2017 plans and products | california - kaiser … kp.org/choosebetter ... 2017 plans and products |...
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Overview Help
A BETTER WAY TO TAKE CARE OF BUSINESS
2017 PLANS AND PRODUCTS | CALIFORNIA
Complete Suite™ plan comparison chartHere’s an overview of our plans that complements the quote you received in your Complete Suite Quote Proposal. You can use it to get information on a wide range of plans, including quick side-by-side comparisons of what different plans have to offer.
Overview HMO CDHCDHMO KPIC
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How to compare plansWith our Complete Suite plan comparison chart, it’s easy to compare different plans side by side. You can choose up to three plans at a time, and you can get as many comparisons as you’d like.
To get a comparison:
1. Click the “Overview” tab at the top of the page.
2. Check the box next to each plan you’d like to compare, then click the “Compare plans” button at the top-right corner of the page.
3. To remove a plan from your comparison, click the checked box to clear it. To remove all plans selected, click the “Reset” button at the bottom of the page.
You can also get more detailed information about each plan type by clicking the tabs at the top of the page — HMO, DHMO, CDHC, or KPIC. To go back to the plan comparison page at any time, simply click the “Overview” tab at the top-left corner of the page.
Are you viewing this on a mobile device?
The interactive features work best when you use a reader like PDF Expert by Readdle.
HMO CDHCDHMO KPIC
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Overview
Traditional HMO — Pay a simple copay for most covered services.
* Available with optical hardware allowance ($175 every 24 months).
HMO plan families NCAL/SCAL plan ID — office visit/hospital inpatient/out-of-pocket maximum
HMO High HMO Mid HMO Low
2017 Complete Suite plans Select the plans that you want to compare. You can choose up to three at a time.
HMO DHMO CDHC KPIC
Plans selected:
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9961/9962 — $10/$0/$1,500
9965/9966 — $15/$0/$1,500
10003/10004 — $20/$0/$1,500
10007/10008* — $20/$0/$1,500
10011/10012 — $15/$250/$1,500
10015/10016 — $20/$250/$1,500
10044/10045* — $20/$250/$1,500
10048/10049 — $25/$250/$1,500
10052/10053 — $20/$500/$1,500
9970/9972 — $25/$500/$1,500
9975/9976* — $25/$500/$1,500
9981/9982 — $30/$500/$1,500
9983/9984 — $20/$250/$2,000
9985/9986* — $20/$250/$2,000
9987/9988 — $30/$250/$2,000
9989/9990 — $20/$500/$2,500
9930/9931 — $25/$500/$2,500
9991/9992 — $30/$500/$2,500
9994/9996* — $30/$500/$2,500
9955/9956 — $20/$250/$3,000
9957/9958 — $30/$250/$3,000
9959/9960 — $20/$500/$3,000
9967/9969 — $30/$500/$3,000
9973/9974— $30/$500/$3,000
9977/9978— $40/$500/$3,000
9979/9980 — $30/$500/$3,500
9942/9943 — $40/$500/$3,500
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HMO CDHCDHMO KPIC
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Overview
Deductible HMO (DHMO) plan families NCAL/SCAL plan ID — deductible/office visit/hospital inpatient
Deductible HMO HO Deductible HMO XD Deductible HMO XP
8776/8777 — $250/$10/10% 8796/8797 — $250/$10/10% 8826/8827 — $1,000/$20/20%
8778/8779* — $250/$10/10% 8798/8799 — $500/$10/10% 9147/9158 — $4,000/$40/30%
8780/8781 — $500/$20/10% 8800/8801 — $500/$20/20% 9148/9159 — $4,500/$50/40%
8782/8783 — $750/$25/20% 8802/8803* — $500/$20/20% 9149/9160 — $4,500/40%/40%
8784/8785 — $1,000/$20/20% 8808/8809 — $750/$25/20% 9151/9163 — $5,000/$50/30%
8786/8787* — $1,000/$20/20% 8804/8805 — $1,000/$20/20% 9150/9161 — $5,500/$50/40%
8788/8789 — $1,000/$30/20% 8806/8807* — $1,000/$20/20%
8790/8791 — $1,500/$20/20% 8810/8811 — $1,000/$30/30%
8792/8793 — $1,500/$40/30% 8812/8813* — $1,000/$30/30%
8794/8795 — $2,500/$20/20% 8814/8815 — $1,500/$20/20%
8816/8817 — $1,500/$40/30%
8818/8819 — $2,000/$20/20%
8820/8821 — $2,500/$40/30%
8822/8823 — $3,000/$40/30%
8824/8825 — $3,500/$40/30%
HMO DHMO CDHC KPIC
2017 Complete Suite plans Click on the specific plan name to see your options for that plan. Plans selected:
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Deductible HMO HO — Hospital-based services, such as inpatient hospital, outpatient surgery, and emergency department services, are subject to a deductible.
Deductible HMO XD — Provider office visits and pharmacy are covered at a copay or coinsurance. All other services, except preventive services, are subject to a deductible.
Deductible HMO XP — All services, except preventive services, are subject to a deductible. Pharmacy is excluded from the deductible on certain plans.* Available with optical hardware allowance ($175 every 24 months).
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HMO CDHCDHMO KPIC
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Overview
HSA-qualified deductible HMO plans — All services, except preventive services, are subject to a deductible.Deductible HMO plans with HRA — All services, except pharmacy and preventive services, are subject to a deductible.
Consumer-directed health care (CDHC) plans NCAL/SCAL plan ID — deductible/office visit/hospital inpatient
HSA-qualified deductible HMO plans Deductible HMO plans with HRA
9153/9164 — $1,300/$20/$250 8759/8760 — $1,000/$20/20%
9155/9165 — $1,600/10%/10% 8761/8762 — $1,500/$20/20%
9156/9166 — $2,000/$30/$250 8763/8764 — $2,000/$20/20%
9157/9167 — $2,700/$30/30% 8765/8766 — $2,500/$20/20%
7871/7872 — $3,000/20%/20%
8126/8127 — $4,500/40%/40% 7823/7824 — $3,000/30%/30%
8122/8125 — $4,500/$50/40% 8767/8768 — $4,000/$20/20%
2017 Complete Suite plans Click on the specific plan name to see your options for that plan.
HMO DHMO CDHC KPIC
Plans selected:
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10426/10427 — $3,500/$30/30%
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HMO CDHCDHMO KPIC
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Overview
Kaiser Permanente Insurance Company (KPIC) NCAL/SCAL plan ID — deductible by tier/office visit by tier
