| Features | Member pays |
| Medical calendar-year deductible (Individual / Family) | $1,500 / $3,000 |
| Pharmacy calendar-year deductible | $250 for brand prescriptions |
| Annual out-of-pocket maximum1 (Individual / Family) | $3,500 / $7,000 |
| IN THE MEDICAL OFFICE | |
| Office visits | $302 |
| Preventive exams | $302 |
| Maternity/Prenatal care3 | $02 |
| Well-child preventive care visits4 | $02 |
| Vaccines (immunizations) | $02 |
| Allergy injections | $5 (after deductible) |
| Infertility services | Not covered |
| Occupational, physical, and speech therapy | $30 (after deductible) |
| Most labs and imaging | $10 (after deductible) |
| MRI/CT/PET | $50 (after deductible) |
| Outpatient surgery | $250 (after deductible) |
| EMERGENCY SERVICES | |
| Emergency Department visits (waived if admitted directly to hospital) | $100 (after deductible) |
| Ambulance | $75 (after deductible) |
| PRESCRIPTIONS5 | (up to a 100-day supply) |
| Generic | $102 |
| Brand | $35 (after $250 pharmacy deductible) |
| HOSPITAL CARE | |
| Physicians' services, room and board, tests, medications, supplies, therapies | $500 per day (after deductible) |
| Skilled nursing facility care (up to 60 days per benefit period) | $50 per day (after deductible) |
| MENTAL HEALTH SERVICES7 | |
| In the medical office (up to 20 visits per calendar year) |
$30 (after deductible for individual therapy) $15 (after deductible for group therapy) |
| In the hospital (up to 30 days per calendar year) | $500 per day (after deductible) |
| CHEMICAL DEPENDENCY SERVICES | |
| In the medical office | $30 (after deductible for individual therapy) |
| In the hospital (detoxification only) | $500 per day (after deductible) |
| OTHER | |
| Certain durable medical equipment (DME)7 | Not covered |
| Optical (eyewear)8 | Not covered |
| Vision exam | $302 |
| Home health care (up to 100 two-hour visits per calendar year) | $02 |
| Hospice care | $02 |
Note: Kaiser Permanente plans do not include a pre-existing condition clause.
Note: The $30/$1,500 Deductible Plan is only available if offered with at least one copay plan. This option is available to groups with two or more eligible employees. If the $30/$1,500 Deductible Plan is offered with two or more copay plans, regular multiple plan offering rules apply.
1 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).
2 This service is not subject to a deductible.
3 Scheduled prenatal visits and the first postpartum visit.
4 23 months or younger.
5 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.
6 Visit or day limits do not apply to serious emotional disturbances of children and severe mental illnesses as described in the Evidence of Coverage.
7 Most DME for home use is not covered. Please refer to your Evidence of Coverage for a description of limited covered items.
8 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.
