Plan Description
Eligibility Requirements
Prescription Drug Program
International Prescription Drug Plan through CRX International – CRX International is a discount prescription drug plan and is in addition to your Sav-RX and Kaiser prescription plans. For more information call CRX toll free at 1-866-488-7874, Monday- Friday 5:30am- 3:30pm Pacific Time or Saturday 6am- 2:30pm Pacific Time.
Principal Benefits for Kaiser Permanente Deductible HMO Plan
- The Services are Medically Necessary; and
- The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive the Services from Plan Providers inside our Northern California Region Service Area (your Home Region), except where specifically noted to the contrary in the Evidence of Coverage (EOC) for authorized referrals, hospice care, emergency care, post-stabilization care, out-of-area urgent care, and emergency ambulance services.
Annual Out-of-Pocket Maximum for Certain ServicesFor Services subject to the maximum, you will not pay any more Cost Sharing during a calendar year if the Copayments and Coinsurance you pay for those Services, plus all your Deductible payments, add up to one of the following amounts: |
|
For self-only enrollment (a Family of one Member) | $3,000 per calendar year |
For anyone Member in a Family of two or more Members | $3,000 per calendar year |
For an entire Family of two or more Members | $6,000 per calendar year |
Deductible for Certain Services
For Services subject to the Deductible, you must pay Charges for Services you receive in a calendar year until you reach one of the following Deductible amounts: |
|
For self-only enrollment (a Family of one Member) | $1,000 per calendar year |
For anyone Member in a Family of two or more Members | $1,000 per calendar year |
For an entire Family of two or more Members | $2,000 per calendar year |
Lifetime Maximum: None | |
Professional Services
(Plan Provider office visits) |
You Pay |
Most primary and specialty care consultations, exams, and treatment | $30 per visit (Deductible doesn’t apply) |
Routine physical maintenance exams | No charge (Deductible doesn’t apply) |
Well-child preventive exams (through age 23 months) | No charge (Deductible doesn’t apply) |
Family planning counseling | No charge (Deductible doesn’t apply) |
Scheduled prenatal care exams and first postpartum follow-up consultation and exam | No charge (Deductible doesn’t apply) |
Eye exams for refraction | No charge (Deductible doesn’t apply) |
Hearing exams | No charge (Deductible doesn’t apply) |
Urgent care consultations, exams, and treatment | $30 per Visit (Deductible doesn’t apply) |
Physical, occupational, and speech therapy | $30 per Visit (Deductible doesn’t apply) |
Outpatient Services | You Pay |
Outpatient surgery and certain other outpatient procedures | 20% Coinsurance after Deductible |
Allergy injections (including allergy serum) | No charge (Deductible doesn’t apply) |
Most immunizations (including the vaccine) | No charge (Deductible doesn’t apply) |
Most X-rays and laboratory tests | $10 per encounter (Deductible doesn’t apply) |
Preventive X-rays, screenings, and laboratory tests as described in the EOC | No charge (Deductible doesn’t apply) |
MRI, most CT, and PET scans | $50 per procedure (Deductible doesn’t apply) |
Health education: Covered individual health education counseling | No charge (Deductible doesn’t apply) |
Health education: Covered health education programs | No charge (Deductible doesn’t apply) |
Hospitalization Services | You Pay |
Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs | 20% Coinsurance after Deductible |
Emergency Health Coverage | You Pay |
Emergency Department visits | 20% Coinsurance after Deductible |
Ambulance Services | You Pay |
Ambulance Services | $150 per trip (Deductible doesn’t apply) |
Prescription Drug Coverage | You Pay |
Covered outpatient items in accord with our drug formulary guidelines: | |
Most generic items at a Plan Pharmacy | $10 for up to a 30-day supply, $20 for a 31- to 60-day supply, or $30 for a 61- to 100-day supply (Deductible doesn’t apply) |
Most generic refills through our mail-order service | $10 for up to a 30-day supply or $20 for a 31- to 100-day supply (Deductible doesn’t apply) |
Most brand-name items at a Plan Pharmacy | $30 for up to a 30-day supply, $60 for a 31- to 60-day supply, or $90 for a 61- to 100-day supply (Deductible doesn’t apply) |
Most brand-name refills through our mail-order service | $30 for up to a 30-day supply or $60 for a 31- to 100-day supply (Deductible doesn’t apply) |
Durable Medical Equipment | You Pay |
Most covered durable medical equipment for home use in accord with our durable medical equipment formulary guidelines | 20% Coinsurance (Deductible doesn’t apply) |
Mental Health Services | You Pay |
Inpatient psychiatric hospitalization | 20% Coinsurance after Deductible |
Individual outpatient mental health evaluation and treatment | $30 per visit (Deductible doesn’t apply) |
Group outpatient mental health treatment | $15 per visit (Deductible doesn’t apply) |
Chemical Dependency Services | You Pay |
Inpatient detoxification | 20% Coinsurance after Deductible |
Individual outpatient chemical dependency evaluation and treatment | $30 per visit (Deductible doesn’t apply) |
Group outpatient chemical dependency treatment | $5 per visit (Deductible doesn’t apply) |
Home Health Services | You Pay |
Home health care (up to 100 visits per calendar year) | No charge (Deductible doesn’t apply) |
Other | You Pay |
Skilled nursing facility care (up to 100 days per benefit period) | 20% Coinsurance (Deductible doesn’t apply) |
Covered external prosthetic devices, orthotic devices, and ostomy and urological
supplies |
No charge (Deductible doesn’t apply) |
All Services related to covered infertility treatment | 50% Coinsurance (Deductible doesn’t apply) |
Hospice care | No charge (Deductible doesn’t apply) |
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Sharing, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Sharing. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies). |
Kaiser – Senior Advantage
The Kaiser Senior Advantage HMO Plan with Part D is available to Retirees on Medicare with no prescription benefits.