Point-of-service (POS) plans PPO plans
5689/5690 — $0/$250/$500; $10/20%/40% 5700/5701 — $250/$500; $15/30%
5685/5686 — $0/$500/$1,000; $25/10%/30% 5704/5705 — $500/$1,000; $20/40%
5669/5670 — $0/$1,000/$2,000; $25/$35/30% 5702/5703 — $1,000/$2,000; $25/50%
5675/5676 — $0/$1,500/$3,000; $35/30%/50% 5698/5699 — $1,500/$3,000; $40/50%
8769/8770 — $3,000/$6,000; $40/50%
7538/7539 — $4,500/$9,000; $40/50%
2017 Complete Suite plans Click on the specific plan name to see your options for that plan.
HMO DHMO CDHC KPIC
Plans selected:
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Overview CDHCDHMO KPIC
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HMO
Complete Suite category
HMO HMO High HMO High HMO High HMO High HMO High
NCAL/SCAL plan ID
Plan deductible (individual/family) None None None None None
Out-of-pocket maximum (individual/family) $1,500/$3,000 $1,500/$3,000 $1,500/$3,000 $1,500/$3,000 $1,500/$3,000
Primary and specialty care visit $10 $15 $20 $20 $15
Hospital inpatient (per admission) No charge No charge No charge No charge $250 per admit
Outpatient surgery (per procedure) $10 $15 $20 $20 $15
Emergency care $100 $100 $100 $100 $100
Prescription drugs
Generic $10 $10 $10 $10 $10
Brand $20 $20 $20 $20 $30
Specialty 20%, not to exceed $150
20%, not to exceed $150
20%, not to exceed $150
20%, not to exceed $150
20%, not to exceed $150
Separate drug deductible None None None None None
Ambulance services (per trip) $50 $50 $50 $50 $50
CT/PET/MRI (per procedure) No charge No charge No charge No charge No charge
Lab/X-ray (per encounter) No charge No charge No charge No charge No charge
Durable medicalequipment 20% 20% 20% 20% 20%
Preventive care No charge No charge No charge No charge No charge
Infertility services Same as medical benefit
Same as medical benefit
Same as medical benefit
Same as medical benefit 50%
Prenatal care and well-baby visits No charge No charge No charge No charge No charge
Optical hardware Not covered Not covered Not covered $175 hardware allowance/24 months Not covered
Prosthetics and orthotics No charge No charge No charge No charge No charge
Skilled nursing facility No charge No charge No charge No charge No charge
Traditional HMO — Pay a simple copay for most covered services.
Plans selected:Compare plans
9961/9962 9965/9966 10003/10004 10007/10008 10011/10012
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Overview CDHCDHMO KPIC
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HMO
Complete Suite category
HMO HMO High HMO High HMO High HMO High HMO High
NCAL/SCAL plan ID
Plan deductible (individual/family) None None None None None
Out-of-pocket maximum (individual/family) $1,500/$3,000 $1,500/$3,000 $1,500/$3,000 $1,500/$3,000 $1,500/$3,000
Primary and specialty care visit $20 $20 $25 $20 $25
Hospital inpatient (per admission) $250 per admit $250 per admit $250 per admit $500 per admit $500 per admit
Outpatient surgery (per procedure) $20 $20 $25 $100 $100
Emergency care $100 $100 $100 $100 $100
Prescription drugs
Generic $10 $10 $10 $15 $15
Brand $30 $30 $30 $35 $35
Specialty 20%, not to exceed $150
20%, not to exceed $150
20%, not to exceed $150
30%, not to exceed $150
30%, not to exceed $150
Separate drug deductible None None None None None
Ambulance services (per trip) $50 $50 $50 $100 $100
CT/PET/MRI (per procedure) No charge No charge No charge $50 $50
Lab/X-ray (per encounter) No charge No charge No charge $10 $10
Durable medicalequipment 20% 20% 20% 20% 20%
Preventive care No charge No charge No charge No charge No charge
Infertility services 50% 50% 50% 50% 50%
Prenatal care and well-baby visits No charge No charge No charge No charge No charge
Optical hardware Not covered $175 hardware allowance/24 months Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge No charge No charge
Skilled nursing facility No charge No charge No charge No charge No charge
Traditional HMO — Pay a simple copay for most covered services.
Plans selected:Compare plans
10015/10016 10044/10045 10048/10049 10052/10053 9970/9972
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Overview CDHCDHMO KPIC
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HMO
Complete Suite category
HMOHMO High HMO High
NCAL/SCAL plan ID
Plan deductible (individual/family) None None None None None
Out-of-pocket maximum (individual/family) $1,500/$3,000 $1,500/$3,000 $2,000/$4,000 $2,000/$4,000 $2,000/$4,000
Primary and specialty care visit $25 $30 $20 $20 $30
Hospital inpatient (per admission) $500 per admit $500 per admit $250 per admit $250 per admit $250 per admit
Outpatient surgery (per procedure) $100 $100 $100 $100 $100
Emergency care $100 $100 $100 $100 $100
Prescription drugs
Generic $15 $15 $15 $15 $15
Brand $35 $35 $30 $30 $30
Specialty 30%, not to exceed $150
30%, not to exceed $150
30%, not to exceed $150
30%, not to exceed $150
30%, not to exceed $150
Separate drug deductible None None None None None
Ambulance services (per trip) $100 $100 $100 $100 $100
CT/PET/MRI (per procedure) $50 $50 $50 $50 $50
Lab/X-ray (per encounter) $10 $10 $10 $10 $10
Durable medicalequipment 20% 20% 20% 20% 20%
Preventive care No charge No charge No charge No charge No charge
Infertility services 50% 50% 50% 50% 50%
Prenatal care and well-baby visits No charge No charge No charge No charge No charge
Optical hardware $175 hardware allowance/24 months Not covered Not covered $175 hardware
allowance/24 months Not covered
Prosthetics and orthotics No charge No charge No charge No charge No charge
Skilled nursing facility No charge No charge No charge No charge No charge
Traditional HMO — Pay a simple copay for most covered services.
Plans selected:Compare plans
9975/9976 9981/9982 9983/9984 9985/9986 9987/9988
HMO Mid HMO Mid HMO Mid
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Overview CDHCDHMO KPIC
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HMO
Complete Suite category
HMO HMO Mid HMO Mid HMO Mid HMO Mid HMO Low
NCAL/SCAL plan ID
Plan deductible (individual/family) None None None None None
Out-of-pocket maximum (individual/family) $2,500/$5,000 $2,500/$5,000 $2,500/$5,000 $2,500/$5,000 $3,000/$6,000
Primary and specialty care visit $20 $25 $30 $30 $20
Hospital inpatient (per admission) $500 per admit $500 per admit $500 per admit $500 per admit $250 per day
up to 3 days
Outpatient surgery (per procedure) $250 $250 $250 $250 $125
Emergency care $100 $100 $100 $100 $100
Prescription drugs
Generic $15 $15 $15 $15 $10
Brand $35 $35 $35 $35 $30
Specialty 30%, not to exceed $150
30%, not to exceed $150
30%, not to exceed $150
30%, not to exceed $150
20%, not to exceed $150
Separate drug deductible None None None None None
Ambulance services (per trip) $100 $100 $100 $100 $100
CT/PET/MRI (per procedure) $50 $50 $50 $50 $100
Lab/X-ray (per encounter) $10 $10 $10 $10 $10
Durable medicalequipment 20% 20% 20% 20% 50%
Preventive care No charge No charge No charge No charge No charge
Infertility services 50% 50% 50% 50% 50%
Prenatal care and well-baby visits No charge No charge No charge No charge No charge
Optical hardware Not covered Not covered Not covered $175 hardware allowance/24 months Not covered
Prosthetics and orthotics No charge No charge No charge No charge No charge
Skilled nursing facility No charge No charge No charge No charge No charge
Traditional HMO — Pay a simple copay for most covered services.
