Kaiser HMO (California Only)
Medical benefits are provided through United Healthcare and Kaiser. Consider the physician networks, premiums, and out-of-pocket costs for each plan when choosing for you and your family.
Kaiser HMO (California Only)
Plan details
- Carrier
- Kaiser
- Plan Type
- HMO
- Out-of-Network Coverage
- No
| Coverage tier | KAISER CALIFORNIA (NORTHERN CALIFORNIA) | KAISER CALIFORNIA (SOUTHERN CALIFORNIA) |
|---|---|---|
| Employee Only | $247.17 | $297.86 |
| Employee + Spouse | $609.52 | $719.62 |
| Employee + Child(ren) | $524.65 | $624.36 |
| Employee + Family | $799.50 | $943.91 |
Employee Only
- KAISER CALIFORNIA (NORTHERN CALIFORNIA)
- $247.17
- KAISER CALIFORNIA (SOUTHERN CALIFORNIA)
- $297.86
Employee + Spouse
- KAISER CALIFORNIA (NORTHERN CALIFORNIA)
- $609.52
- KAISER CALIFORNIA (SOUTHERN CALIFORNIA)
- $719.62
Employee + Child(ren)
- KAISER CALIFORNIA (NORTHERN CALIFORNIA)
- $524.65
- KAISER CALIFORNIA (SOUTHERN CALIFORNIA)
- $624.36
Employee + Family
- KAISER CALIFORNIA (NORTHERN CALIFORNIA)
- $799.50
- KAISER CALIFORNIA (SOUTHERN CALIFORNIA)
- $943.91
| Benefit | IN-NETWORK ONLY |
|---|---|
| Annual Deductible - Individual | $0 |
| Annual Deductible - Family | $0 |
| Coinsurance (Plan Pays) | 100%* |
| Annual Out-Of-Pocket Maximum (Maximum Includes Deductible) - Individual | $1,500 |
| Annual Out-Of-Pocket Maximum (Maximum Includes Deductible) - Family | $3,000 |
| Preventive Care | 100% covered |
| Primary Care | $20 copay |
| Specialist Services | $35 copay |
| Major Diagnostic Imaging | 100% covered |
| Inpatient | $250 per admission |
| Urgent Care | $20 copay |
| Emergency Room | $100 copay |
Annual Deductible - Individual
- IN-NETWORK ONLY
- $0
Annual Deductible - Family
- IN-NETWORK ONLY
- $0
Coinsurance (Plan Pays)
- IN-NETWORK ONLY
- 100%*
Annual Out-Of-Pocket Maximum (Maximum Includes Deductible) - Individual
- IN-NETWORK ONLY
- $1,500
Annual Out-Of-Pocket Maximum (Maximum Includes Deductible) - Family
- IN-NETWORK ONLY
- $3,000
Preventive Care
- IN-NETWORK ONLY
- 100% covered
Primary Care
- IN-NETWORK ONLY
- $20 copay
Specialist Services
- IN-NETWORK ONLY
- $35 copay
Major Diagnostic Imaging
- IN-NETWORK ONLY
- 100% covered
Inpatient
- IN-NETWORK ONLY
- $250 per admission
Urgent Care
- IN-NETWORK ONLY
- $20 copay
Emergency Room
- IN-NETWORK ONLY
- $100 copay
- *After deductible
| Benefit | IN-NETWORK ONLY |
|---|---|
| Retail Rx (30-Day Supply) - Generic | $10 copay |
| Retail Rx (30-Day Supply) - Preferred | $35 copay |
| Retail Rx (30-Day Supply) - Non-Preferred | $35 copay |
| Retail Rx (30-Day Supply) - Specialty | 20% up to $150 |
| Mail Order Rx - 100-Day Supply - Generic | $20 copay |
| Mail Order Rx - 100-Day Supply - Preferred | $70 copay |
| Mail Order Rx - 100-Day Supply - Non-Preferred | $70 copay |
Retail Rx (30-Day Supply) - Generic
- IN-NETWORK ONLY
- $10 copay
Retail Rx (30-Day Supply) - Preferred
- IN-NETWORK ONLY
- $35 copay
Retail Rx (30-Day Supply) - Non-Preferred
- IN-NETWORK ONLY
- $35 copay
Retail Rx (30-Day Supply) - Specialty
- IN-NETWORK ONLY
- 20% up to $150
Mail Order Rx - 100-Day Supply - Generic
- IN-NETWORK ONLY
- $20 copay
Mail Order Rx - 100-Day Supply - Preferred
- IN-NETWORK ONLY
- $70 copay
Mail Order Rx - 100-Day Supply - Non-Preferred
- IN-NETWORK ONLY
- $70 copay
Plan Notes
- In-network services are paid with copays or coinsurance.
- You may seek care from in-network providers only.
- In-network providers are contracted with the insurance company to provide services at a discounted fee.
- Out-of-network services are not covered.
- This plan is available to residents in its service area only; out-of-network services are not covered and a referral is needed to see a specialist.