Kaiser HMO Plan – CA Residents Only
Kaiser HMO Plan – CA Residents Only
The Kaiser HMO plan is an in-network only plan. This means all care must be received through a Kaiser contracted network provider. There is no coverage out-of-network, with the exception of medical emergencies or if care isn’t available in the network. Additionally, to see a specialist, a referral from a primary care doctor may be required.
| Kaiser HMO Plan |
|
|---|---|
| IN-NETWORK | |
| CALENDAR YEAR DEDUCTIBLE | |
| Individual | $1,000 |
| Family | $2,000 |
| CALENDAR YEAR OUT OF POCKET MAXIMUM (INCLUDES DEDUCIBLE) | |
| Individual | $3,000 |
| Family | $6,000 |
| COINSURANCE | YOU PAY |
| Preventive Care | $0 |
| Virtual Visits | $0 |
| Primary Care Physician | $20 copay |
| Specialist | $20 copay |
| Mental Health | Office Visit: $20 copay Other: 20%* |
| Urgent Care | $20 copay |
| Emergency Room | 20%* |
| Labs/X-Ray | $10 copay |
| PHARMACY | |
| RETAIL RX (UP TO 30-DAY SUPPLY) | |
| Generic | $10 copay |
| Preferred | $30 copay |
| Non-Preferred | $30 copay |
| Specialty | 20% up to $250 maximum |
| MAIL ORDER RX (UP TO 90-DAY SUPPLY) | |
| Generic | $20 copay |
| Preferred | $60 copay |
| Non-Preferred | $60 copay |
| Specialty | N/A |