Plans selected:Compare plans
9989/9990 9930/9931 9991/9992 9994/9996 9955/9956
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Overview CDHCDHMO KPIC
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HMO
Complete Suite category
HMO HMO Low HMO Low HMO Low HMO Low HMO Low
NCAL/SCAL plan ID
Plan deductible (individual/family) None None None None None
Out-of-pocket maximum (individual/family) $3,000/$6,000 $3,000/$6,000 $3,000/$6,000 $3,000/$6,000 $3,000/$6,000
Primary and specialty care visit $30 $20 $30 $30 $40
Hospital inpatient (per admission)
$250 per day up to 3 days
$500 per day up to 3 days
$500 per day up to 3 days $500 per day $500 per day
Outpatient surgery (per procedure) $125 $250 $250 $250 $250
Emergency care $100 $150 $150 $150 $150
Prescription drugs
Generic $10 $15 $15 $15 $15
Brand $30 $35 $35 $35 $35
Specialty 20%, not to exceed $150
30%, not to exceed $150
30%, not to exceed $150
30%, not to exceed $150
30%, not to exceed $150
Separate drug deductible None None None None None
Ambulance services (per trip) $100 $150 $150 $150 $150
CT/PET/MRI (per procedure) $100 $100 $100 $100 $100
Lab/X-ray (per encounter) $10 $10 $10 $10 $10
Durable medicalequipment 50% 50% 50% 50% 50%
Preventive care No charge No charge No charge No charge No charge
Infertility services 50% 50% 50% 50% 50%
Prenatal care and well-baby visits No charge No charge No charge No charge No charge
Optical hardware Not covered Not covered Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge No charge No charge
Skilled nursing facility No charge No charge No charge No charge No charge
Traditional HMO — Pay a simple copay for most covered services.
Plans selected:Compare plans
9957/9958 9959/9960 9967/9969 9973/9974 9977/9978
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Overview CDHCDHMO KPIC
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HMO
Complete Suite category
HMOHMO Low HMO Low
NCAL/SCAL plan ID
Plan deductible (individual/family) None None
Out-of-pocket maximum (individual/family) $3,500/$7,000 $3,500/$7,000
Primary and specialty care visit $30 and $50 $40 and $50
Hospital inpatient (per admission) $500 per day $500 per day
Outpatient surgery (per procedure) $250 $250
Emergency care $150 $150
Prescription drugs
Generic $15 $15
Brand $35 $35
Specialty 30%, not to exceed $150 30%, not to exceed $150
Separate drug deductible None None
Ambulance services (per trip) $150 $150
CT/PET/MRI (per procedure) $100 $100
Lab/X-ray (per encounter) $10 $10
Durable medicalequipment 50% 50%
Preventive care No charge No charge
Infertility services 50% 50%
Prenatal care and well-baby visits No charge No charge
Optical hardware Not covered Not covered
Prosthetics and orthotics No charge No charge
Skilled nursing facility No charge No charge
Traditional HMO — Pay a simple copay for most covered services.
Plans selected:Compare plans
9979/9980 9942/9943
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Overview HMO CDHC KPIC
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DHMO
Complete Suite category
DHMO
Deductible HMO HO Deductible HMO HO Deductible HMO HO Deductible HMO HO Deductible HMO HO
NCAL/SCAL plan ID 8776/8777 8778/8779 8780/8781 8782/8783 8784/8785
Plan deductible (individual/family) $250/$500 $250/$500 $500/$1,000 $750/$1,500 $1,000/$2,000
Out-of-pocket maximum (individual/family)
$3,000/$6,000 $3,000/$6,000 $3,000/$6,000 $3,000/$6,000 $3,000/$6,000
Primary and specialty care visit $10 $10 $20 $25 $20
Hospital inpatient (per admission) 10% after deductible 10% after deductible 10% after deductible 20% after deductible 20% after deductible
Outpatient surgery (per procedure) 10% after deductible 10% after deductible 10% after deductible 20% after deductible 20% after deductible
Emergency care 10% after deductible 10% after deductible 10% after deductible 20% after deductible 20% after deductible
Prescription drugs
Generic $10 $10 $10 $10 $10
Brand $30 $30 $30 $30 $30
Specialty 20%, not to exceed $150
20%, not to exceed $150
20%, not to exceed $150
20%, not to exceed $150
20%, not to exceed $150
Separate drug deductible None None None None None
Ambulance services (per trip) $150 $150 $150 $150 $150
CT/PET/MRI (per procedure) $150 $150 $150 $150 $150
Lab/X-ray (per encounter) $10 $10 $10 $10 $10
Durable medicalequipment 20% 20% 20% 20% 20%
Preventive care No charge No charge No charge No charge No charge
Infertility services 50% 50% 50% 50% 50%
Prenatal care and well-baby visits No charge No charge No charge No charge No charge
Optical hardware Not covered $175 hardware allowance/24 months Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge No charge No charge
Skilled nursing facility 10% 10% 10% 20% 20%
Deductible HMO HO — Hospital-based services, such as inpatient hospital, outpatient surgery, and emergency department services, are subject to a deductible.
Plans selected:Compare plans
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Overview HMO CDHC KPIC
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DHMO
Complete Suite category
DHMO
Deductible HMO HO Deductible HMO HO Deductible HMO HO Deductible HMO HO Deductible HMO HO
NCAL/SCAL plan ID 8786/8787 8788/8789 8790/8791 8792/8793 8794/8795
Plan deductible (individual/family) $1,000/$2,000 $1,000/$2,000 $1,500/$3,000 $1,500/$3,000 $2,500/$5,000
Out-of-pocket maximum (individual/family) $3,000/$6,000 $3,000/$6,000 $4,000/$8,000 $4,000/$8,000 $5,000/$10,000
Primary and specialty care visit $20 $30 $20 $40 $20
Hospital inpatient (per admission) 20% after deductible 20% after deductible 20% after deductible 30% after deductible 20% after deductible
Outpatient surgery (per procedure) 20% after deductible 20% after deductible 20% after deductible 30% after deductible 20% after deductible
Emergency care 20% after deductible 20% after deductible 20% after deductible 30% after deductible 20% after deductible
Prescription drugs
Generic $10 $10 $10 $10 $10
Brand $30 $30 after drug deductible $30 $30 $30
Specialty 20%, not to exceed $150
20%, not to exceed $150
after drug deductible
20%, not to exceed $150
20%, not to exceed $150
20%, not to exceed $150
Separate drug deductible None $250 None None None
Ambulance services (per trip) $150 $150 $150 $150 $150
CT/PET/MRI (per procedure) $150 $150 $150 $150 $150
Lab/X-ray (per encounter) $10 $10 $10 $10 $10
Durable medicalequipment 20% 20% 20% 20% 20%
Preventive care No charge No charge No charge No charge No charge
Infertility services 50% 50% 50% 50% 50%
Prenatal care and well-baby visits No charge No charge No charge No charge No charge
Optical hardware $175 hardware allowance/24 months Not covered Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge No charge No charge
Skilled nursing facility 20% 20% 20% 30% 20%
Deductible HMO HO — Hospital-based services, such as inpatient hospital, outpatient surgery, and emergency department services, are subject to a deductible.
