2018 plans and products | california - kaiser … plans and products | california. ......

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2018 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.

http://kp.org/choosebetter

Overview HMO CDHCDHMO POS/PPO


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 3 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 POS/PPO. 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.


https://readdle.com/products/pdfexpert5

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HMO CDHCDHMO POS/PPO


Overview

Traditional HMO — Pay a simple copay for most covered services.

*Available with optical hardware allowance.

HMO plan families NCAL/SCAL plan ID — office visit/hospital inpatient/out-of-pocket maximum

HMO High HMO Mid HMO Low

9961/9962 — $10/$0/$1,500 9983/9984 — $20/$250/$2,000 9955/9956 — $20/$250/$3,000

9965/9966 — $15/$0/$1,500 10682/10683* — $20/$250/$2,000 9957/9958 — $30/$250/$3,000

10003/10004 — $20/$0/$1,500 9987/9988 — $30/$250/$2,000 9959/9960 — $20/$500/$3,000

10650/10652* — $20/$0/$1,500 9989/9990 — $20/$500/$2,500 9967/9969 — $30/$500/$3,000

10011/10012 — $15/$250/$1,500 9930/9931 — $25/$500/$2,500 9973/9974 — $30/$500/$3,000

10015/10016 — $20/$250/$1,500 9991/9992 — $30/$500/$2,500 9977/9978 — $40/$500/$3,000

10678/10679* — $20/$250/$1,500 10684/10685* — $30/$500/$2,500 9979/9980 — $30/$500/$3,500

10048/10049 — $25/$250/$1,500 9942/9943 — $40/$500/$3,500

10052/10053 — $20/$500/$1,500

9970/9972 — $25/$500/$1,500

10680/10681* — $25/$500/$1,500

9981/9982 — $30/$500/$1,500

2018 Complete Suite plans Select the plans that you want to compare. You can choose up to 3 at a time.

HMO DHMO CDHC POS/PPO

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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% 9147/9158 — $4,000/$40/30%

10686/10687* — $250/$10/10% 8798/8799 — $500/$10/10% 9148/9159 — $4,500/$50/40%

8780/8781 — $500/$20/10% 8800/8801 — $500/$20/20% 9149/9160 — $4,500/40%/40%

8782/8783 — $750/$25/20% 10694/10695* — $500/$20/20% 9151/9163 — $5,000/$50/30%

8784/8785 — $1,000/$20/20% 8808/8809 — $750/$25/20% 9150/9161 — $5,500/$50/40%

10690/10691* — $1,000/$20/20% 8804/8805 — $1,000/$20/20%

8788/8789 — $1,000/$30/20% 10696/10697* — $1,000/$20/20%

8790/8791 — $1,500/20%/20% 8810/8811 — $1,000/$30/30%

10692/10693* — $1,500/$20/20% 8814/8815 — $1,500/$20/20%

8792/8793 — $1,500/$40/30% 8816/8817 — $1,500/$40/30%

8794/8795 — $2,500/$20/20% 8818/8819 — $2,000/$20/20%

10208/10209 — $3,000/$40/30% 8820/8821 — $2,500/$40/30%

10212/10213 — $4,500/$40/30% 8822/8823 — $3,000/$40/30%

10216/10217 — $5,500/$50/30% 8824/8825 — $3,500/$40/30%


2018 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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Overview

HSA-qualified deductible HMO plans — All services, except 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

10534/10541 — $1,350/$20/$250 8759/8760 — $1,000/$20/20%

10537/10542 — $1,600/10%/10% 8761/8762 — $1,500/$20/20%

10539/10546 — $2,000/$30/$250 8763/8764 — $2,000/$20/20%

9157/9167 — $2,700/$30/30% 8765/8766 — $2,500/$20/20%

10426/10427 — $3,500/$30/30% 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%

10160/10161 — $5,500/$50/40% 10156/10157 — $5,000/$20/20%

2018 Complete Suite plans Click on the specific plan name to see your options for that plan.


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Overview

Point-of-Service (POS)/PPO plans NCAL/SCAL plan ID — deductible by tier/office visit by tier

POS plans PPO plans

5671/5672 — $0/$500/$1,000; $20/$30/40% 10220/10221 — $250/$500; $15/30%

5681/5682 — $0/$500/$1,000; $20/20%/40% 10229/10230 — $500/$1,000; $20/40%

5679/5680 — $0/$1,000/$2,000; $25/20%/40% 10225/10226 — $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%

