|
Kaiser Essential |
Kaiser CDHP with HSA |
Kaiser Enhanced |
|
|---|---|---|---|
|
Annual Deductible |
|||
|
Individual | Family |
$4,000 | $8,000 |
$2,500 | $5,000 |
$1,000 | $2,000 |
|
Maximum Out-of-pocket |
|||
|
Individual | Family |
$8,000 | $16,000 |
$5,000 | $10,000 |
$3,500 | $7,000 |
|
Hospital Inpatient |
|||
|
Services rendered while hospitalized |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Maternity Inpatient |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient |
|||
|
Primary Care |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Urgent Care |
$50 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$50 per visit (Plan Deductible does not apply) |
|
Specialist |
$50 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$50 per visit (Plan Deductible does not apply) |
|
Well-child & Preventive Care visits |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Routine prenatal care |
30% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient surgery |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Therapies (PT/OT/ST) |
$30 per visit after Plan Deductible limited to 30 visits per therapy per accumulation period |
20% Coinsurance after Plan Deductible limited to 30 visits per therapy per accumulation period |
$25 per visit (Plan Deductible does not apply) limited to 30 visits per therapy per accumulation period |
|
X-rays and Lab tests |
X-ray $15 per encounter after Plan Deductible; Lab $15 per encounter after Plan Deductible |
X-ray 20% Coinsurance after Plan Deductible; Lab 20% Coinsurance after Plan Deductible |
X-ray $10 per encounter (Plan Deductible does not apply); Lab $10 per encounter (Plan Deductible does not apply) |
|
Advanced Imaging (CT / MRI / PET) |
$150 per encounter after Plan Deductible |
20% Coinsurance after Plan Deductible |
$100 per encounter (Plan Deductible does not apply) |
|
Ambulance services |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
$150 per trip (Plan Deductible does not apply) |
|
Emergency department visits |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
$250 per visit after Plan Deductible waived if admitted |
|
Outpatient Prescription Drugs |
|||
|
Generic Drugs |
$10 Copay Retail (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply) |
$10 Copay Retail after Plan Deductible, $20 Copay Mail Order after Plan Deductible |
$10 Copay Retail (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply) |
|
Brand Drugs |
$30 Copay Retail (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply) |
$30 Copay Retail after Plan Deductible, $60 Copay Mail Order after Plan Deductible |
$30 Copay Retail (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply) |
|
Non-preferred Brand Drugs |
$60 Copay Retail (Plan Deductible does not apply), $120 Copay Mail Order (Plan Deductible does not apply) |
$60 Copay Retail after Plan Deductible, $120 Copay Mail Order after Plan Deductible |
$60 Copay Retail (Plan Deductible does not apply), $120 Copay Mail Order (Plan Deductible does not apply); when approved through the formulary exception process |
|
Specialty Drugs |
20% Coinsurance up to a maximum of $150 (Plan Deductible does not apply) |
20% Coinsurance up to a maximum of $150 after Plan Deductible |
20% Coinsurance up to a maximum of $150 (Plan Deductible does not apply) |
|
Pharmacy Deductible |
This Plan does not have a drug deductible |
This Plan does not have a drug deductible |
This Plan does not have a drug deductible |
|
Days Supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
|
Mental Health Services |
|||
|
Inpatient psychiatric care |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient individual therapy visits |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Outpatient group therapy visits |
$15 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$12 per visit (Plan Deductible does not apply) |
|
Substance Use Services |
|||
|
Inpatient detoxification |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient individual therapy visits |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Outpatient group therapy visits |
$15 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$12 per visit (Plan Deductible does not apply) |
|
Infertility Services |
|||
|
Covered services related to the treatment of infertility |
Cost share is determined by place of service. Includes IVF, GIFT & ZIFT. Includes Infertility drugs at applicable Pharmacy Cost Shares |
Cost share is determined by place of service after Plan Deductible. Includes IVF, GIFT & ZIFT. Includes Infertility drugs at applicable Pharmacy Cost Shares |
Cost share is determined by place of service. Includes IVF, GIFT & ZIFT. Includes Infertility drugs at applicable Pharmacy Cost Shares |
|
Additional Benefits |
|||
|
Base Durable Medical Equipment |
20% Coinsurance (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
20% Coinsurance (Plan Deductible does not apply) |
|
Skilled Nursing Facility |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
|
Home Health |
No Charge (Plan Deductible does not apply) limited to 120 visits per accumulation period |
No Charge after Plan Deductible limited to 120 visits per accumulation period |
No Charge (Plan Deductible does not apply) limited to 120 visits per accumulation period |
|
Hospice Care |
No Charge (Plan Deductible does not apply) (Unlimited Visits) |
No Charge after Plan Deductible (Unlimited Visits) |
No Charge (Plan Deductible does not apply) (Unlimited Visits) |
|
Vision Exam |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Riders |
|||
|
Hearing aids |
$1000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply) and Pediatric 20% Coinsurance / 1 device per ear / every 60 months after Plan Deductible |
$1000 allowance / 1 device per ear / every 36 months after Plan Deductible and Pediatric 20% Coinsurance / 1 device per ear / every 60 months after Plan Deductible |
$1000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply) and Pediatric 20% Coinsurance / 1 device per ear / every 60 months after Plan Deductible |