Plans selected:Compare plans
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Overview HMO CDHC KPIC
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DHMO
Complete Suite category
DHMODeductible HMO XD Deductible HMO XD Deductible HMO XD
NCAL/SCAL plan ID 8796/8797 8798/8799 8800/8801
Plan deductible (individual/family) $250/$500 $500/$1,000 $500/$1,000
Out-of-pocket maximum (individual/family) $2,500/$5,000 $3,000/$6,000 $3,000/$6,000
Primary and specialty care visit $10 $10 $20
Hospital inpatient (per admission) 10% after deductible 10% after deductible 20% after deductible
Outpatient surgery (per procedure) 10% after deductible 10% after deductible 20% after deductible
Emergency care 10% after deductible 10% after deductible 20% after deductible
Prescription drugs
Generic $10 $10 $10
Brand $30 $30 $30 after drug deductible
Specialty 20%, not to exceed $150 20%, not to exceed $150 20%, not to exceed $150 after drug deductible
Separate drug deductible None None $100
Ambulance services (per trip) $150 after deductible $150 after deductible $150 after deductible
CT/PET/MRI (per procedure) $150 after deductible $150 after deductible $150 after deductible
Lab/X-ray (per encounter) $10 after deductible $10 after deductible $10 after deductible
Durable medicalequipment 20% 20% 20%
Preventive care No charge No charge No charge
Infertility services 50% 50% 50%
Prenatal care and well-baby visits No charge No charge No charge
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge
Skilled nursing facility 10% after deductible 10% after deductible 20% after deductible
Deductible HMO XD — Provider office visits and pharmacy are covered at a copay or coinsurance. All other services, except preventive services, are subject to a deductible.
Plans selected:Compare plans
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Overview HMO CDHC KPIC
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DHMO
Complete Suite category
DHMO Deductible HMO XD Deductible HMO XD Deductible HMO XD Deductible HMO XD
NCAL/SCAL plan ID 8802/8803 8808/8809 8804/8805 8806/8807
Plan deductible (individual/family) $500/$1,000 $750/$1,500 $1,000/$2,000 $1,000/$2,000
Out-of-pocket maximum (individual/family) $3,000/$6,000 $3,000/$6,000 $3,000/$6,000 $3,000/$6,000
Primary and specialty care visit $20 $25 $20 $20
Hospital inpatient (per admission) 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Outpatient surgery (per procedure) 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Emergency care 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Prescription drugs
Generic $10 $10 $10 $10
Brand $30 after drug deductible $30 $30 $30
Specialty 20%, not to exceed $150 after $100 drug deductible 20%, not to exceed $150 20%, not to exceed $150 20%, not to exceed $150
Separate drug deductible $100 None None None
Ambulance services (per trip) $150 after deductible $150 after deductible $150 after deductible $150 after deductible
CT/PET/MRI (per procedure) $150 after deductible $150 after deductible $150 after deductible $150 after deductible
Lab/X-ray (per encounter) $10 after deductible $10 after deductible $10 after deductible $10 after deductible
Durable medicalequipment 20% 20% 20% 20%
Preventive care No charge No charge No charge No charge
Infertility services 50% 50% 50% 50%
Prenatal care and well-baby visits No charge No charge No charge No charge
Optical hardware $175 hardware allowance/24 months Not covered Not covered $175 hardware
allowance/24 months
Prosthetics and orthotics No charge No charge No charge No charge
Skilled nursing facility 20% after deductible 20% after deductible 20% after deductible 20% after deductible
Deductible HMO XD — Provider office visits and pharmacy are covered at a copay or coinsurance. All other services, except preventive services, are subject to a deductible.
Plans selected:Compare plans
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Overview HMO CDHC KPIC
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DHMO
Complete Suite category
DHMO Deductible HMO XD Deductible HMO XD Deductible HMO XD Deductible HMO XD
NCAL/SCAL plan ID 8810/8811 8812/8813 8814/8815 8816/8817
Plan deductible (individual/family) $1,000/$2,000 $1,000/$2,000 $1,500/$3,000 $1,500/$3,000
Out-of-pocket maximum (individual/family) $3,000/$6,000 $3,000/$6,000 $4,000/$8,000 $4,000/$8,000
Primary and specialty care visit $30 $30 $20 $40
Hospital inpatient (per admission) 30% after deductible 30% after deductible 20% after deductible 30% after deductible
Outpatient surgery (per procedure) 30% after deductible 30% after deductible 20% after deductible 30% after deductible
Emergency care 30% after deductible 30% after deductible 20% after deductible 30% after deductible
Prescription drugs
Generic $10 $10 $10 $10
Brand $30 after drug deductible $30 after drug deductible $30 $30
Specialty 20%, not to exceed $150after drug deductible
20%, not to exceed $150 after drug deductible 20%, not to exceed $150 20%, not to exceed $150
Separate drug deductible $100 $100 None None
Ambulance services (per trip) $150 after deductible $150 after deductible $150 after deductible $150 after deductible
CT/PET/MRI (per procedure) $150 after deductible $150 after deductible $150 after deductible $150 after deductible
Lab/X-ray (per encounter) $10 after deductible $10 after deductible $10 after deductible $10 after deductible
Durable medicalequipment 20% 20% 20% 20%
Preventive care No charge No charge No charge No charge
Infertility services 50% 50% 50% 50%
Prenatal care and well-baby visits No charge No charge No charge No charge
Optical hardware Not covered $175 hardware allowance/24 months Not covered Not covered
Prosthetics and orthotics No charge No charge No charge No charge
Skilled nursing facility 30% after deductible 30% after deductible 20% after deductible 30% after deductible
Deductible HMO XD — Provider office visits and pharmacy are covered at a copay or coinsurance. All other services, except preventive services, are subject to a deductible.
Plans selected:Compare plans
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Overview HMO CDHC KPIC
18 kp.org/choosebetter
DHMO
Complete Suite category
DHMO Deductible HMO XD Deductible HMO XD Deductible HMO XD Deductible HMO XD
NCAL/SCAL plan ID 8818/8819 8820/8821 8822/8823 8824/8825
Plan deductible (individual/family) $2,000/$4,000 $2,500/$5,000 $3,000/$6,000 $3,500/$7,000
Out-of-pocket maximum (individual/family) $4,000/$8,000 $5,000/$10,000 $6,000/$12,000 $6,450/$12,900
Primary and specialty care visit $20 $40 $40 $40
Hospital inpatient (per admission) 20% after deductible 30% after deductible 30% after deductible 30% after deductible
Outpatient surgery (per procedure) 20% after deductible 30% after deductible 30% after deductible 30% after deductible
Emergency care 20% after deductible 30% after deductible 30% after deductible 30% after deductible
Prescription drugs
Generic $10 $10 $10 $10
Brand $30 $30 $30 $30
Specialty 20%, not to exceed $150 20%, not to exceed $150 20%, not to exceed $150 20%, not to exceed $150
Separate drug deductible None None None None
Ambulance services (per trip) $150 after deductible $150 after deductible $150 after deductible $150 after deductible
CT/PET/MRI (per procedure) $150 after deductible $150 after deductible $150 after deductible $150 after deductible
Lab/X-ray (per encounter) $10 after deductible $10 after deductible $10 after deductible $10 after deductible
Durable medicalequipment 20% 20% 20% 20%
Preventive care No charge No charge No charge No charge
Infertility services 50% 50% 50% 50%
Prenatal care and well-baby visits No charge No charge No charge No charge
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge No charge
Skilled nursing facility 20% after deductible 30% after deductible 30% after deductible 30% after deductible
Deductible HMO XD — Provider office visits and pharmacy are covered at a copay or coinsurance. All other services, except preventive services, are subject to a deductible.