10233/10234 — $4,500/$9,000; $40/50%

2018 Complete Suite plans Click on the specific plan name to see your options for that plan.


Plans selected:

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Overview CDHCDHMO POS/PPO


HMO

Complete Suite categoryHMO

HMO High HMO High HMO High HMO High HMO High

NCAL/SCAL plan ID 9961/9962 9965/9966 10003/10004 10650/10652 10011/10012

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 $200

20%, not to exceed $200




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

Fertility 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 $150 hardware allowance/12 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


Plans selected:Compare plans


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HMO


HMO High HMO High HMO High HMO High HMO High

NCAL/SCAL plan ID 10015/10016 10678/10679 10048/10049 10052/10053 9970/9972




Hospital inpatient (per admission) $250 per admit $250 per admit $250 per admit $500 per admit $500 per admit


Emergency care $100 $100 $100 $100 $100

Prescription drugs

Generic $10 $10 $10 $15 $15

Brand $30 $30 $30 $35 $35








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



Fertility services 50% 50% 50% 50% 50%


Optical hardware Not covered $150 hardware allowance/12 months Not covered Not covered Not covered






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HMO


HMO High HMO High HMO Mid HMO Mid HMO Mid

NCAL/SCAL plan ID 10680/10681 9981/9982 9983/9984 10682/10683 9987/9988




Hospital inpatient (per admission) $500 per admit $500 per admit $250 per admit $250 per admit $250 per admit


Emergency care $100 $100 $100 $100 $100

Prescription drugs

Generic $15 $15 $15 $15 $15

Brand $35 $35 $30 $30 $30








CT/PET/MRI (per procedure) $50 $50 $50 $50 $50

Lab/X-ray (per encounter) $10 $10 $10 $10 $10





Optical hardware $150 hardware allowance/24 months Not covered Not covered $150 hardware

allowance/24 months Not covered






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HMO


HMO Mid HMO Mid HMO Mid HMO Mid HMO Low

NCAL/SCAL plan ID 9989/9990 9930/9931 9991/9992 10684/10685 9955/9956




Hospital inpatient (per admission) $500 per admit $500 per admit $500 per admit $500 per admit $250 per day

up to 3 days


Emergency care $100 $100 $100 $100 $100

Prescription drugs

Generic $15 $15 $15 $15 $10

Brand $35 $35 $35 $35 $30














Optical hardware Not covered Not covered Not covered $150 hardware allowance/24 months Not covered






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HMO


HMO Low HMO Low HMO Low HMO Low HMO Low

NCAL/SCAL plan ID 9957/9958 9959/9960 9967/9969 9973/9974 9977/9978




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


Emergency care $100 $150 $150 $150 $150

Prescription drugs

Generic $10 $15 $15 $15 $15

Brand $30 $35 $35 $35 $35














Optical hardware Not covered Not covered Not covered Not covered Not covered






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HMO


HMO Low HMO Low

NCAL/SCAL plan ID 9979/9980 9942/9943

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 $200 30%, not to exceed $200

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

Fertility 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




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Overview HMO CDHC POS/PPO


DHMO

Complete Suite categoryDHMO

Deductible HMO HO Deductible HMO HO Deductible HMO HO Deductible HMO HO Deductible HMO HO

NCAL/SCAL plan ID 8776/8777 10686/10687 8780/8781 8782/8783 8784/8785

Plan deductible (individual/family) $250/$500 $250/$500 $500/$1,000 $750/$1,500 $1,000/$2,000



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














Optical hardware Not covered $130 hardware allowance/12 months Not covered Not covered Not covered


Skilled nursing facility 10% 10% 10% 20% 20%




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DHMO


Deductible HMO HO Deductible HMO HO Deductible HMO HO Deductible HMO HO Deductible HMO HO

NCAL/SCAL plan ID 10690/10691 8788/8789 8790/8791 10692/10693 8792/8793

Plan deductible (individual/family) $1,000/$2,000 $1,000/$2,000 $1,500/$3,000 $1,500/$3,000 $1,500/$3,000



Hospital inpatient (per admission) 20% after deductible 20% after deductible 20% after deductible 20% after deductible 30% after deduct-

ible

Outpatient surgery (per procedure) 20% after deductible 20% after deductible 20% after deductible 20% after deductible 30% after deduct-

ible

Emergency care 20% after deductible 20% after deductible 20% after deductible 20% after deductible 30% after deduct-ible

