Kaiser HMO

HMO coverage through Kaiser Permanente for employees in Kaiser service areas. Kaiser CA is for California employees and Kaiser NW is for Oregon and SW Washington employees. Both are shown below.

Kaiser HMO

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Key Details

Carrier: Kaiser Permanente
Plan Type: HMO
Network: Kaiser Permanente
HSA Eligible: No
FSA Eligible: Yes

Semi-Monthly Premiums

Coverage Tier	Semi-Monthly Cost
Employee Only	$42.00
Employee + Spouse	$143.50
Employee + Child(ren)	$117.50
Employee + Family (Spouse & Child(ren))	$174.50

Employee Only

Semi-Monthly Cost: $42.00

Employee + Spouse

Semi-Monthly Cost: $143.50

Employee + Child(ren)

Semi-Monthly Cost: $117.50

Employee + Family (Spouse & Child(ren))

Semi-Monthly Cost: $174.50

Coverage Details

Service	Kaiser CA HMO	Kaiser NW HMO
Annual Deductible (Embedded)	$500 Individual $1,000 Family	$500 Individual $1,000 Family
Annual Out-of-Pocket Maximum	$1,500 Individual $3,000 Family	$1,500 Individual $3,000 Family
Coinsurance	20%	20%
Office Visit Primary Provider	$20 Copay	$20 Copay
Office Visit Specialist	$30 Copay	$30 Copay
Preventive Care	Covered in Full	Covered in Full
Lab and X-ray	$10 Copay	$10 Copay
Urgent Care	$20 Copay	$30 Copay
Emergency Room	$200 after deductible (Waived if admitted)	$200 per visit (Waived if admitted)
Hospitalization	20% after deductible	20% after deductible
Outpatient Surgery	20% after deductible	20% after deductible

Annual Deductible (Embedded)

Kaiser CA HMO: $500 Individual $1,000 Family
Kaiser NW HMO: $500 Individual $1,000 Family

Annual Out-of-Pocket Maximum

Kaiser CA HMO: $1,500 Individual $3,000 Family
Kaiser NW HMO: $1,500 Individual $3,000 Family

Coinsurance

Kaiser CA HMO: 20%
Kaiser NW HMO: 20%

Office Visit Primary Provider

Kaiser CA HMO: $20 Copay
Kaiser NW HMO: $20 Copay

Office Visit Specialist

Kaiser CA HMO: $30 Copay
Kaiser NW HMO: $30 Copay

Preventive Care

Kaiser CA HMO: Covered in Full
Kaiser NW HMO: Covered in Full

Lab and X-ray

Kaiser CA HMO: $10 Copay
Kaiser NW HMO: $10 Copay

Urgent Care

Kaiser CA HMO: $20 Copay
Kaiser NW HMO: $30 Copay

Emergency Room

Kaiser CA HMO: $200 after deductible (Waived if admitted)
Kaiser NW HMO: $200 per visit (Waived if admitted)

Hospitalization

Kaiser CA HMO: 20% after deductible
Kaiser NW HMO: 20% after deductible

Outpatient Surgery

Kaiser CA HMO: 20% after deductible
Kaiser NW HMO: 20% after deductible

Prescription Drugs

Tier	Kaiser CA HMO	Kaiser NW HMO
Retail (30-day supply) - Generic	$10 Copay	$10 Copay
Retail (30-day supply) - Preferred Brand	$30 Copay	$30 Copay
Retail (30-day supply) - Non-Preferred Brand	$30 Copay	$60 Copay
Retail (30-day supply) - Specialty	20% up to $250	20% up to $250
Mail Order (90-day supply) - Generic	$20 Copay	$20 Copay
Mail Order (90-day supply) - Preferred Brand	$60 Copay	$60 Copay
Mail Order (90-day supply) - Non- Preferred Brand	$60 Copay	$120 Copay
Mail Order (90-day supply) - Specialty	N/A	N/A

Retail (30-day supply) - Generic

Kaiser CA HMO: $10 Copay
Kaiser NW HMO: $10 Copay

Retail (30-day supply) - Preferred Brand

Kaiser CA HMO: $30 Copay
Kaiser NW HMO: $30 Copay

Retail (30-day supply) - Non-Preferred Brand

Kaiser CA HMO: $30 Copay
Kaiser NW HMO: $60 Copay

Retail (30-day supply) - Specialty

Kaiser CA HMO: 20% up to $250
Kaiser NW HMO: 20% up to $250

Mail Order (90-day supply) - Generic

Kaiser CA HMO: $20 Copay
Kaiser NW HMO: $20 Copay

Mail Order (90-day supply) - Preferred Brand

Kaiser CA HMO: $60 Copay
Kaiser NW HMO: $60 Copay

Mail Order (90-day supply) - Non- Preferred Brand

Kaiser CA HMO: $60 Copay
Kaiser NW HMO: $120 Copay

Mail Order (90-day supply) - Specialty

Kaiser CA HMO: N/A
Kaiser NW HMO: N/A

Plan Notes

Kaiser is available in California and the Northwest region (WA & OR); eligibility is based on ZIP codes in Kaiser service areas. Visit the Hub for details.
Aggregate Deductible - When covering more than 1 person, co-insurance applies after the entire family deductible has been met.
Embedded Deductible - When covering more than 1 person, co-insurance applies after the individual deductible has been met.