Plans selected:Compare plans
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Overview HMO CDHC KPIC
19 kp.org/choosebetter
DHMO
Complete Suite category
DHMO Deductible HMO XP Deductible HMO XP Deductible HMO XP Deductible HMO XP
NCAL/SCAL plan ID 8826/8827 9147/9158 9148/9159 9149/9160
Plan deductible (individual/family) $1,000/$2,000 $4,000/$8,000 $4,500/$9,000 $4,500/$9,000
Out-of-pocket maximum (individual/family) $3,000/$6,000 $6,450/$12,900 $6,500/$13,000 $6,500/$13,000
Primary and specialty care visit $20 after deductible $40 after deductible* $50 after deductible 40% after deductible
Hospital inpatient (per admission) 20% after deductible 30% after deductible 40% after deductible 40% after deductible
Outpatient surgery (per procedure) 20% after deductible 30% after deductible 40% after deductible 40% after deductible
Emergency care 20% after deductible 30% after deductible $250 after deductible 40% after deductible
Prescription drugs
Generic $10 $15 $15 30%, not to exceed $50
Brand $30 after drug deductible $35 $35 40%, not to exceed $100
Specialty 20%, not to exceed $150 after drug deductible 30%, not to exceed $150 30%, not to exceed $150 40%, not to exceed $200
Separate drug deductible $250 None None None
Ambulance services (per trip) $150 after deductible $150 after deductible 40% after deductible 40% after deductible
CT/PET/MRI (per procedure) $150 after deductible $150 after deductible $150 after deductible 40% after deductible
Lab/X-ray (per encounter) $10 after deductible 40% after deductible 40% after deductible
Durable medicalequipment 20% 30% 40% 40%
Preventive care No charge No charge No charge No charge
Infertility services 50% Not covered Not covered Not covered
Prenatal care and well-baby visits No charge No charge No charge No charge
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge No charge
Skilled nursing facility 20% after deductible 30% after deductible 40% after deductible 40% after deductible
Deductible HMO XP — All services, except preventive services, are subject to a deductible. Pharmacy is excluded from the deductible on certain plans.* Plan deductible doesn’t apply to the first 3 visits combined for primary care, urgent care, mental health, and chemical dependency.
Plans selected:Compare plans
$10 after deductible
##
Overview HMO CDHC KPIC
20 kp.org/choosebetter
DHMO
Complete Suite category
DHMODeductible HMO XP Deductible HMO XP
NCAL/SCAL plan ID 9151/9163 9150/9161
Plan deductible (individual/family) $5,000/$10,000 $5,500/$11,000
Out-of-pocket maximum (individual/family) $6,850/$13,700 $6,850/$13,700
Primary and specialty care visit $50 after deductible* $50 after deductible*
Hospital inpatient (per admission) 30% after deductible 40% after deductible
Outpatient surgery (per procedure) 30% after deductible 40% after deductible
Emergency care 30% after deductible 40% after deductible
Prescription drugs†
Generic $15 after plan deductible $15 after plan deductible
Brand $50 after plan deductible 40%, not to exceed $100after plan deductible
Specialty 30%, not to exceed $150 after plan deductible 40%, not to exceed $200 after plan deductible
Separate drug deductible None None
Ambulance services (per trip) 30% after deductible 40% after deductible
CT/PET/MRI (per procedure) 30% after deductible 40% after deductible
Lab/X-ray (per encounter) 30% after deductible 40% after deductible
Durable medicalequipment 30% 40%
Preventive care No charge No charge
Infertility services Not covered Not covered
Prenatal care and well-baby visits No charge No charge
Optical hardware Not covered Not covered
Prosthetics and orthotics No charge No charge
Skilled nursing facility 30% after deductible 40% after deductible
Deductible HMO XP — All services, except preventive services, are subject to a deductible. Pharmacy is excluded from the deductible on certain plans.* Plan deductible doesn’t apply to the first 3 visits combined for primary care, urgent care, mental health, and chemical dependency.† Supplemental preventive drugs available at a lower cost share and before plan deductible.
Supplemental preventive drug list available on account.kp.org/completesuite.
Plans selected:Compare plans
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Overview HMO DHMO KPIC
21 kp.org/choosebetter
CDHC
Complete Suite category
CDHC HSA-qualified DHMO HSA-qualified DHMO HSA-qualified DHMO HSA-qualified DHMO
NCAL/SCAL plan ID 9153/9164 9155/9165 9156/9166 9157/9167
Plan deductible
Self-only $1,300 $1,600 $2,000 $2,700
Family member/family $2,600/$2,600 $2,600/$3,200 $2,600/$4,000 $2,700/$5,450
Out-of-pocket maximum
Self-only $3,000 $3,200 $3,500 $5,250
Family member/family $3,000/$6,000 $3,200/$6,400 $3,500/$7,000 $5,250/$10,500
Primary and specialty care visit $20 after plan deductible 10% after plan deductible $30 after plan deductible $30 after plan deductible
Hospital inpatient (per admission) $250 after plan deductible 10% after plan deductible $250 after plan deductible 30% after plan deductible
Outpatient surgery (per procedure) $150 after plan deductible 10% after plan deductible $150 after plan deductible 30% after plan deductible
Emergency care $100 after plan deductible 10% after plan deductible $100 after plan
deductible 30% after plan deductible
Prescription drugs
Generic $10 after plan deductible $10 after plan deductible $10 after plan deductible $15 after plan deductible
Brand $30 after plan deductible $30 after plan deductible $30 after plan deductible $30 after plan deductible
Specialty 20%, not to exceed $150 after plan deductible
20%, not to exceed $150 after plan deductible
20%, not to exceed $150 after plan deductible
20%, not to exceed $150 after plan deductible
Separate drug deductible None None None None
Ambulance services (per trip)
$100 after plan deductible 10% after plan deductible $100 after plan
deductible$100 after plan
deductible
CT/PET/MRI (per procedure)
$150 after plan deductible 10% after plan deductible $150 after plan
deductible$150 after plan
deductible
Lab/X-ray (per encounter) $10 after plan deductible 10% after plan deductible $10 after plan deductible $10 after plan deductible
Durable medical equipment 20% after plan deductible 10% after plan deductible 20% after plan deductible 20% after plan deductible
Preventive care No charge No charge No charge No charge
Infertility services Not covered Not covered Not covered Not covered
Prenatal care and well-baby visits No charge No charge No charge No charge
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics No charge after plan deductible
No charge after plan deductible
No charge after plan deductible
No charge after plan deductible
Skilled nursing facility $250 after plan deductible 10% after plan deductible $250 after plan
deductible 30% after plan deductible
HSA-qualified deductible HMO plans — All services, except preventive services, are subject to a deductible.