Prescription drugs

Generic $10 $10 $10 $10 $10

Brand $30 $30 after drug deductible $30 $30 $30


20%, not to exceed $200 after drug deductible




Separate drug deductible None $250 None None None









allowance/24 months Not covered


Skilled nursing facility 20% 20% 20% 20% 30%




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DHMO


Deductible HMO HO Deductible HMO HO Deductible HMO HO Deductible HMO HO

NCAL/SCAL plan ID 8794/8795 10208/10209 10212/10213 10216/10217

Plan deductible (individual/family) $2,500/$5,000 $3,000/$6,000 $4,500/$9,000 $5,500/$11,000

Out-of-pocket maximum (individual/family) $5,000/$10,000 $6,000/$12,000 $6,500/$13,000 $6,500/$13,000

Primary and specialty care visit $20 $40 $40 $50


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 $15 $15

Brand $30 $30 $35 $50





Separate drug deductible None None None None

Ambulance services (per trip) $150 $150 $150 $150

CT/PET/MRI (per procedure) $150 $150 $150 $150

Lab/X-ray (per encounter) $10 $10 $10 $10

Durable medical equipment 20% 20% 30% 30%

Preventive care No charge No charge No charge No charge

Fertility services 50% 50% 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% 30% 30% 30%




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DHMO


Deductible 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 $200 20%, not to exceed $200 20%, not to exceed $200 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

Fertility 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




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DHMO


Deductible HMO XD Deductible HMO XD Deductible HMO XD Deductible HMO XD

NCAL/SCAL plan ID 10694/10695 8808/8809 8804/8805 10696/10697

Plan deductible (individual/family) $500/$1,000 $750/$1,500 $1,000/$2,000 $1,000/$2,000



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


Prescription drugs

Generic $10 $10 $10 $10

Brand $30 after drug deductible $30 $30 $30

Specialty 20%, not to exceed $200 after drug deductible 20%, not to exceed $200 20%, not to exceed $200 20%, not to exceed $200

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%


Fertility services 50% 50% 50% 50%



allowance/24 months


Skilled nursing facility 20% after deductible 20% after deductible 20% after deductible 20% after deductible




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DHMO


Deductible HMO XD Deductible HMO XD Deductible HMO XD

NCAL/SCAL plan ID 8810/8811 8814/8815 8816/8817

Plan deductible (individual/family) $1,000/$2,000 $1,500/$3,000 $1,500/$3,000


Primary and specialty care visit $30 $20 $40



Emergency care 30% after deductible 20% after deductible 30% after deductible

Prescription drugs

Generic $10 $10 $10

Brand $30 after drug deductible $30 $30

Specialty 20%, not to exceed $200 after drug deductible 20%, not to exceed $200 20%, not to exceed $200

Separate drug deductible $100 None None

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%


Fertility services 50% 50% 50%








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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




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


Prescription drugs

Generic $10 $10 $10 $10

Brand $30 $30 $30 $30

Specialty 20%, not to exceed $200 20%, not to exceed $200 20%, not to exceed $200 20%, not to exceed $200


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







Skilled nursing facility 20% after deductible 30% after deductible 30% after deductible 30% after deductible




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DHMO


Deductible HMO XP Deductible HMO XP Deductible HMO XP

NCAL/SCAL plan ID 9147/9158 9148/9159 9149/9160

Plan deductible (individual/family) $4,000/$8,000 $4,500/$9,000 $4,500/$9,000


Primary and specialty care visit $40 after deductible1 $50 after deductible 40% after deductible



Emergency care 30% after deductible $250 after deductible 40% after deductible

Prescription drugs

Generic $15 $15 30%, not to exceed $50

Brand $35 $35 40%, not to exceed $100

Specialty 30%, not to exceed $200 30%, not to exceed $200 40%, not to exceed $200

Separate drug deductible None None None

Ambulance services (per trip) $150 after deductible 40% after deductible 40% after deductible

CT/PET/MRI (per procedure) $150 after deductible $150 after deductible 40% after deductible

Lab/X-ray (per encounter) $10 after deductible 40% after deductible 40% after deductible

Durable medical equipment 30%2 40%2 40%2


Fertility services Not covered Not covered Not covered





Deductible HMO XP — All services, except preventive services, are subject to a deductible. Pharmacy is excluded from the deductible on certain plans.1Plan deductible doesn’t apply to the first 3 visits combined for primary care, urgent care, mental health, and chemical dependency.2This plan is limited to durable medical equipment (DME) items that are essential health benefits in accordance with our DME formulary guidelines.



