Below is a brief outline of benefits provided in 2019. Refer to the official benefits booklet for a comprehensive description of plan benefits. Under all circumstances, the benefits booklet will take precedence over information contained on this website. The 2020 HMO Benefits Booklet will be available by April 1, 2020. Contact Kaiser Permanente for questions of coverage.
Benefit
| Deductible |
None |
| Annual Out of Pocket Max |
$2,000 individual/$4,000 family |
| Lifetime maximum benefit |
Unlimited |
| Office Visits |
100% after $25 copay |
Preventive Care
| Immunizations |
100% |
| Adult physicals |
100% |
| Well-woman exams/screenings |
100% |
| Well-baby exams |
100% |
Other Care
Emergency Room
(copay waived if admitted) |
$100 copay |
| Inpatient hospital services |
100% |
| Outpatient hospital services |
100% after $25 copay |
| Outpatient surgical center |
100% after $25 copay |
Prescription drugs (retail/pharmacy)
| | 30-day supply |
|---|
| Generic |
$10 copay |
| Brand formulary |
$30 copay |
| Nonformulary |
N/A |
Prescription drugs (mail order)
| | 90-day supply |
|---|
| Generic |
$20 copay |
| Brand formulary |
$60 copay |
| Nonformulary |
N/A |
