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Kaiser HMO
Pacific Southwest Realty Services also gives you the choice of enrolling in an HMO Plan
managed by Kaiser Permanente.
Kaiser Gold 80 HMO w ChildDental Plan
In-Network
Annual Deductible
None
Annual Out-of-Pocket Max
Individual
Family
$6,750
$13,500
Office Visit
Primary Provider
$30 copay
Specialist
$55 copay
Preventive Services
No charge
Chiropractic Care
Not covered
Acupuncture
$30 copay
(physician referral required)
Basic Lab
Basic X-ray
Complex Imaging
(MRI, CT Scan, PET Scan, Etc.)
$35 copay
$55 copay
$275 copay
Inpatient Hospitalization
$655 copay per day
(up to 5 days per admission)
Outpatient Surgery
$655 copay per procedure
Urgent Care
$30 copay
Emergency Room
$325 copay
(copay waived if admitted)
Retail Pharmacy
Tier 1
$15 copay
Tier 2
$55 copay
Tier 3
$55 copay (when approved through exception process)
Tier 4
(only available in a max. 30 day supply)
20% up to $250 max per RX
Supply Limit
Up to 30 days
Mail Order Pharmacy
Tier 1
$30 copay
Tier 2
$110 copay
Tier 3
$110 copay
(when approved through exception process)
Tier 4
N/A
Supply Limit
Up to 100 days