Plans selected:Compare plans
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Overview HMO DHMO KPIC
22 kp.org/choosebetter
CDHC
Complete Suite category
CDHCHSA-qualified DHMO HSA-qualified DHMO HSA-qualified DHMO
NCAL/SCAL plan ID 8126/8127 8122/8125
Plan deductible
Self-only $3,500 $4,500 $4,500
Family member/family $3,500/$7,000 $4,500/$9,000 $4,500/$9,000
Out-of-pocket maximum
Self-only $6,000 $6,250 $6,250
Family member/family $6,000/$12,000 $6,250/$12,500 $6,250/$12,500
Primary and specialty care visit $30 after plan deductible 40% after plan deductible $50 after plan deductible
Hospital inpatient (per admission) 30% after plan deductible 40% after plan deductible 40% after plan deductible
Outpatient surgery (per procedure) 30% after plan deductible 40% after plan deductible 40% after plan deductible
Emergency care 30% after plan deductible 40% after plan deductible $250 after plan deductible
Prescription drugs
Generic $15 after plan deductible 30% after plan deductible $15 after plan deductible
Brand $35 after plan deductible 40% after plan deductible $35 after plan deductible
Specialty 30%, not to exceed $200 after plan deductible
40%, not to exceed $200 after plan deductible
30%, not to exceed $150 after plan deductible
Separate drug deductible None None None
Ambulance services (per trip) 30% after plan deductible 40% after plan deductible 40% after plan deductible
CT/PET/MRI (per procedure) 30% after plan deductible 40% after plan deductible $150 after plan deductible
Lab/X-ray (per encounter) 40% after plan deductible 40% after plan deductible
Durable medical equipment 30% after plan deductible 40% after plan deductible 40% after plan deductible
Preventive care No charge No charge No charge
Infertility services Not covered Not covered Not covered
Prenatal care and well-baby visits No charge No charge No charge
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge after plan deductible No charge after plan deductible No charge after plan deductible
Skilled nursing facility 30% after plan deductible 40% after plan deductible 40% after plan deductible
HSA-qualified deductible HMO plans — All services, except preventive services, are subject to a deductible.
Plans selected:Compare plans
$10 after deductible
10426/10427
##
Overview HMO DHMO KPIC
23 kp.org/choosebetter
CDHC
Complete Suite category
CDHCDHMO with HRA DHMO with HRA DHMO with HRA DHMO with HRA
NCAL/SCAL plan ID 8759/8760 8761/8762 8763/8764 8765/8766
Plan deductible (individual/family) $1,000/$2,000 $1,500/$3,000 $2,000/$4,000 $2,500/$5,000
Out-of-pocket maximum (individual/family) $2,000/$4,000 $3,000/$6,000 $4,000/$8,000 $5,000/$10,000
Primary and specialty care visit $20 after plan deductible $20 after plan deductible $20 after plan deductible $20 after plan deductible
Hospital inpatient (per admission) 20% after plan deductible 20% after plan deductible 20% after plan deductible 20% after plan deductible
Outpatient surgery (per procedure) 20% after plan deductible 20% after plan deductible 20% after plan deductible 20% after plan deductible
Emergency care 20% after plan deductible 20% after plan deductible 20% after plan deductible 20% after plan deductible
Prescription drugs
Generic $10 $10 $10 $10
Brand $30 $30 $30 $30
Specialty 20%, not to exceed $150 20%, not to exceed $150 20%, not to exceed $150 20%, not to exceed $150
Separate drug deductible None None None None
Ambulance services (per trip)
$150 after plan deductible
$150 after plan deductible
$150 after plan deductible
$150 after plan deductible
CT/PET/MRI (per procedure)
$150 after plan deductible
$150 after plan deductible
$150 after plan deductible
$150 after plan deductible
Lab/X-ray (per encounter) $10 after plan deductible $10 after plan deductible $10 after plan deductible $10 after plan deductible
Durable medicalequipment 20% 20% 20% 20%
Preventive care No charge No charge No charge No charge
Infertility services 50% 50% 50% 50%
Prenatal care and well-baby visits No charge No charge No charge No charge
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge No charge
Skilled nursing facility 20% after plan deductible 20% after plan deductible 20% after plan deductible 20% after plan deductible
Deductible HMO plans with HRA — All services, except pharmacy and preventive services, are subject to a deductible.
Plans selected:Compare plans
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Overview HMO DHMO KPIC
24 kp.org/choosebetter
CDHC
Complete Suite category
CDHCDHMO with HRA DHMO with HRA DHMO with HRA
NCAL/SCAL plan ID 7871/7872 7823/7824 8767/8768
Plan deductible (individual/family) $3,000/$6,000 $3,000/$6,000 $4,000/$8,000
Out-of-pocket maximum (individual/family) $6,000/$12,000 $6,000/$12,000 $6,000/$12,000
Primary and specialty care visit 20% after plan deductible 30% after plan deductible $20 after plan deductible
Hospital inpatient (per admission) 20% after plan deductible 30% after plan deductible 20% after plan deductible
Outpatient surgery (per procedure) 20% after plan deductible 30% after plan deductible 20% after plan deductible
Emergency care 20% after plan deductible 30% after plan deductible 20% after plan deductible
Prescription drugs
Generic 20% 30% $10
Brand 20% 30% $30
Specialty 20%, not to exceed $150 30%, not to exceed $150 20%, not to exceed $150
Separate drug deductible None None None
Ambulance services (per trip) 20% after plan deductible 30% after plan deductible $150 after plan deductible
CT/PET/MRI (per procedure) 20% after plan deductible 30% after plan deductible $150 after plan deductible
Lab/X-ray (per encounter) 20% after plan deductible 30% after plan deductible $10 after plan deductible
Durable medicalequipment 20% 30% 20%
Preventive care No charge No charge No charge
Infertility services 50% 50% 50%
Prenatal care and well-baby visits No charge No charge No charge
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge No charge No charge
Skilled nursing facility 20% after plan deductible 30% after plan deductible 20% after plan deductible
Deductible HMO plans with HRA — All services, except pharmacy and preventive services, are subject to a deductible.
Plans selected:Compare plans
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Overview HMO CDHCDHMO
25 kp.org/choosebetter
KPIC
Complete Suite category
KPICPOS
NCAL/SCAL plan ID 5689/5690
Tier Tier 1 Tier 2 Tier 3
Plan deductible (individual/family) $0/$0 $250/$500 $500/$1,000
Out-of-pocket maximum (individual/family) $1,500/$3,000 $2,500/$5,000 $5,000/$10,000
Primary and specialty care visit $10 20% after plan deductible 40% after plan deductible
Hospital inpatient (per admission) $200 $250 + 20% after plan deductible $500 + 40% after plan deductible
Outpatient surgery (per procedure) $100 20% after plan deductible 40% after plan deductible
Emergency care $100 Covered as HMO benefit Covered as HMO benefit
Prescription drugs
Generic $10 $20 preferred, $50 nonpreferred Not covered
Brand $30 $40 preferred, $50 nonpreferred Not covered
Specialty 20%, not to exceed $150 30%, not to exceed $250 Not covered
Separate drug deductible None None None
Ambulance services (per trip) $150 40% after plan deductible 40% after plan deductible
CT/PET/MRI (per procedure) No charge 20% after plan deductible 40% after plan deductible
Lab/X-ray (per encounter) No charge 20% after plan deductible 40% after plan deductible
Durable medicalequipment 20% 30% after plan deductible 50% after plan deductible
Preventive care No charge No charge 40%
Infertility services $10 20% 40%
Prenatal care and well-baby visits No charge No charge 40%
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge Covered by HMO In-Network only Covered by HMO In-Network only
Skilled nursing facility $200 $250 + 20% after plan deductible $500 + 40% after plan deductible
The Kaiser Permanente provider option of the POS plan is underwritten by Kaiser Foundation Health Plan, Inc. (KFHP). The PHCS Network and nonparticipating provider options of the POS plan are underwritten by Kaiser Permanente Insurance Company (KPIC). KPIC is a subsidiary of KFHP.