|
Chiropractic |
$30 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
20% Coinsurance / 20 visit limit per accumulation period after Plan Deductible |
$25 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
|
Acupuncture |
$30 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
20% Coinsurance / 20 visit limit per accumulation period after Plan Deductible |
$25 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
|
Bariatric surgery |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Kaiser Essential |
Kaiser CDHP with HSA |
Kaiser Enhanced |
|
|---|---|---|---|
|
Annual Deductible |
|||
|
Individual | Family |
$4,000 | $8,000 |
$2,500 | $5,000 |
$1,000 | $2,000 |
|
Maximum Out-of-pocket |
|||
|
Individual | Family |
$8,000 | $16,000 |
$5,000 | $10,000 |
$3,500 | $7,000 |
|
Hospital Inpatient |
|||
|
Services rendered while hospitalized |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Maternity Inpatient |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient |
|||
|
Primary Care |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Urgent Care |
$50 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$50 per visit (Plan Deductible does not apply) |
|
Specialist |
$50 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$50 per visit (Plan Deductible does not apply) |
|
Well-child & Preventive Care visits |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Routine prenatal care |
30% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient surgery |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Therapies (PT/OT/ST) |
$50 per visit after Plan Deductible limited to 30 visits per therapy per accumulation period |
20% Coinsurance after Plan Deductible limited to 30 visits per therapy per accumulation period |
$50 per visit (Plan Deductible does not apply) limited to 30 visits per therapy per accumulation period |
|
X-rays and Lab tests |
X-ray $15 per encounter after Plan Deductible; Lab $15 per encounter after Plan Deductible |
X-ray 20% Coinsurance after Plan Deductible; Lab 20% Coinsurance after Plan Deductible |
X-ray $10 per encounter (Plan Deductible does not apply); Lab $10 per encounter (Plan Deductible does not apply) |
|
Advanced Imaging (CT / MRI / PET) |
$150 per encounter after Plan Deductible |
20% Coinsurance after Plan Deductible |
$100 per encounter (Plan Deductible does not apply) |
|
Ambulance services |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
$150 per trip (Plan Deductible does not apply) |
|
Emergency department visits |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
$250 per visit after Plan Deductible waived if admitted |
|
Outpatient Prescription Drugs |
|||
|
Generic Drugs |
$10 Copay Retail (Plan Deductible does not apply), $20 Copay Community Pharmacy (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply) |
$10 Copay Retail after Plan Deductible, $20 Copay Community Pharmacy after Plan Deductible, $20 Copay Mail Order after Plan Deductible |
$10 Copay Retail (Plan Deductible does not apply), $20 Copay Community Pharmacy (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply) |
|
Brand Drugs |
$30 Copay Retail (Plan Deductible does not apply), $40 Copay Community Pharmacy (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply) |
$30 Copay Retail after Plan Deductible, $40 Copay Community Pharmacy after Plan Deductible, $60 Copay Mail Order after Plan Deductible |
$30 Copay Retail (Plan Deductible does not apply), $40 Copay Community Pharmacy (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply) |
|
Non-preferred Brand Drugs |
$60 Copay Retail (Plan Deductible does not apply), $70 Copay Community Pharmacy (Plan Deductible does not apply), $120 Copay Mail Order (Plan Deductible does not apply) |
$60 Copay Retail after Plan Deductible, $70 Copay Community Pharmacy after Plan Deductible, $120 Copay Mail Order after Plan Deductible |
$60 Copay Retail (Plan Deductible does not apply), $70 Copay Community Pharmacy (Plan Deductible does not apply), $120 Copay Mail Order (Plan Deductible does not apply) |
|
Specialty Drugs |
20% Coinsurance up to a maximum of $150 (Plan Deductible does not apply) |
20% Coinsurance up to a maximum of $150 after Plan Deductible |
20% Coinsurance up to a maximum of $150 (Plan Deductible does not apply) |
|
Pharmacy Deductible |
This Plan does not have a drug deductible |
This Plan does not have a drug deductible |
This Plan does not have a drug deductible |
|
Days Supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
|
Mental Health Services |
|||
|
Inpatient psychiatric care |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient individual therapy visits |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Outpatient group therapy visits |
$15 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$12 per visit (Plan Deductible does not apply) |
|
Substance Use Services |
|||
|
Inpatient detoxification |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient individual therapy visits |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Outpatient group therapy visits |
$15 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$12 per visit (Plan Deductible does not apply) |
|
Infertility Services |
|||
|
Covered services related to the treatment of infertility |
50% Coinsurance after Plan Deductible. Includes IVF, GIFT & ZIFT up to $30,000 per lifetime. Includes Infertility drugs |
50% Coinsurance after Plan Deductible. Includes IVF, GIFT & ZIFT up to $30,000 per lifetime. Includes Infertility drugs |
50% Coinsurance after Plan Deductible. Includes IVF, GIFT & ZIFT up to $30,000 per lifetime. Includes Infertility drugs |
|
Additional Benefits |
|||
|
Base Durable Medical Equipment |
20% Coinsurance (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
20% Coinsurance (Plan Deductible does not apply) |
|
Skilled Nursing Facility |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
|
Home Health |
No Charge (Plan Deductible does not apply) limited to 120 visits per accumulation period |
