Medical Plan

Kaiser Permanente HMO Plan†

Enjoy a low deductible and low annual out-of-pocket maximum. Benefit Tip: This plan does not provide out-of-network coverage, and you must designate a Primary Care Physician before visiting the doctor. Kaiser HMO Plan Summary of Benefits

† Available to employees in the following states only: California, Colorado, Mid Atlantic, Georgia, Northwest and Washington.
Kaiser Permanente†*
In-Network Only
Calendar Year Deductible
Individual$250
Family$500
Calendar Year Out-of-Pocket Maximum (Includes Deductible)
Individual$2,000
Family$4,000
Coinsurance/CopaysYou Pay
Preventive Care$0
Primary Care Physician$25
Specialist$30
Urgent Care$30
Emergency Room$200
Inpatient Hospital10%**
Mental Health & Substance AbuseYou Pay
Inpatient$12
Outpatient$5
Pharmacy Retail Rx (up to 30-day supply)You Pay
PreventiveN/A
Generic$10
Preferred Brand$30
Non-Preferred Brand$60
Specialty10% up to $250 max
Mail Order Rx (up to 90-day supply)You Pay
PreventiveN/A
Generic$20
Preferred Brand$60
Non-Preferred Brand$120
Specialty (30-day supply only)10% up to $250
*The benefits for Colorado are as follows: Inpatient Hospital is 10% coinsurance. Inpatient Mental Health & Substance Abuse is $20 copay.
**Copay/cost share applies after plan deductible is met.
† Available to employees in the following states only: California, Colorado, Mid Atlantic, Georgia, Northwest and Washington.