursement.

•Are 100% responsible for dependent claims and premiums.  Individual funding $7,550

KAISER RESOURCES  Use your Wex Visa Card until all funds are exhausted.
Kaiser Acupuncture Department

 https://thrive.kaiserpermanente.org/care-near-you/northern-california/gsaa/departments/acupuncture/  Your Wex Visa Card is not an insurance card, it’s simply a form of payment provided to you on
behalf of your employer.
Take control of your health plan
 You will not receive a Wex Visa Card if you are enrolled with Dependents

 Make appointments  Find a facility near you How to view your Card balance: Submit Claims via Email:

 Order prescription refills  View your medical record
 Go to www.yourwexcard.com  Send to: service@ebam.com
 Email doctors office  Pay medical Bills
My Health Manager  Login/Register
 Use your SSN as member ID
Stay connected with your doctor anytime, anywhere.

 Get your personalized care in  Schedule and manage your EBA&M—Employee Benefits Administrator
one place doctors appointments
 View your upcoming health  Have a video visit with your Manage your HRA easily Get started with the EBA&M’s new cloud platform in minutes
My Doctor Online reminders doctor
(NCAL Only)  Get Reimbursed quickly Download the Mobile App:

Download at:  Track Receipts
 Check Balances EBA&M FSA HRA
You can also visit https://m.kp.org https://m.kp.org for more info