No Charge after Plan Deductible limited to 120 visits per accumulation period |
No Charge (Plan Deductible does not apply) limited to 120 visits per accumulation period |
|
Hospice Care |
No Charge (Plan Deductible does not apply) (Unlimited Visits) |
No Charge after Plan Deductible (Unlimited Visits) |
No Charge (Plan Deductible does not apply) (Unlimited Visits) |
|
Vision Exam |
$50 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$50 per visit (Plan Deductible does not apply) |
|
Riders |
|||
|
Hearing aids |
$1000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply) and Pediatric $3000 allowance / 1 device per ear / every 48 months (Plan Deductible does not apply) |
$1000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply) and Pediatric $3000 allowance / 1 device per ear / every 48 months (Plan Deductible does not apply) |
$1000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply) and Pediatric $3000 allowance / 1 device per ear / every 48 months (Plan Deductible does not apply) |
|
Chiropractic |
$30 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
20% Coinsurance / 20 visit limit per accumulation period after Plan Deductible |
$25 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
|
Acupuncture |
$30 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
20% Coinsurance / 20 visit limit per accumulation period after Plan Deductible |
$25 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
|
Bariatric surgery |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Kaiser Essential |
Kaiser CDHP with HSA |
Kaiser Enhanced |
|
|---|---|---|---|
|
Annual Deductible |
|||
|
Individual | Family |
$4,000 | $8,000 |
$2,500 | $5,000 |
$1,000 | $2,000 |
|
Maximum Out-of-pocket |
|||
|
Individual | Family |
$8,000 | $16,000 |
$5,000 | $10,000 |
$3,500 | $7,000 |
|
Hospital Inpatient |
|||
|
Services rendered while hospitalized |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Maternity Inpatient |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient |
|||
|
Primary Care |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Urgent Care |
$50 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$50 per visit (Plan Deductible does not apply) |
|
Specialist |
$50 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$50 per visit (Plan Deductible does not apply) |
|
Well-child & Preventive Care visits |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Routine prenatal care |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Outpatient surgery |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Therapies (PT/OT/ST) |
$50 per visit after Plan Deductible limited to 30 visits per therapy per accumulation period |
20% Coinsurance after Plan Deductible limited to 30 visits per therapy per accumulation period |
$50 per visit (Plan Deductible does not apply) limited to 30 visits per therapy per accumulation period |
|
X-rays and Lab tests |
X-ray $15 per encounter after Plan Deductible; Lab $15 per encounter after Plan Deductible |
X-ray 20% Coinsurance after Plan Deductible; Lab 20% Coinsurance after Plan Deductible |
X-ray $10 per encounter (Plan Deductible does not apply); Lab $10 per encounter (Plan Deductible does not apply) |
|
Advanced Imaging (CT / MRI / PET) |
$150 per encounter after Plan Deductible |
20% Coinsurance after Plan Deductible |
$100 per encounter (Plan Deductible does not apply) |
|
Ambulance services |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
$150 per trip (Plan Deductible does not apply) |
|
Emergency department visits |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
$250 per visit after Plan Deductible waived if admitted |
|
Outpatient Prescription Drugs |
|||
|
Generic Drugs |
$10 Copay Retail (Plan Deductible does not apply), $20 Copay Community Pharmacy (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply) |
$10 Copay Retail after Plan Deductible, $20 Copay Community Pharmacy after Plan Deductible, $20 Copay Mail Order after Plan Deductible |
$10 Copay Retail (Plan Deductible does not apply), $20 Copay Community Pharmacy (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply) |
|
Brand Drugs |
$30 Copay Retail (Plan Deductible does not apply), $40 Copay Community Pharmacy (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply) |
$30 Copay Retail after Plan Deductible, $40 Copay Community Pharmacy after Plan Deductible, $60 Copay Mail Order after Plan Deductible |
$30 Copay Retail (Plan Deductible does not apply), $40 Copay Community Pharmacy (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply) |
|
Non-preferred Brand Drugs |
$60 Copay Retail (Plan Deductible does not apply), $70 Copay Community Pharmacy (Plan Deductible does not apply), $120 Copay Mail Order (Plan Deductible does not apply) |
$60 Copay Retail after Plan Deductible, $70 Copay Community Pharmacy after Plan Deductible, $120 Copay Mail Order after Plan Deductible |
$60 Copay Retail (Plan Deductible does not apply), $70 Copay Community Pharmacy (Plan Deductible does not apply), $120 Copay Mail Order (Plan Deductible does not apply) |
|
Specialty Drugs |
20% Coinsurance up to a maximum of $150 (Plan Deductible does not apply) |
20% Coinsurance up to a maximum of $150 after Plan Deductible |
20% Coinsurance up to a maximum of $150 (Plan Deductible does not apply) |
|
Pharmacy Deductible |
This Plan does not have a drug deductible |
This Plan does not have a drug deductible |
This Plan does not have a drug deductible |
|
Days Supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
|
Mental Health Services |
|||
|
Inpatient psychiatric care |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient individual therapy visits |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Outpatient group therapy visits |
$15 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$12 per visit (Plan Deductible does not apply) |
|
Substance Use Services |
|||
|
Inpatient detoxification |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient individual therapy visits |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Outpatient group therapy visits |