Plans selected:Compare plans
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Overview HMO CDHCDHMO
26 kp.org/choosebetter
KPIC
Complete Suite category
KPICPOS
NCAL/SCAL plan ID 5685/5686
Tier Tier 1 Tier 2 Tier 3
Plan deductible (individual/family) $0/$0 $500/$1,000 $1,000/$2,000
Out-of-pocket maximum (individual/family) $1,500/$3,000 $2,500/$5,000 $5,000/$10,000
Primary and specialty care visit $25 10% after plan deductible 30% after plan deductible
Hospital inpatient (per admission) $200 $250 + 10% after plan deductible $500 + 30% after plan deductible
Outpatient surgery (per procedure) $100 10% after plan deductible 30% after plan deductible
Emergency care $100 Covered as HMO benefit Covered as HMO benefit
Prescription drugs
Generic $10 $20 preferred, $50 nonpreferred Not covered
Brand $30 $40 preferred, $50 nonpreferred Not covered
Specialty 20%, not to exceed $150 30%, not to exceed $250 Not covered
Separate drug deductible None None None
Ambulance services (per trip) $150 30% after plan deductible 30% after plan deductible
CT/PET/MRI (per procedure) No charge 10% after plan deductible 30% after plan deductible
Lab/X-ray (per encounter) No charge 10% after plan deductible 30% after plan deductible
Durable medicalequipment 20% 30% after plan deductible 50% after plan deductible
Preventive care No charge No charge 30%
Infertility services $25 10% 30%
Prenatal care and well-baby visits No charge No charge 30%
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge Covered by HMO In-Network only Covered by HMO In-Network only
Skilled nursing facility $200 $250 + 10% after plan deductible $500 + 30% after plan deductible
The Kaiser Permanente provider option of the POS plan is underwritten by Kaiser Foundation Health Plan, Inc. (KFHP). The PHCS Network and nonparticipating provider options of the POS plan are underwritten by Kaiser Permanente Insurance Company (KPIC). KPIC is a subsidiary of KFHP.
Plans selected:Compare plans
##
Overview HMO CDHCDHMO
27 kp.org/choosebetter
KPIC
Complete Suite category
KPICPOS
NCAL/SCAL plan ID 5669/5670
Tier Tier 1 Tier 2 Tier 3
Plan deductible (individual/family) $0/$0 $1,000/$2,000 $2,000/$4,000
Out-of-pocket maximum (individual/family) $1,500/$3,000 $4,000/$8,000 $8,000/$16,000
Primary and specialty care visit $25 $35 30% after plan deductible
Hospital inpatient (per admission) $250 $250 + 10% after plan deductible $500 + 30% after plan deductible
Outpatient surgery (per procedure) $100 10% after plan deductible 30% after plan deductible
Emergency care $100 Covered as HMO benefit Covered as HMO benefit
Prescription drugs
Generic $10 $20 preferred, $50 nonpreferred Not covered
Brand $30 $40 preferred, $50 nonpreferred Not covered
Specialty 20%, not to exceed $150 30%, not to exceed $250 Not covered
Separate drug deductible None None None
Ambulance services (per trip) $150 30% after plan deductible 30% after plan deductible
CT/PET/MRI (per procedure) No charge $35 30% after plan deductible
Lab/X-ray (per encounter) No charge $35 30% after plan deductible
Durable medicalequipment 20% 30% 50% after plan deductible
Preventive care No charge No charge 30%
Infertility services $25 10% 30%
Prenatal care and well-baby visits No charge No charge 30%
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge Covered by HMO In-Network only Covered by HMO In-Network only
Skilled nursing facility $250 $250 + 10% after plan deductible $500 + 30% after plan deductible
The Kaiser Permanente provider option of the POS plan is underwritten by Kaiser Foundation Health Plan, Inc. (KFHP). The PHCS Network and nonparticipating provider options of the POS plan are underwritten by Kaiser Permanente Insurance Company (KPIC). KPIC is a subsidiary of KFHP.
Plans selected:Compare plans
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Overview HMO CDHCDHMO
28 kp.org/choosebetter
KPIC
Complete Suite category
KPICPOS
NCAL/SCAL plan ID 5675/5676
Tier Tier 1 Tier 2 Tier 3
Plan deductible (individual/family) $0/$0 $1,500/$3,000 $3,000/$6,000
Out-of-pocket maximum (individual/family) $1,500/$3,000 $4,500/$9,000 $9,000/$18,000
Primary and specialty care visit $35 30% after plan deductible 50% after plan deductible
Hospital inpatient (per admission) $200 $250 + 30% after plan deductible $500 + 50% after plan deductible
Outpatient surgery (per procedure) $100 30% after plan deductible 50% after plan deductible
Emergency care $100 Covered as HMO benefit Covered as HMO benefit
Prescription drugs
Generic $10 $20 preferred, $50 nonpreferred Not covered
Brand $30 $40 preferred, $50 nonpreferred Not covered
Specialty 20%, not to exceed $150 30%, not to exceed $250 Not covered
Separate drug deductible None None None
Ambulance services (per trip) $150 50% after plan deductible 50% after plan deductible
CT/PET/MRI (per procedure) No charge 30% after plan deductible 50% after plan deductible
Lab/X-ray (per encounter) No charge 30% after plan deductible 50% after plan deductible
Durable medicalequipment 20% 30% after plan deductible 50% after plan deductible
Preventive care No charge No charge 50%
Infertility services $35 30% 50%
Prenatal care and well-baby visits No charge No charge 50%
Optical hardware Not covered Not covered Not covered
Prosthetics and orthotics No charge Covered by HMO In-Network only Covered by HMO In-Network only
Skilled nursing facility $250 $250 + 30% after plan deductible $500 + 50% after plan deductible
The Kaiser Permanente provider option of the POS plan is underwritten by Kaiser Foundation Health Plan, Inc. (KFHP). The PHCS Network and nonparticipating provider options of the POS plan are underwritten by Kaiser Permanente Insurance Company (KPIC). KPIC is a subsidiary of KFHP.