Annual Out-of-pocket Maximums | |
For any one Member in the same Family Unit | $3,000 per calendar year |
For an entire Family Unit of two or more Members | $6,000 per calendar year |
Copayments and Coinsurance for most Services and all Deductible payments count toward this maximum as described in the Evidence of Coverage. | |
Deductibles | |
For any one Member in the same Family Unit | $300 per calendar year |
For an entire Family Unit of two or more Members | $600 per calendar year |
Lifetime Maximum | None |
Coordination of Benefits | Included |
Professional Services (Plan Provider Office Visits) |
|
Primary and specialty care visits (includes routine and Urgent Care appointments) | $20 per visit (Deductible doesn’t apply) |
Routine preventive physical exams | $20 per visit (Deductible doesn’t apply) |
Well-child preventive care visits (0–23 months) | $10 per visit (Deductible doesn’t apply) |
Family planning visits | $20 per visit (Deductible doesn’t apply) |
Scheduled prenatal care and first postpartum visit | $10 per visit (Deductible doesn’t apply) |
Eye exams | $20 per visit (Deductible doesn’t apply) |
Hearing tests | $20 per visit (Deductible doesn’t apply) |
Physical, occupational, and speech therapy visits | $20 per visit (Deductible doesn’t apply) |
Outpatient Services | |
Outpatient surgery | 10% Coinsurance after Deductible |
Allergy injection visits | No charge (Deductible doesn’t apply) |
Allergy testing visits | $20 per visit (Deductible doesn’t apply) |
Vaccines (immunizations) | No charge (Deductible doesn’t apply) |
X-rays and lab tests | $10 per encounter (except that MRI, CT, and PET are $50 per procedure) (Deductible doesn’t apply) |
Health education | $20 per individual visit (Deductible doesn’t apply) |
No charge for group visits (Deductible doesn’t apply) | |
Hospitalization Services | |
Room and board, surgery, anesthesia, X-rays, lab tests, and drugs | 10% Coinsurance after Deductible |
Emergency Health Coverage | |
Emergency Department visits | 10% Coinsurance after Deductible |
Ambulance Services | |
Ambulance Services | $150 per trip (Deductible doesn’t apply) |
Prescription Drug Coverage | |
Most covered outpatient items in accord with our drug formulary from Plan Pharmacies: | |
Generic items from a Plan Pharmacy | $10 for up to a 30 day supply, $20 for a 31–60 day supply, or $30 for a 61–100 day supply (Deductible doesn’t apply) |
Refills from our mail order program | $20 for up to a 100 day supply (Deductible doesn’t apply) |
Brand name items from a Plan Pharmacy | $20 for up to a 30 day supply, $40 for a 31–60 day supply, or $60 for a 61–100 day supply (Deductible doesn’t apply) |
Refills from our mail order program | $40 for up to a 100 day supply (Deductible doesn’t apply) |
Durable Medical Equipment | |
Most covered durable medical equipment for home use in accord with our DME formulary | 20% Coinsurance (Deductible doesn’t apply) |
Mental Health Services | |
Inpatient psychiatric care (up to 30 days per calendar year) | 10% Coinsurance after Deductible |
Outpatient visits: | |
Up to a total of 20 individual and group therapy visits per calendar year | $20 per individual therapy visit (Deductible doesn’t apply) |
$10 per group therapy visit (Deductible doesn’t apply) | |
Up to 20 additional group therapy visits that meet the Medical Group criteria in the same calendar year | $10 per group therapy visit (Deductible doesn’t apply) |
Note: Visit and day limits do not apply to serious emotional disturbances of children and severe mental illnesses as described in the Evidence of Coverage. | |
Chemical Dependency Services | |
Inpatient detoxification | 10% Coinsurance after Deductible |
Outpatient individual therapy visits | $20 per visit (Deductible doesn’t apply) |
Outpatient group therapy visits | $5 per visit (Deductible doesn’t apply) |
Transitional residential recovery Services (up to 60 days per calendar year, not to exceed 120 days in any five-year period) | $100 per admission (Deductible doesn’t apply) |
Home Health Services | |
Home health care (up to 100 two-hour visits per calendar year) | No charge (Deductible doesn’t apply) |
Other | |
Skilled nursing facility care (up to 100 days per benefit period) | 10% Coinsurance (Deductible doesn’t apply) |
Covered infertility inpatient care and outpatient surgery | 50% Coinsurance after Deductible |
All other covered Services related to infertility treatment | 50% Coinsurance (Deductible doesn’t apply) |
Hospice care | No charge (Deductible doesn’t apply) |