$15 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$12 per visit (Plan Deductible does not apply) |
|
Infertility Services |
|||
|
Covered services related to the treatment of infertility |
50% Coinsurance after Plan Deductible. Includes IVF up to $100,000 per lifetime. Includes Infertility drugs |
50% Coinsurance after Plan Deductible. Includes IVF up to $100,000 per lifetime. Includes Infertility drugs |
50% Coinsurance (Plan Deductible does not apply). Includes IVF up to $100,000 per lifetime. Includes Infertility drugs |
|
Additional Benefits |
|||
|
Base Durable Medical Equipment |
20% Coinsurance (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
20% Coinsurance (Plan Deductible does not apply) |
|
Skilled Nursing Facility |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
|
Home Health |
No Charge (Plan Deductible does not apply) limited to 120 visits per accumulation period |
No Charge after Plan Deductible limited to 120 visits per accumulation period |
No Charge (Plan Deductible does not apply) limited to 120 visits per accumulation period |
|
Hospice Care |
No Charge (Plan Deductible does not apply) (Unlimited Visits) |
No Charge after Plan Deductible (Unlimited Visits) |
No Charge (Plan Deductible does not apply) (Unlimited Visits) |
|
Vision Exam |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Riders |
|||
|
Hearing aids |
$1000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply) and Pediatric $1500 allowance / 1 device per ear / every 24 months (Plan Deductible does not apply) |
$1000 allowance / 1 device per ear / every 36 months after Plan Deductible and Pediatric $1500 allowance / 1 device per ear / every 24 months after Plan Deductible |
$1000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply) and Pediatric $1500 allowance / 1 device per ear / every 24 months (Plan Deductible does not apply) |
|
Chiropractic |
$30 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
20% Coinsurance / 20 visit limit per accumulation period after Plan Deductible |
$25 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
|
Acupuncture |
$30 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
20% Coinsurance / 20 visit limit per accumulation period after Plan Deductible |
$25 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
|
Bariatric surgery |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Kaiser Essential |
Kaiser CDHP with HSA |
Kaiser Enhanced |
|
|---|---|---|---|
|
Annual Deductible |
|||
|
Individual | Family |
$4,000 | $8,000 |
$2,500 Individual | $3,400 Individual Family Member | $5,000 Family |
$1,000 | $2,000 |
|
Maximum Out-of-pocket |
|||
|
Individual | Family |
$8,000 | $16,000 |
$5,000 | $10,000 |
$3,500 | $7,000 |
|
Hospital Inpatient |
|||
|
Services rendered while hospitalized |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Maternity Inpatient |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient |
|||
|
Primary Care |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Urgent Care |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Specialist |
$50 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$50 per visit (Plan Deductible does not apply) |
|
Well-child & Preventive Care visits |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Routine prenatal care |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Outpatient surgery |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Therapies (PT/OT/ST) |
$30 per visit after Plan Deductible (Unlimited Visits) |
20% Coinsurance after Plan Deductible (Unlimited Visits) |
$25 per visit (Plan Deductible does not apply) (Unlimited Visits) |
|
X-rays and Lab tests |
X-ray $15 per encounter after Plan Deductible; Lab $15 per encounter after Plan Deductible |
X-ray 20% Coinsurance after Plan Deductible; Lab 20% Coinsurance after Plan Deductible |
X-ray $10 per encounter (Plan Deductible does not apply); Lab $10 per encounter (Plan Deductible does not apply) |
|
Advanced Imaging (CT / MRI / PET) |
$150 per encounter after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance (Plan Deductible does not apply) up to a maximum of $100 |
|
Ambulance services |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
$150 per trip (Plan Deductible does not apply) |
|
Emergency department visits |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
$250 per visit after Plan Deductible waived if admitted |
|
Outpatient Prescription Drugs |
|||
|
Generic Drugs |
$10 Copay Retail (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply) |
$10 Copay Retail after Plan Deductible, $20 Copay Mail Order after Plan Deductible |
$10 Copay Retail (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply) |
|
Brand Drugs |
$30 Copay Retail (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply) |
$30 Copay Retail after Plan Deductible, $60 Copay Mail Order after Plan Deductible |
$30 Copay Retail (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply) |
|
Non-preferred Brand Drugs |
$30 Copay Retail (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply); when approved through the formulary exception process |
$30 Copay Retail after Plan Deductible, $60 Copay Mail Order after Plan Deductible; when approved through the formulary exception process |
$30 Copay Retail (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply); when approved through the formulary exception process |
|
Specialty Drugs |
20% Coinsurance up to a maximum of $150 (Plan Deductible does not apply) |
20% Coinsurance up to a maximum of $150 after Plan Deductible |
20% Coinsurance up to a maximum of $150 (Plan Deductible does not apply) |
|
Pharmacy Deductible |
This Plan does not have a drug deductible |
This Plan does not have a drug deductible |
This Plan does not have a drug deductible |
|
Days Supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 100-day supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 100-day supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 100-day supply |
|
Mental Health Services |
