| Features | Member pays |
| Medical calendar-year deductible | $0 |
| Pharmacy calendar-year deductible | $250 for brand prescriptions |
| Annual out-of-pocket maximum1 (Self-only enrollment/Family enrollment) | $3,500 / $7,000 |
| IN THE MEDICAL OFFICE | |
| Office visits | $50 |
| Preventive exams | $50 |
| Maternity/Prenatal care2 | $15 |
| Well-child preventive care visits3 | $15 |
| Vaccines (immunizations) | $0 |
| Allergy injections | $5 |
| Infertility services | Not covered |
| Occupational, physical, and speech therapy | $50 |
| Most labs and imaging | $10 |
| MRI/CT/PET | $50 |
| Outpatient surgery | $250 per procedure |
| EMERGENCY SERVICES | |
| Emergency Department visits (waived if admitted directly to hospital) | $150 |
| Ambulance | $300 |
| PRESCRIPTIONS4 | (up to a 100-day supply) |
| Generic | $105 |
| Brand-name | $35 (after pharmacy deductible) |
| HOSPITAL CARE | |
| Physicians' services, room and board, tests, medications, supplies, therapies | $500 per day |
| Skilled nursing facility care (up to 100 days per benefit period) | $0 |
| MENTAL HEALTH SERVICES6 | |
| In the medical office (up to 20 visits per calendar year) | $50 individual, $25 group |
| In the hospital (up to 30 days per calendar year) | $500 per day |
| CHEMICAL DEPENDENCY SERVICES | |
| In the medical office | $50 individual |
| In the hospital (detoxification only) | $500 per day |
| OTHER | |
| Certain durable medical equipment (DME) | Not covered7 |
| Optical (eyewear) | Not covered8 |
| Vision exam | $50 |
| Home health care (up to 100 two-hour visits per calendar year) | $0 |
| Hospice care | $0 |
Note: Kaiser Permanente plans do not include a pre-existing condition clause.
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 Scheduled prenatal visits and the first postpartum visit.
3 23 months or younger.
4 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.
5 This service is not subject to a deductible.
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.
9 Allowance toward the cost of eyeglass lenses, frames, and contact lenses fitting and dispensing every 24 months.