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DHMO


Deductible 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 deductible1 $50 after deductible1

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 drugs2

Generic $15 after plan deductible $15 after plan deductible

Brand $50 after plan deductible 40%, not to exceed $100 after plan deductible

Specialty 30%, not to exceed $200 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 medical equipment 30%3 40%3

Preventive care No charge No charge

Fertility 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.1Plan deductible doesn’t apply to the first 3 visits combined for primary care, urgent care, mental health, and chemical dependency.2 Supplemental preventive drugs available at a lower cost share and before plan deductible. All other prescriptions are subject to plan deductible.

3 This plan is limited to durable medical equipment (DME) items that are essential health benefits in accordance with our DME formulary guidelines.

Supplemental preventive drug list available on account.kp.org/completesuite.



https://account.kp.org/broker-employer/poc?uri=center:large-business&article=434EF1F4-69CE-11E4-86A9-95F6381FB8B9&region=CA

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Overview HMO DHMO POS/PPO


CDHC

Complete Suite categoryCDHC

HSA-qualified DHMO HSA-qualified DHMO HSA-qualified DHMO HSA-qualified DHMO

NCAL/SCAL plan ID 10534/10541 10537/10542 10539/10546 9157/9167

Plan deductible

Self-only $1,350 $1,600 $2,000 $2,700

Family member/family $2,700/$5,450 $2,700/$3,200 $2,700/$4,000 $2,700/$5,450

Out-of-pocket maximum

Self-only $3,000 $3,200 $3,500 $5,250


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 $200 after plan deductible

20%, not to exceed $200 after plan deductible




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


Fertility services Not covered Not covered Not covered Not covered



Prosthetics and orthotics 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.



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CDHC



HSA-qualified DHMO HSA-qualified DHMO HSA-qualified DHMO HSA-qualified DHMO

NCAL/SCAL plan ID 10426/10427 8126/8127 8122/8125 10160/10161

Plan deductible

Self-only $3,500 $4,500 $4,500 $5,500


Out-of-pocket maximum

Self-only $6,000 $6,250 $6,250 $6,550


Primary and specialty care visit $30 after plan deductible 40% after plan deductible $50 after plan deductible $50 after plan deductible

Hospital inpatient (per admission) 30% after plan deductible 40% 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 40% after plan deductible

Emergency care 30% after plan deductible 40% after plan deductible $250 after plan deductible 40% 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 40%, not to exceed $100after plan deductible

Specialty 30%, not to exceed $200 after plan deductible





Ambulance services (per trip) 30% after plan deductible 40% 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 40% after plan deductible

Lab/X-ray (per encounter) $10 after plan deductible 40% after plan deductible 40% after plan deductible 40% after plan deductible

Durable medical equipment 30% after plan deductible2 40% after plan deductible2 40% after plan deductible2 40% after plan deductible2


Fertility services Not covered Not covered Not covered Not covered



Prosthetics and orthotics No charge after plan deductible




Skilled nursing facility 30% after plan deductible 40% after plan deductible 40% after plan deductible 40% after plan deductibleHSA-qualified deductible HMO plans — All services, except preventive services, are subject to a deductible.1 Supplemental preventive drugs available at a lower cost share and before plan deductible.2This plan is limited to durable medical equipment (DME) items that are essential health benefits in accordance with our DME formulary guidelines.

$15 after plan deductible1


##



CDHC


DHMO with HRA DHMO with HRA DHMO with HRA DHMO with HRA

NCAL/SCAL plan ID 8759/8760 8761/8762 8763/8764 8765/8766



Primary and specialty care visit $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 $200 20%, not to exceed $200 20%, not to exceed $200 20%, not to exceed $200


Ambulance services (per trip)

$150 after plan deductible




CT/PET/MRI (per procedure) $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







Skilled nursing facility 20% after plan deductible 20% after plan deductible 20% after plan deductible 20% after plan deductible



##



CDHC


DHMO with HRA DHMO with HRA DHMO with HRA DHMO with HRA

NCAL/SCAL plan ID 7871/7872 7823/7824 8767/8768 10156/10157



Primary and specialty care visit 20% after plan deductible 30% after plan deductible $20 after plan deductible $20 after plan deductible