|||
|
Inpatient psychiatric care |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient individual therapy visits |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Outpatient group therapy visits |
$15 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$12 per visit (Plan Deductible does not apply) |
|
Substance Use Services |
|||
|
Inpatient detoxification |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient individual therapy visits |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Outpatient group therapy visits |
$15 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$12 per visit (Plan Deductible does not apply) |
|
Infertility Services |
|||
|
Covered services related to the treatment of infertility |
Cost share is determined by place of service. Includes IVF, GIFT & ZIFT. Includes Infertility drugs at applicable Pharmacy Cost Shares |
Cost share is determined by place of service after Plan Deductible. Includes IVF, GIFT & ZIFT. Includes Infertility drugs at applicable Pharmacy Cost Shares |
Cost share is determined by place of service. Includes IVF, GIFT & ZIFT. Includes Infertility drugs at applicable Pharmacy Cost Shares |
|
Additional Benefits |
|||
|
Base Durable Medical Equipment |
20% Coinsurance (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
20% Coinsurance (Plan Deductible does not apply) |
|
Skilled Nursing Facility |
20% Coinsurance after Plan Deductible limited to 100 days per benefit period |
20% Coinsurance after Plan Deductible limited to 100 days per benefit period |
20% Coinsurance after Plan Deductible limited to 100 days per benefit period |
|
Home Health |
No Charge (Plan Deductible does not apply) limited to 120 visits per accumulation period |
No Charge after Plan Deductible limited to 120 visits per accumulation period |
No Charge (Plan Deductible does not apply) limited to 120 visits per accumulation period |
|
Hospice Care |
No Charge (Plan Deductible does not apply) (Unlimited Visits) |
No Charge after Plan Deductible (Unlimited Visits) |
No Charge (Plan Deductible does not apply) (Unlimited Visits) |
|
Vision Exam |
No Charge (Plan Deductible does not apply) |
20% Coinsurance (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Riders |
|||
|
Hearing aids |
$1000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply) |
Not Included |
$1000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply) |
|
Chiropractic |
$30 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
20% Coinsurance / 20 visit limit per accumulation period after Plan Deductible |
$25 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
|
Acupuncture |
$30 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
20% Coinsurance / 20 visit limit per accumulation period after Plan Deductible |
$25 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
|
Bariatric surgery |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Kaiser Essential |
Kaiser CDHP with HSA |
Kaiser Enhanced |
|
|---|---|---|---|
|
Annual Deductible |
|||
|
Individual | Family |
$4,000 | $8,000 |
$2,500 Individual | $3,400 Individual Family Member | $5,000 Family |
$1,000 | $2,000 |
|
Maximum Out-of-pocket |
|||
|
Individual | Family |
$8,000 | $16,000 |
$5,000 Individual | $5,000 Individual Family Member | $10,000 Family |
$3,500 | $7,000 |
|
Hospital Inpatient |
|||
|
Services rendered while hospitalized |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Maternity Inpatient |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient |
|||
|
Primary Care |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Urgent Care |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Specialist |
$50 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$50 per visit (Plan Deductible does not apply) |
|
Well-child & Preventive Care visits |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Routine prenatal care |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Outpatient surgery |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Therapies (PT/OT/ST) |
$30 per visit after Plan Deductible (Unlimited Visits) |
20% Coinsurance after Plan Deductible (Unlimited Visits) |
$25 per visit (Plan Deductible does not apply) (Unlimited Visits) |
|
X-rays and Lab tests |
X-ray $15 per encounter after Plan Deductible; Lab $15 per encounter after Plan Deductible |
X-ray 20% Coinsurance after Plan Deductible; Lab 20% Coinsurance after Plan Deductible |
X-ray $10 per encounter (Plan Deductible does not apply); Lab $10 per encounter (Plan Deductible does not apply) |
|
Advanced Imaging (CT / MRI / PET) |
$150 per encounter after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance (Plan Deductible does not apply) up to a maximum of $100 |
|
Ambulance services |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
$150 per trip (Plan Deductible does not apply) |
|
Emergency department visits |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
$250 per visit after Plan Deductible waived if admitted |
|
Outpatient Prescription Drugs |
|||
|
Generic Drugs |
$10 Copay Retail (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply) |
$10 Copay Retail after Plan Deductible, $20 Copay Mail Order after Plan Deductible |
$10 Copay Retail (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply) |
|
Brand Drugs |
$30 Copay Retail (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply) |
$30 Copay Retail after Plan Deductible, $60 Copay Mail Order after Plan Deductible |
$30 Copay Retail (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply) |
|
Non-preferred Brand Drugs |
$30 Copay Retail (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply); when approved through the formulary exception process |
$30 Copay Retail after Plan Deductible, $60 Copay Mail Order after Plan Deductible; when approved through the formulary exception process |
$30 Copay Retail (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply); when approved through the formulary exception process |
|
Specialty Drugs |
20% Coinsurance up to a maximum of $150 (Plan Deductible does not apply) |
