CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Annual Deductible: Individual/Family | N/A
|
N/A |
Calendar or Contract Year | N/A | N/A |
Calendar or Contract Year - Embedded or Aggregate | N/A | N/A |
Maximum Out-of-Pocket | $1500/$3000 | $1500/$3000 |
Maximum Out-of-Pocket - Embedded or Aggregate | N/A | N/A |
Coinsurance Member Cost Share | N/A | N/A |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Primary Care | $25 | $25 |
Specialist | $25 | $25 |
Telemedicine | 100% Covered | 100% Covered |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Services rendered while hospitalized (Per admit) | $500 | $500 |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share (In and Out of Plan) | $50 | $50 |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Outpatient surgery in hospital or ambulatory surgical facility | $25 | $25 |
Office Surgery Cost Share | $25 | $25 |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Tier 1 Generic | $10 | $101 |
Tier 2 Formulary Brand | $20 | $202 |
Tier 3 Non-Formulary Brand | Not Available | Not Covered |
Specialty Rx | 20% up to a max of $150 | 20% up to a max of $150
|
Day Supply | 30 days | 30 days |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Tier 1 Generic | $20 | $20 |
Tier 2 Formulary Brand | $40 | $40 |
Tier 3 Non-Formulary Brand | Not Available | Not Covered |
Day Supply | 100 days | 90 days |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Contraceptives | $0 | $0 |
Growth Hormone | Equal to generic/brand cost share | Equal to generic/brand cost share |
Infertility | 50% | 50% |
Sexual Dysfunction Cost Share | 50% | 50% |
Smoking Cessation Cost Share | 0% | 0% |
Weight Control | Not Covered | Not Covered |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | 50% | 50% |
IVF, GIFT and ZIFT | Not Covered | Not Covered |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | $0 | $0 |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | $0 | $0 |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | $0 | $0 |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | $0 | $0 |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | $0 | $0 |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | $0 | $0 |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | Not Covered (unless where mandated) | Not Covered (unless where mandated)3 |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | Not Covered | Not Covered4 |
Limits | N/A | N/A5 |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | $25 | $25 |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Annual Deductible: Individual/Family | $2000/$2800/$4000 (due to state law CA AB 1305) | $2000/$4000 |
Calendar or Contract Year | Calendar | Calendar |
Calendar or Contract Year - Embedded or Aggregate | Embedded | Aggregate |
Maximum Out-of-Pocket | $4000/$4000/$7900 | $4000/$7900 |
Maximum Out-of-Pocket - Embedded or Aggregate | Embedded | Aggregate |
Coinsurance Member Cost Share | 20% | 20% |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Primary Care | 20% coinsurance after deductible | 20% coinsurance after deductible
|
Specialist | 20% coinsurance after deductible
|
20% coinsurance after deductible
|
Telemedicine | 100% after deductible | 100% after deductible |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Services rendered while hospitalized (Per admit) | 20% coinsurance after deductible | 20% coinsurance after deductible |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share (In and Out of Plan) | 20% coinsurance after deductible | 20% coinsurance after deductible |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Outpatient surgery in hospital or ambulatory surgical facility | 20% coinsurance after deductible | 20% coinsurance after deductible |
Office Surgery Cost Share | 20% coinsurance after deductible | 20% coinsurance after deductible |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Tier 1 Generic | 20% coinsurance after deductible up to per script max of $50 | 20% coinsurance after deductible 6 |
Tier 2 Formulary Brand | 20% coinsurance after deductible up to per script max of $100 | 20% coinsurance after deductible 6 |
Tier 3 Non-Formulary Brand | Not Available | Not Covered |
Specialty Rx | 20% coinsurance after deductible up to per script max of $100 | 20% coinsurance after deductible |
Day Supply | 30 days | 30 days |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Tier 1 Generic | 20% coinsurance after deductible up to per script max of $50 | 20% coinsurance after deductible |
Tier 2 Formulary Brand | 20% coinsurance after deductible up to per script max of $100 | 20% coinsurance after deductible |
Tier 3 Non-Formulary Brand | Not Available | Not Available |
Day Supply | 100 days | 90 days |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Contraceptives | $0 | $0 |
Growth Hormone | Equal to generic/brand cost share | Equal to generic/brand cost share |
Infertility | 50% coinsurance after deductible | 50% coinsurance after deductible |
Sexual Dysfunction Cost Share | 50% coinsurance after deductible | 50% coinsurance after deductible |
Smoking Cessation Cost Share | 0% | 0% |
Weight Control | Not Covered | Not Covered |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | 50% coinsurance after deductible | 50% coinsurance after deductible |
IVF, GIFT and ZIFT | Not Covered | Not Covered |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | 20% coinsurance after deductible | 20% coinsurance after deductible
|
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | 20% coinsurance after deductible | 20% coinsurance after deductible |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | 20% coinsurance after deductible | 20% coinsurance after deductible |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | 20% coinsurance after deductible | 20% coinsurance after deductible |
Out of Network | Worldwide Emergency Coverage only (same as in Network) | Worldwide Emergency Coverage only (same as in Network) |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | 20% coinsurance after deductible | 20% coinsurance after deductible |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | 20% coinsurance after deductible | 20% coinsurance after deductible |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | Not Covered | Not Covered |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | Not Covered (unless where mandated) | Not Covered (unless where mandated)3 |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | Not Covered | Not Covered7 |
Limits | N/A | N/A8 |
CA | CO, GA, MD, DC, VA, OR and WA | |
---|---|---|
Cost Share | 20% coinsurance after deductible | 20% coinsurance after deductible |
View the Kaiser Permanente SBC for teammates in California.
View the Kaiser Permanente SBC for teammates in Colorado.
View the Kaiser Permanente SBC for teammates in Georgia.
View the Kaiser Permanente SBC for teammates in Mid-Atlantic states.
View the Kaiser Permanente SBC for teammates in the Northwest.
View the Kaiser Permanente SBC for teammates in Washington.