Kaiser HMO (CA Only)
Medical coverage options through Kaiser Permanente (California residents only) and UnitedHealthcare.
Plan Details
Network
Kaiser Permanente network
Administrator
Kaiser Permanente
Plan Type
HMO
HSA Eligible
No
FSA Eligible
Yes
Eligibility
Available only to residents of California
Premium Contributions
| Coverage Tier | Per-Paycheck Contribution |
|---|---|
| Employee Only | $24.92 |
| Employee + Spouse | $304.92 |
| Employee + Child(ren) | $205.61 |
| Employee + Family | $398.53 |
Employee Only
- Per-Paycheck Contribution
- $24.92
Employee + Spouse
- Per-Paycheck Contribution
- $304.92
Employee + Child(ren)
- Per-Paycheck Contribution
- $205.61
Employee + Family
- Per-Paycheck Contribution
- $398.53
Covered Services
| Service | In-Network |
|---|---|
| Deductible (Individual/Family) | None / None |
| Out-of-Pocket Max (Individual/Family) | $4,000 / $8,000 |
| Office Visits (physician/specialist) | $35 / $50 copay |
| Routine Preventive Care | No charge |
| Diagnostics (lab/X-ray) | $15 copay |
| Complex Imaging | 20% |
| Chiropractic | $15 copay |
| Ambulance | $150 copay |
| Emergency Room | 20% |
| Urgent Care Facility | $35 copay |
| Inpatient Hospital Stay | 20% |
| Outpatient Surgery | 20% |
Deductible (Individual/Family)
- In-Network
- None / None
Out-of-Pocket Max (Individual/Family)
- In-Network
- $4,000 / $8,000
Office Visits (physician/specialist)
- In-Network
- $35 / $50 copay
Routine Preventive Care
- In-Network
- No charge
Diagnostics (lab/X-ray)
- In-Network
- $15 copay
Complex Imaging
- In-Network
- 20%
Chiropractic
- In-Network
- $15 copay
Ambulance
- In-Network
- $150 copay
Emergency Room
- In-Network
- 20%
Urgent Care Facility
- In-Network
- $35 copay
Inpatient Hospital Stay
- In-Network
- 20%
Outpatient Surgery
- In-Network
- 20%
- Coinsurance percentages and copay amounts shown in the above chart represent what the member is responsible for paying.
- *Benefits with an asterisk ( * ) require that the deductible be met before the Plan begins to pay.
Pharmacy Benefits
| Tier | In-Network |
|---|---|
| Retail (30-day supply) – Tier 1 | $15 |
| Retail (30-day supply) – Tier 2 | $40 |
| Retail (30-day supply) – Specialty | 20% up to $250 |
| Mail Order (90-day supply) – Tier 1 | $30 |
| Mail Order (90-day supply) – Tier 2 | $80 |
| Mail Order (90-day supply) – Non-Formulary | N/A |
Retail (30-day supply) – Tier 1
- In-Network
- $15
Retail (30-day supply) – Tier 2
- In-Network
- $40
Retail (30-day supply) – Specialty
- In-Network
- 20% up to $250
Mail Order (90-day supply) – Tier 1
- In-Network
- $30
Mail Order (90-day supply) – Tier 2
- In-Network
- $80
Mail Order (90-day supply) – Non-Formulary
- In-Network
- N/A
Plan Notes
- The Kaiser Permanente HMO plans are only available to residents of California.
- You must use the Kaiser Permanente network of providers and facilities unless you need emergency care.
- Kaiser Permanente administers prescription drug services for its plans.
- Find additional information and resources at kp.org.