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Kaiser HMO Benefit Summary In-Network |
Copays are a first dollar Benefit and are not subject to the Deductible;
all other Benefits are subject to the Deductible unless stated otherwise. |
All Benefits & Deductibles are per person, per calendar year, unless stated otherwise.
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| Benefits at a Glance |
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Premier Plan |
Plan 500 |
Plan 1000 |
Plan 2000 |
Plan 3000 |
Plan 5000 |
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In-Network Coverage |
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Office Visit1 |
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Primary Doctor |
$30 Copay |
$30 Copay |
$30 Copay |
$30 Copay |
$30 Copay |
$30 Copay |
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Specialist |
$50 Copay |
$50 Copay |
$50 Copay |
$50 Copay |
$50 Copay |
$50 Copay |
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Preventative Care Adults |
$30 Copay |
$30 Copay |
$30 Copay |
$30 Copay |
$30 Copay |
$30 Copay |
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Preventative Care Children |
Plan pays 100% |
Plan pays 100% |
Plan pays 100% |
Plan pays 100% |
Plan pays 100% |
Plan pays 100% |
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Emergency Room |
$150 Copay |
$150 Copay |
$150 Copay |
$150 Copay |
$150 Copay |
$150 Copay |
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Prescription Drugs |
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Rx Deductible |
$200 |
$200 |
$200 |
$200 |
$200 |
$500 |
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Generic |
$15 Copay |
$15 Copay |
$15 Copay |
$15 Copay |
$15 Copay |
$15 Copay |
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Brand |
$30 Copay |
$30 Copay |
$30 Copay |
$30 Copay |
$30 Copay |
$30 Copay |
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Non-Formulary |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
Not Covered |
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Calendar Year Max Rx Benefit |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
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Deductible |
None |
$500 |
$1,000 |
$2,000 |
$3,000 |
$5,000 |
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Coinsurance |
100% / 0% |
70% / 30% |
70% / 30% |
70% / 30% |
70% / 30% |
70% / 30% |
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Coinsurance Limit |
$0 |
$2,000 |
$2,000 |
$2,000 |
$2,000 |
$2,000 |
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Out-of-Pocket Limit |
$0
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$2,500
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$3,000 |
$4,000
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$5,000 |
$7,000
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deductible + coinsurance |
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Lifetime Maximum |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
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Hospitalization |
$500 per admission
$100 Copay
100% |
30% Coinsurance
after deductible |
30% Coinsurance
after deductible |
30% Coinsurance
after deductible
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30% Coinsurance
after deductible |
30% Coinsurance
after deductible |
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Surgery |
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Lab / X-Ray |
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Maternity |
$3,000 Copay |
$3,000 Copay |
$3,000 Copay |
$3,000 Copay |
$3,000 Copay |
$3,000 Copay |
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Pre-Existing Conditions |
No waiting period |
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Rate Guarantee |
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1 year |
1 year |
1 year |
1 year |
1 year |
1 year |
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Renewal Years |
1 year |
1 year |
1 year |
1 year |
1 year |
1 year |
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B+ |
B+ |
B+ |
B+ |
B+ |
B+ |
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Price Stability Rating |
A |
A |
A |
A |
A |
A |
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1 Office Visit Copays include charges for x-rays and labs when performed and billed by the doctor's office.
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Kaiser is a HMO. There are no out of Network benefits. This is an outline of coverage only.
Please see full plan brochure including exclusions and limitations before applying. |
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