20% Coinsurance up to a maximum of $150 after Plan Deductible |
20% Coinsurance up to a maximum of $150 (Plan Deductible does not apply) |
|
Pharmacy Deductible |
This Plan does not have a drug deductible |
This Plan does not have a drug deductible |
This Plan does not have a drug deductible |
|
Days Supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 100-day supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 100-day supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 100-day supply |
|
Mental Health Services |
|||
|
Inpatient psychiatric care |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient individual therapy visits |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Outpatient group therapy visits |
$15 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$12 per visit (Plan Deductible does not apply) |
|
Substance Use Services |
|||
|
Inpatient detoxification |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient individual therapy visits |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Outpatient group therapy visits |
$15 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$12 per visit (Plan Deductible does not apply) |
|
Infertility Services |
|||
|
Covered services related to the treatment of infertility |
Cost share is determined by place of service. Includes IVF, GIFT & ZIFT. Includes Infertility drugs at applicable Pharmacy Cost Shares |
Cost share is determined by place of service after Plan Deductible. Includes IVF, GIFT & ZIFT. Includes Infertility drugs at applicable Pharmacy Cost Shares |
Cost share is determined by place of service. Includes IVF, GIFT & ZIFT. Includes Infertility drugs at applicable Pharmacy Cost Shares |
|
Additional Benefits |
|||
|
Base Durable Medical Equipment |
20% Coinsurance (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
20% Coinsurance (Plan Deductible does not apply) |
|
Skilled Nursing Facility |
20% Coinsurance after Plan Deductible limited to 100 days per benefit period |
20% Coinsurance after Plan Deductible limited to 100 days per benefit period |
20% Coinsurance after Plan Deductible limited to 100 days per benefit period |
|
Home Health |
No Charge (Plan Deductible does not apply) limited to 120 visits per accumulation period |
No Charge after Plan Deductible limited to 120 visits per accumulation period |
No Charge (Plan Deductible does not apply) limited to 120 visits per accumulation period |
|
Hospice Care |
No Charge (Plan Deductible does not apply) (Unlimited Visits) |
No Charge after Plan Deductible (Unlimited Visits) |
No Charge (Plan Deductible does not apply) (Unlimited Visits) |
|
Vision Exam |
No Charge (Plan Deductible does not apply) |
20% Coinsurance (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Riders |
|||
|
Hearing aids |
$1000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply) |
Not Included |
$1000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply) |
|
Chiropractic |
$30 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
20% Coinsurance / 20 visit limit per accumulation period after Plan Deductible |
$25 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
|
Acupuncture |
$30 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
20% Coinsurance / 20 visit limit per accumulation period after Plan Deductible |
$25 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
|
Bariatric surgery |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Kaiser Essential |
Kaiser CDHP with HSA |
Kaiser Enhanced |
|
|---|---|---|---|
|
Annual Deductible |
|||
|
Individual | Family |
$4,000 | $8,000 |
$2,500 | $5,000 |
$1,000 | $2,000 |
|
Maximum Out-of-pocket |
|||
|
Individual | Family |
$8,000 | $16,000 |
$5,000 | $10,000 |
$3,500 | $7,000 |
|
Hospital Inpatient |
|||
|
Services rendered while hospitalized |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Maternity Inpatient |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient |
|||
|
Primary Care |
$30 per visit (Plan Deductible does not apply)* |
20% Coinsurance after Plan Deductible* |
$25 per visit (Plan Deductible does not apply)* |
|
Urgent Care |
$50 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$50 per visit (Plan Deductible does not apply) |
|
Specialist |
$50 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$50 per visit (Plan Deductible does not apply) |
|
Well-child & Preventive Care visits |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Routine prenatal care |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Outpatient surgery |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Therapies (PT/OT/ST) |
$50 per visit after Plan Deductible limited to 30 visits per therapy per accumulation period |
20% Coinsurance after Plan Deductible limited to 30 visits per therapy per accumulation period |
$50 per visit (Plan Deductible does not apply) limited to 30 visits per therapy per accumulation period |
|
X-rays and Lab tests |
X-ray $15 per encounter after Plan Deductible; Lab $15 per encounter after Plan Deductible |
X-ray 20% Coinsurance after Plan Deductible; Lab 20% Coinsurance after Plan Deductible |
X-ray $10 per encounter (Plan Deductible does not apply); Lab $10 per encounter (Plan Deductible does not apply) |
|
Advanced Imaging (CT / MRI / PET) |
$150 per encounter after Plan Deductible |
20% Coinsurance after Plan Deductible |
$100 per encounter (Plan Deductible does not apply) |
|
Ambulance services |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
$150 per trip (Plan Deductible does not apply) |
|
Emergency department visits |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
$250 per visit after Plan Deductible waived if admitted |
|
Outpatient Prescription Drugs |
|||
|
Generic Drugs |
$10 Copay Retail (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply) |
$10 Copay Retail after Plan Deductible, $20 Copay Mail Order after Plan Deductible |
$10 Copay Retail (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply) |
|
Brand Drugs |
$30 Copay Retail (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply) |
