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Your Medical Plan Choices
Medical Plan Kaiser
Kaiser
High Option
HMO Plan
Kaiser
Minimum Value
HMO Plan
PPO Three Tier Option Plan
Tier 1
Kaiser Provider
Tier 2
PHCS Providers
Tier 3
Any Licensed Provider
Deductible
•Individual
•Family
$1,500
$4,500
$3,000
$6,000
$0
$0
$500
$1,500
$1,000
$3,000
Annual Out of Pocket Maximum
•Individual
•Family
$3,500
$10,500
$6,350
$12,500
$1,500
$4,500
$2,500
$7,500
$5,000
$15,000
Maximum Benefit
Unlimited
Unlimited
Unlimited
Unlimited
$2,000,000
Office Services
Primary Care
Specialist Care
$30 Copay
$50 Copay
(PCP Referral)
$25 Copay
$45 Copay
(PCP Referral)
$20 Copay
$30 Copay
$30 Copay
$40 Copay
Plan pay 60%
You pay 40%
After annual deductible
Preventive Care
Plan pay 100%
Plan pay 100%
Plan pay 100%
Plan pay 100%
Plan pay 60%
You pay 40%
After annual deductible
Maternity Care
Plan pay 100%
Plan pay 100%
Plan pay 100%
Plan pay 100%
Plan pay 60%
You pay 40%
After annual deductible
LAB/Radiology Services
Diagnostic
Plan pay 90%
You pay 10%
After annual deductible
Plan pay 70%
You pay 30%
After annual deductible
$100 PCP Copay
$30 PCP Copay
$40 Specialist Copay
Plan pay 60%
You pay 40%
After annual deductible
Outpatient Facility/
Professional Services
Plan pay 90%
You pay 10%
After annual deductible
Plan pay 70%
You pay 30%
After annual deductible
$100 Copay
Plan pay 80%
You pay 20%
After annual deductible
Plan pay 60%
You pay 40%
After annual deductible
Physical And Occupational Therapy
Plan pay 90%
You pay 10%
After annual deductible
Plan pay 70%
You pay 30%
After annual deductible
$30 Copay
Plan pay 80%
You pay 20%
After annual deductible
Plan pay 60%
You pay 40%
After annual deductible
Emergency Services
Emergency Room
Urgent Care Facility
Ambulance
$100 Copay
$60 Copay
$100 Copay
$200 Copay
$50 Copay
$100 Copay
$200 Copay
$40 Copay
$100 Copay
$200 Copay
$50 Copay
$100 Copay
$200 Copay
Plan pay 60%
$100 Copay
After annual deductible
Inpatient Hospital Facility
Plan pay 90%
You pay 10%
After annual deductible
Plan pay 70%
You pay 30%
After annual deductible
$300 Copay
Plan pay 80%
You pay 20%
Plan pay 60%
You pay 40%
After annual deductible
Inpatient Mental Health/Chemical Dependency
Unlimited
Plan pay 90%
You pay 10%
After annual deductible
Plan pay 70%
You pay 30%
After annual deductible
$300 Copay
Plan pay 80%
You pay 20%
Plan pay 60%
You pay 40%
After annual deductible
Outpatient Mental Health/Chemical
Dependency
Unlimited
$30 Copay
$25 Copay
$20 Copay
$40 Copay
Plan pay 60%
You pay 40%
After annual deductible
Vision Exam
$50 Copay
$45 Copay
$30 Copay
$40 Copay
Plan pay 60%
You pay 40%
After annual deductible
Prescription Drugs
30 Day supply at Kaiser
Permanente Pharmacies
$15 Generic Copay
$30 Brand Copay
$25 Generic Copay
$50 Brand Copay
Non-Preferred not covered
$15 Generic Copay
$30 Brand Copay
$45 Brand Non-Preferred
$25 Generic Copay
$45 Brand Copay
$65 Brand Non-Preferred
$25 Generic Deductible
$45 Brand Deductible
$65 Brand Non-Preferred
30 Day Supply at Network Pharmacies
$25 Generic Copay
$40 Brand Copay
$35 Generic Copay
$60 Brand Copay
Non-Preferred not covered
Available thru Med-
Impact
Available thru MedImpact
Available thru MedImpact
Mail Order Pharmacy
90 Day supply
If less than 90 day supply you still pay 90 day copay
$30 Generic Copay
$60 Brand Copay
$50 Generic Copay
$100 Brand Copay
Non-Preferred not covered
$30 Generic Copay
$60 Brand Copay
$90 Brand Non-Preferred
$75 Generic Copay
$135 Brand Copay
$195 Brand Non-Preferred
$75 Generic Copay
$135 Brand Copay
$195 Brand Non-Preferred