Plans selected:Compare plans
##
Overview HMO CDHCDHMO
29 kp.org/choosebetter
KPIC
Complete Suite category
KPICPPO
NCAL/SCAL plan ID 5700/5701 5704/5705
Tier Tier 1 Tier 2 Tier 1 Tier 2
Plan deductible (individual/family) $250/$500 $500/$1,000 $500/$1,000 $1,000/$2,000
Out-of-pocket maximum (individual/family) $2,000/$4,000 $5,000/$10,000 $2,000/$4,000 $5,500/$11,000
Primary and specialty care visit $15 30% $20 40%
Hospital inpatient (per admission)
$250 + 10% after plan deductible
$500 + 30% after plan deductible
$250 + 20% after plan deductible
$500 + 40% after plan deductible
Outpatient surgery (per procedure)
$100 +10% after plan deductible
$150 + 30% after plan deductible
$100 + 20% after plan deductible
$150 + 40% after plan deductible
Emergency care $100 + 10% after plan deductible
$100 + 10% after plan deductible
$100 + 20% after plan deductible
$100 + 20% after plan deductible
Prescription drugs
Generic $15 Not covered $15 Not covered
Brand $40 Not covered $40 Not covered
Specialty 30%, not to exceed $200 Not covered 30%, not to exceed $200 Not covered
Separate drug deductible None None None None
Ambulance services (per trip) 30% after plan deductible 30% after plan deductible 40% after plan deductible 40% after plan deductible
CT/PET/MRI (per procedure) 10% after plan deductible 30% after plan deductible 20% after plan deductible 40% after plan deductible
Lab/X-ray (per encounter) 10% after plan deductible 30% after plan deductible 20% after plan deductible 40% after plan deductible
Durable medicalequipment 30% after plan deductible 50% after plan deductible 20% after plan deductible 40% after plan deductible
Preventive care No charge 30% No charge 40%
Infertility services 10% 30% 20% 40%
Prenatal care and well-baby visits No charge 30% No charge 40%
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics 10% after plan deductible 30% after plan deductible 20% after plan deductible 40% after plan deductible
Skilled nursing facility $250 +10% after plan deductible
$500 + 30% after plan deductible
$250 + 20% after plan deductible
$500 + 40% after plan deductible
The Kaiser Permanente PPO Insurance Plan is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc.
Plans selected:Compare plans
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Overview HMO CDHCDHMO
30 kp.org/choosebetter
KPIC
Complete Suite category
KPICPPO
NCAL/SCAL plan ID 5702/5703 5698/5699
Tier Tier 1 Tier 2 Tier 1 Tier 2
Plan deductible (individual/family) $1,000/$2,000 $2,000/$4,000 $1,500/$3,000 $3,000/$6,000
Out-of-pocket maximum (individual/family) $2,500/$5,000 $6,500/$13,000 $6,000/$12,000 $12,000/$24,000
Primary and specialty care visit $25 50% $40 50%
Hospital inpatient (per admission)
$500 + 30% after plan deductible
$1,000 + 50% after plan deductible
$1,000 + 30% after plan deductible
$1,500 + 50% after plan deductible
Outpatient surgery (per procedure)
$100 + 30% after plan deductible
$150 + 50% after plan deductible
$100 + 30% after plan deductible
$150 + 50% after plan deductible
Emergency care $100 + 30% after plan deductible
$100 + 30% after plan deductible
$100 + 30% after plan deductible
$100 + 30% after plan deductible
Prescription drugs
Generic $15 Not covered $15 Not covered
Brand $40 Not covered $40 Not covered
Specialty 30%, not to exceed $200 Not covered 30%, not to exceed $200 Not covered
Separate drug deductible None None None None
Ambulance services (per trip) 50% after plan deductible 50% after plan deductible 50% after plan deductible 50% after plan deductible
CT/PET/MRI (per procedure) 30% after plan deductible 50% after plan deductible 30% after plan deductible 50% after plan deductible
Lab/X-ray (per encounter) 30% after plan deductible 50% after plan deductible 30% after plan deductible 50% after plan deductible
Durable medicalequipment 30% after plan deductible 50% after plan deductible 30% after plan deductible 50% after plan deductible
Preventive care No charge 50% No charge 50%
Infertility services 30% 50% 30% 50%
Prenatal care and well-baby visits No charge 50% No charge 50%
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics 30% after plan deductible 50% after plan deductible 30% after plan deductible 50% after plan deductible
Skilled nursing facility $500 + 30% after plan deductible
$1,000 + 50% after plan deductible
$1,000 + 30% after plan deductible
$1,500 + 50% after plan deductible
The Kaiser Permanente PPO Insurance Plan is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc.
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Overview HMO CDHCDHMO
31 kp.org/choosebetter
KPIC
Complete Suite category
KPICPPO
NCAL/SCAL plan ID 8769/8770 7538/7539
Tier Tier 1 Tier 2 Tier 1 Tier 2
Plan deductible (individual/family) $3,000/$6,000 $6,000/$12,000 $4,500/$9,000 $9,000/$18,000
Out-of-pocket maximum (individual/family) $6,000/$12,000 $12,000/$24,000 $6,000/$12,000 $12,000/$24,000
Primary and specialty care visit $40 50% $40 50%
Hospital inpatient (per admission)
$1,000 + 30% after plan deductible
$1,500 + 50% after plan deductible
$1,000 + 30% after plan deductible
$1,500 + 50% after plan deductible
Outpatient surgery (per procedure)
$100 + 30% after plan deductible
$150 + 50% after plan deductible
$100 + 30% after plan deductible
$150 + 50% after plan deductible
Emergency care $100 + 30% after plan deductible
$100 + 30% after plan deductible
$100 + 30% after plan deductible
$100 + 30% after plan deductible
Prescription drugs
Generic $15 Not covered $15 Not covered
Brand $40 Not covered $40 Not covered
Specialty 30%, not to exceed $200 Not covered 30%, not to exceed $200 Not covered
Separate drug deductible None None None None
Ambulance services (per trip) 50% after plan deductible 50% after plan deductible 50% after plan deductible 50% after plan deductible
CT/PET/MRI (per procedure) 30% after plan deductible 50% after plan deductible 30% after plan deductible 50% after plan deductible
Lab/X-ray (per encounter) 30% after plan deductible 50% after plan deductible 30% after plan deductible 50% after plan deductible
Durable medical equipment 30% after plan deductible 50% after plan deductible 30% after plan deductible 50% after plan deductible
Preventive care No charge 50% No charge 50%
Infertility services 30% 50% 30% 50%
Prenatal care and well-baby visits No charge 50% No charge 50%
Optical hardware Not covered Not covered Not covered Not covered
Prosthetics and orthotics 30% after plan deductible 50% after plan deductible 30% after plan deductible 50% after plan deductible
Skilled nursing facility $1,000 + 30% after plan deductible
$1,500 + 50% after plan deductible
$1,000 + 30% after plan deductible
$1,500 + 50% after plan deductible
The Kaiser Permanente PPO Insurance Plan is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc.
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# 32 kp.org/choosebetter
Overview HMO CDHCDHMO KPIC
Complete Suite category
NCAL/SCAL plan ID
Plan deductible Individual (Self-only)/ Family member/Family
Out-of-pocket maximum Individual (Self-only)/ Family member/Family
Primary and specialty care visit
Hospital inpatient (per admission)
Outpatient surgery (per procedure)
Emergency care
Prescription drugs
Generic
Brand
Specialty
Separate drug deductible
Ambulance services (per trip)
CT/PET/MRI (per procedure)
Lab/X-ray (per encounter)
Durable medicalequipment
Preventive care
Infertility services
Prenatal care and well-baby visits
Optical hardware
Prosthetics and orthotics
Skilled nursing facility
The plan summary highlights the most frequently asked-about benefits and is for illustration purposes only. For a complete description, please refer to the appropriate Certificate of Insurance or contact your broker or Kaiser Permanente account manager.
Information may have changed since publication.
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Business Marketing 60609211 May 2017 ©2017 Kaiser Foundation Health Plan, Inc.