Menu

MEDICAL & PRESCRIPTION

MEDICAL & PRESCRIPTION

KAISER PERMANENTE Traditional HMO

Traditional HMO Network Providers
Calendar Year Deductible:
Single/Family		 $0 / $0
Maximum Out of Pocket Limit:
Single/Family		 $1,500 / $3,000
PCP Office Visit $15 copay
Specialist Office Visit $15 copay
Urgent Care Visit $15 copay
Emergency Room $100 copay
Inpatient Services Ded + 20%
Outpatient Services Ded + 20%
Prescription Drugs (Retail/30-day Supply)
Generic $10 copay
Preferred and Non-Preferred $20 copay
Specialty 20% up to $250
Resources
Traditional SBC 2022
Self Care Apps
Telehealth Options
Active Fit
Employee Bi-Weekly Costs:
Employee Only $74.95
Employee + Spouse $449.69
Employee + Child(ren) $374.74
Family $749.48

KAISER PERMANENTE DHMO Plan A

Deductible HMO Network Providers
Calendar Year Deductible:
Single/Family		 $750 / $1,500
Maximum Out of Pocket Limit:
Single/Family		 $3,000 / $6,000
PCP Office Visit $25 copay
Specialist Office Visit $25 copay
Urgent Care Visit $25 copay
Emergency Room 20% coinsurance
Inpatient Services 20% coinsurance
Outpatient Services 20% coinsurance
Prescription Drugs (Retail/30-day Supply)
Generic $10 copay
Preferred and Non-Preferred $30 copay
Specialty 20% up to $20
Resources
DHMO Plan A SBC
Employee Bi-Weekly Costs:
Employee Only $65.96
Employee + Spouse $395.75
Employee + Child(ren) $329.79
Family $659.58

KAISER PERMANENTE DHMO Plan B

Deductible HMO Network Providers
Calendar Year Deductible:
Single/Family		 $1,500 / $3,000
Maximum Out of Pocket Limit:
Single/Family		 $4,000 / $8,000
PCP Office Visit $40 copay
Specialist Office Visit  $50 copay
Urgent Care Visit $40 copay
Emergency Room 30% coinsurance
Inpatient Services 30% coinsurance
Outpatient Services 30% coinsurance
Prescription Drugs (Retail/30-day Supply)
Generic $10 copay
Preferred and Non-Preferred $30 copay
Specialty 20% up to $250
Resources
DHMO Plan B SBC
Employee Bi-Weekly Costs:
Employee Only $59.74
Employee + Spouse $358.46
Employee + Child(ren) $298.72
Family $597.44