Resources‎ > ‎

Kaiser CA HMO

 
PLAN FEATURES

NETWORK ONLY
Coinsurance
100%
Calendar Year Deductible: Individual
None
Calendar Year Deductible: Family
None
Maximum Annual Out-of-Pocket: Individual
$1,500
Maximum Annual Out-of-Pocket: Family
$3,000
OFFICE VISITS AND OUTPATIENT SERVICES  
Primary Care Provider (PCP)
$20 Copay
Specialist
$20 Copay
Chiropractic (30 visit calendar year maximum)
$10 Copay
         Acupuncture      $20 Copay, no visit maximum
Urgent Care
$20 Copay
         Telehealth      No Charge
PREVENTIVE CARE  
Routine preventive physical exams – including related preventive screenings and immunizations
No Charge
LABORATORY AND X-RAY SERVICES  
Physician’s Office
No Charge
Outpatient
No Charge
HOSPITAL SERVICES  
Emergency Room (waived if admitted)
  $100 Copay then 100% 
Hospital Inpatient
No Charge
INFERTILITY TREATMENT  
Covered Services
50% coinsurance for diagnosis, treatment and artificial insemination; GIFT ZIFT or IVF not covered
Lifetime Maximum Benefit
N/A
GENDER CONFIRMATION BENEFITS  
Covered Services
Coverage of medically necessary transitional related care for gender dysphoria include behavioral health services, hormone therapy, mastectomy with chest reconstruction, lower body gender confirming surgeries for both Male to Female (MtF) and Female to Male (FtM), tracheal shave and facial hair removal. Additional procedures may be covered if they meet the definition of Reconstructive Surgery.
MENTAL HEALTH & SUBSTANCE ABUSE/CHEMICAL DEPENDENCY  
Inpatient
No Charge
Outpatient - Physician's Office
$20 Copay
Outpatient - Facility
$20 Copay
PRESCRIPTION DRUGS  
Retail (30-day supply)
Generic
Formulary brand
Non-formulary brand
 
$15
$30
$30
Mail Order (100-day supply)
Generic
Formulary brand
Non-formulary brand
 
$30
$60
$60