Emergency care 20% after plan deductible 30% after plan deductible 20% after plan deductible 20% after plan deductible

Prescription drugs

Generic 20% 30% $10 $10

Brand 20% 30% $30 $30

Specialty 20%, not to exceed $200 20%, not to exceed $200 20%, not to exceed $250



20% after plan deductible




CT/PET/MRI (per procedure)





Lab/X-ray (per encounter) 20% after plan deductible 30% after plan deductible $10 after plan deductible $10 after plan deductible

Durable medical equipment 20% 30% 20% 20%






Skilled nursing facility 20% after plan deductible 30% after plan deductible 20% after plan deductible 20% after plan deductible




##

Overview HMO CDHCDHMO


POS/PPO


Complete Suite category POS

NCAL/SCAL plan ID 5671/5672

Tier HMO Tier Participating Provider Tier Non-Participating Provider Tier

Plan deductible (individual/family) $0/$0 $500/$1,000 $1,000/$2,000


Primary and specialty care visit $20 $30 40% after plan deductible

Hospital inpatient (per admission) $250 $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 under the HMO Tier Covered under the HMO Tier

Prescription drugs

Generic $10 $20 preferred, $50 nonpreferred Not covered

Brand $30 $40 preferred, $50 nonpreferred Not covered

Specialty 20%, not to exceed $200 30%, not to exceed $250 Not covered


Ambulance services (per trip) $150 40% after plan deductible 40% after plan deductible

CT/PET/MRI (per procedure) No charge $30 40% after plan deductible

Lab/X-ray (per encounter) No charge $30 40% after plan deductible

Durable medical equipment 20% 30% after plan deductible 50% after plan deductible

Preventive care No charge No charge 40%

Fertility services $20 20% 40%

Prenatal care and well-baby visits No charge No charge 40%


Prosthetics and orthotics No charge Only covered under the HMO Tier Only covered under the HMO Tier

Skilled nursing facility $250 $250 + 20% after plan deductible $500 + 40% after plan deductible

The HMO Tier of the Point-of-Service (POS) plan is underwritten by Kaiser Foundation Health Plan, Inc. (KFHP), while the Participating Provider and Non-Participating Provider tiers of the POS plan are underwritten by Kaiser Permanente Insurance Company (KPIC). KPIC is a subsidiary of KFHP.


##



POS/PPO





Plan deductible (individual/family) $0/$0 $500/$1,000 $1,000/$2,000


Primary and specialty care visit $20 20% after plan deductible 40% after plan deductible




Prescription drugs






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










##



POS/PPO





Plan deductible (individual/family) $0/$0 $1,000/$2,000 $2,000/$4,000






Prescription drugs

















##



POS/PPO





Plan deductible (individual/family) $0/$0 $1,500/$3,000 $3,000/$6,000






Prescription drugs

















##



POS/PPO

Complete Suite category PPO

NCAL/SCAL plan ID 10220/10221 10229/10230

Tier Participating Provider Tier Non-Participating Provider Tier Participating Provider Tier Non-Participating Provider

Tier

Plan deductible (individual/family) $250/$500 $500/$1,000 $500/$1,000 $1,000/$2,000


Primary and specialty care visit $15 30% $20 40%


$250 + 10% after plan deductible





$100 +10% after plan deductible




Emergency care $100 + 10% 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



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%


Prenatal care and well-baby visits No charge 30% No charge 40%


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




The Kaiser Permanente PPO Plan is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc.



##



POS/PPO


NCAL/SCAL plan ID 10225/10226 5698/5699


Tier






$1,000 + 50% after plan deductible












Prescription drugs








Durable medicalequipment 30% after plan deductible 50% after plan deductible 30% after plan deductible 50% after plan deductible






Skilled nursing facility $500 + 30% after plan deductible







##



POS/PPO


NCAL/SCAL plan ID 8769/8770 10233/10234


Tier


















Prescription drugs








Durable medical equipment 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







# 33 kp.org/choosebetter

Overview HMO CDHCDHMO POS/PPO

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



Emergency care

Prescription drugs

Generic

Brand

Specialty

Separate drug deductible


CT/PET/MRI (per procedure)

Lab/X-ray (per encounter)

Durable medicalequipment

Preventive care

Fertility 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 60570711 July 2017 ©2017 Kaiser Foundation Health Plan, Inc.


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