| Features | Member pays |
| Medical calendar-year deductible (Individual / Family) | $2,700 / $5,4501 |
| Pharmacy calendar-year deductible | N/A |
| Annual out-of-pocket maximum3 (Individual / Family) | $2,700 / $5,450 |
| IN THE MEDICAL OFFICE | |
| Office visits | $0 (after deductible) |
| Preventive exams | $04 |
| Maternity/Prenatal care5 | $04 |
| Well-child preventive care visits6 | $04 |
| Vaccines (immunizations) | $04 |
| Allergy injections | $0 (after deductible) |
| Infertility services | Not covered |
| Occupational, physical, and speech therapy | $0 (after deductible) |
| Most labs and imaging | $0 (after deductible) |
| MRI/CT/PET | $0 (after deductible) |
| Outpatient surgery | $0 (after deductible) |
| EMERGENCY SERVICES | |
| Emergency Department visits (waived if admitted directly to hospital) | $0 (after deductible) |
| Ambulance | $0 (after deductible) |
| PRESCRIPTIONS7 | (up to a 100-day supply) |
| Generic | $0 (after deductible) |
| Brand-name | $0 (after deductible) |
| HOSPITAL CARE | |
| Physicians' services, room and board, tests, medications, supplies, therapies | $0 per admission (after deductible) |
| Skilled nursing facility care (up to 100 days per benefit period) | $0 per admission (after deductible) |
| MENTAL HEALTH SERVICES8 | |
| In the medical office (up to 20 visits per calendar year) |
$0 (after deductible for individual therapy) $0 (after deductible for group therapy) |
| In the hospital (up to 30 days per calendar year) | $0 per admission (after deductible) |
| CHEMICAL DEPENDENCY SERVICES | |
| In the medical office | $0 (after deductible for individual therapy) |
| In the hospital (detoxification only) | $0 per admission (after deductible) |
| OTHER | |
| Certain durable medical equipment (DME)9 | Not covered |
| Optical (eyewear) | Not covered10 |
| Vision exam | $0 (after deductible) |
| Home health care (up to 100 two-hour visits per calendar year) | $0 (after deductible) |
| Hospice care | $0 (after deductible) |
Note: Kaiser Permanente plans do not include a pre-existing condition clause.
1 Each family member becomes eligible for copayments after meeting his or her individual deductible.
2 The entire family deductible must be met before copayments apply for individual family members.
3 The annual out-of-pocket maximum is the limit to the total amount that an individual or family must pay for certain services in a calendar year (as discussed in the Evidence of Coverage).
4 This service is not subject to a deductible.
5 Scheduled prenatal visits.
6 23 months or younger.
7 Prescription drugs are covered in accord with our formulary when prescribed by a Plan physician and obtained at Plan pharmacies. A few drugs have different copayments; please refer to the Evidence of Coverage for detailed information about prescription drug copayments.
8 Visit or day limits do not apply to serious emotional disturbances of children and severe mental illnesses as described in the Evidence of Coverage.
9 Most DME for home use is not covered. Please refer to your Evidence of Coverage for a description of limited covered items.
10 Kaiser Permanente members are entitled to a 20 percent discount on eyeglasses and contact lenses purchased at Kaiser Permanente optical centers. These discounts may not be coordinated with any other Health Plan vision benefit. The discounts do not apply to any sale, promotional, or packaged eyewear program, for any contact lenses extended purchase agreement, or to low-vision aids or devices.
