Below is a brief outline of benefits provided in 2020. 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. 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 |