$30 Copay Retail after Plan Deductible, $60 Copay Mail Order after Plan Deductible |
$30 Copay Retail (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply) |
|
Non-preferred Brand Drugs |
$60 Copay Retail (Plan Deductible does not apply), $120 Copay Mail Order (Plan Deductible does not apply) |
$60 Copay Retail after Plan Deductible, $120 Copay Mail Order after Plan Deductible |
$60 Copay Retail (Plan Deductible does not apply), $120 Copay Mail Order (Plan Deductible does not apply) |
|
Specialty Drugs |
20% Coinsurance up to a maximum of $150 (Plan Deductible does not apply) |
20% Coinsurance up to a maximum of $150 after Plan Deductible |
20% Coinsurance up to a maximum of $150 (Plan Deductible does not apply) |
|
Pharmacy Deductible |
This Plan does not have a drug deductible |
This Plan does not have a drug deductible |
This Plan does not have a drug deductible |
|
Days Supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
|
Mental Health Services |
|||
|
Inpatient psychiatric care |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient individual therapy visits |
$30 per visit (Plan Deductible does not apply)* |
20% Coinsurance after Plan Deductible* |
$25 per visit (Plan Deductible does not apply)* |
|
Outpatient group therapy visits |
$15 per visit (Plan Deductible does not apply)* |
20% Coinsurance after Plan Deductible* |
$12 per visit (Plan Deductible does not apply)* |
|
Substance Use Services |
|||
|
Inpatient detoxification |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient individual therapy visits |
$30 per visit (Plan Deductible does not apply)* |
20% Coinsurance after Plan Deductible* |
$25 per visit (Plan Deductible does not apply)* |
|
Outpatient group therapy visits |
$15 per visit (Plan Deductible does not apply)* |
20% Coinsurance after Plan Deductible* |
$12 per visit (Plan Deductible does not apply)* |
|
Infertility Services |
|||
|
Covered services related to the treatment of infertility |
50% Coinsurance after Plan Deductible. Includes IVF, GIFT & ZIFT up to $25,000 per lifetime. Includes Infertility drugs up to $5,000 per lifetime |
50% Coinsurance after Plan Deductible. Includes IVF, GIFT & ZIFT up to $25,000 per lifetime. Includes Infertility drugs up to $5,000 per lifetime |
50% Coinsurance after Plan Deductible. Includes IVF, GIFT & ZIFT up to $25,000 per lifetime. Includes Infertility drugs up to $5,000 per lifetime |
|
Additional Benefits |
|||
|
Base Durable Medical Equipment |
20% Coinsurance (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
20% Coinsurance (Plan Deductible does not apply) |
|
Skilled Nursing Facility |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
|
Home Health |
No Charge (Plan Deductible does not apply) limited to 130 visits per accumulation period |
No Charge after Plan Deductible limited to 130 visits per accumulation period |
No Charge (Plan Deductible does not apply) limited to 130 visits per accumulation period |
|
Hospice Care |
No Charge (Plan Deductible does not apply) (Unlimited Visits) |
No Charge after Plan Deductible (Unlimited Visits) |
No Charge (Plan Deductible does not apply) (Unlimited Visits) |
|
Vision Exam |
$50 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$50 per visit (Plan Deductible does not apply) |
|
Riders |
|||
|
Hearing aids |
$1000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply) and Pediatric 20% Coinsurance / 1 device per ear / every 36 months (Plan Deductible does not apply) |
(OR) $1000 allowance / 1 device per ear / every 36 months after Plan Deductible and Pediatric 20% Coinsurance / 1 device per ear / every 36 months after Plan Deductible / (WA) 20% Coinsurance / 1 device per ear / every 36 months after Plan Deductible |
(OR) $1000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply) and Pediatric 20% Coinsurance / 1 device per ear / every 36 months (Plan Deductible does not apply) / (WA) 20% Coinsurance / 1 device per ear / every 36 months (Plan Deductible does not apply) |
|
Chiropractic |
$30 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
20% Coinsurance / 20 visit limit per accumulation period after Plan Deductible |
$25 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
|
Acupuncture |
$30 per visit / 20 visit limit per accumulation period (Combined with Chiropractic) (Plan Deductible does not apply) |
20% Coinsurance / 20 visit limit per accumulation period after Plan Deductible |
$25 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
|
Bariatric surgery |
20% Coinsurance after Plan Deductible |
Cost share based on place of service (3) |
Applicable cost share based on place of service (3) |
|
Kaiser Essential |
Kaiser CDHP with HSA |
Kaiser Enhanced |
|
|---|---|---|---|
|
Annual Deductible |
|||
|
Individual | Family |
$4,000 Individual | $8,000 Family (Embedded) |
$2,500 Individual | $5,000 Family (Aggregate) |
$1,000 Individual | $2,000 Family (Embedded) |
|
Maximum Out-of-pocket |
|||
|
Individual | Family |
$8,000 Individual | $16,000 Family (Embedded) |
$5,000 Individual | $10,000 Family (Aggregate) |
$3,500 Individual | $7,000 Family (Embedded) |
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Hospital Inpatient |
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Services rendered while hospitalized |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Maternity Inpatient |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
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Outpatient |
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Primary Care |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
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Urgent Care |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
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Specialist |
$50 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$50 per visit (Plan Deductible does not apply) |
|
Well-child & Preventive Care visits |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Routine prenatal care |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Outpatient surgery |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Therapies (PT/OT/ST) |
$50 per visit (Plan Deductible does not apply) limited to 90 combined visits |
20% Coinsurance after Plan Deductible limited to 90 combined visits |
$50 per visit (Plan Deductible does not apply) limited to 90 combined visits |
|
X-rays and Lab tests |
X-ray $15 per encounter after Plan Deductible; Lab $15 per encounter after Plan Deductible |
X-ray 20% Coinsurance after Plan Deductible; Lab 20% Coinsurance after Plan Deductible |
X-ray $10 per encounter (Plan Deductible does not apply); Lab $10 per encounter (Plan Deductible does not apply) |
|
Advanced Imaging (CT / MRI / PET) |
$150 per encounter after Plan Deductible |
20% Coinsurance after Plan Deductible |
$100 per encounter (Plan Deductible does not apply) |
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Ambulance services |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
$150 per trip (Plan Deductible does not apply) |
|
Emergency department visits |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
$250 per visit after Plan Deductible waived if admitted |
|
Outpatient Prescription Drugs |
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Generic Drugs |
$10 Copay Retail (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply) |
$10 Copay Retail after Plan Deductible, $20 Copay Mail Order after Plan Deductible |
$10 Copay Retail (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply) |
|
Brand Drugs |
$30 Copay Retail (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply) |
$30 Copay Retail after Plan Deductible, $60 Copay Mail Order after Plan Deductible |
$30 Copay Retail (Plan Deductible does not apply), $60 Copay Mail Order (Plan Deductible does not apply) |
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Non-preferred Brand Drugs |
$60 Copay Retail (Plan Deductible does not apply), $120 Copay Mail Order (Plan Deductible does not apply) |
$60 Copay Retail after Plan Deductible, $120 Copay Mail Order after Plan Deductible |
$60 Copay Retail (Plan Deductible does not apply), $120 Copay Mail Order (Plan Deductible does not apply) |
|
Specialty Drugs |
20% Coinsurance up to a maximum of $150 (Plan Deductible does not apply) |
20% Coinsurance up to a maximum of $150 after Plan Deductible |
20% Coinsurance up to a maximum of $150 (Plan Deductible does not apply) |
|
Pharmacy Deductible |
This Plan does not have a drug deductible |
This Plan does not have a drug deductible |
This Plan does not have a drug deductible |
|
Days Supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply |
|
Mental Health Services |
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Inpatient psychiatric care |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient individual therapy visits |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Outpatient group therapy visits |
No Charge (Plan Deductible does not apply) |
No Charge after Plan Deductible |
No Charge after Plan Deductible |
|
Substance Use Services |
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Inpatient detoxification |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
|
Outpatient individual therapy visits |
$30 per visit (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
$25 per visit (Plan Deductible does not apply) |
|
Outpatient group therapy visits |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
|
Infertility Services |
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Covered services related to the treatment of infertility |
50% Coinsurance after Plan Deductible. Includes IVF, GIFT & ZIFT up to $25,000 per lifetime. Includes Infertility drugs up to $5,000 per lifetime |
50% Coinsurance after Plan Deductible. Includes IVF, GIFT & ZIFT up to $25,000 per lifetime. Includes Infertility drugs up to $5,000 per lifetime |
50% Coinsurance after Plan Deductible. Includes IVF, GIFT & ZIFT up to $25,000 per lifetime. Includes Infertility drugs up to $5,000 per lifetime |
|
Additional Benefits |
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Base Durable Medical Equipment |
20% Coinsurance (Plan Deductible does not apply) |
20% Coinsurance after Plan Deductible |
20% Coinsurance (Plan Deductible does not apply) |
|
Skilled Nursing Facility |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
20% Coinsurance after Plan Deductible limited to 100 days per accumulation period |
|
Home Health |
No Charge (Plan Deductible does not apply) limited to 130 visits per accumulation period |
No Charge after Plan Deductible limited to 130 visits per accumulation period |
No Charge (Plan Deductible does not apply) limited to 130 visits per accumulation period |
|
Hospice Care |
No Charge (Plan Deductible does not apply) (Unlimited Visits) |
No Charge after Plan Deductible (Unlimited Visits) |
No Charge (Plan Deductible does not apply) (Unlimited Visits) |
|
Vision Exam |
$30 per visit (Plan Deductible does not apply) |
No Charge (Plan Deductible does not apply) |
$25 per visit (Plan Deductible does not apply) |
|
Riders |
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Hearing aids |
20% Coinsurance / 1 device per ear / every 36 months (Plan Deductible does not apply) |
20% Coinsurance / 1 device per ear / every 36 months after Plan Deductible |
20% Coinsurance / 1 device per ear / every 36 months (Plan Deductible does not apply) |
|
Chiropractic |
$30 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
20% Coinsurance / 20 visit limit per accumulation period after Plan Deductible |
$25 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
|
Acupuncture |
$30 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
20% Coinsurance / 20 visit limit per accumulation period after Plan Deductible |
$25 per visit / 20 visit limit per accumulation period (Plan Deductible does not apply) |
|
Bariatric surgery |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
20% Coinsurance after Plan Deductible |
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