Santen Kaiser Permanente Plans
The charts below outline each plan’s provisions, deductibles, copays and coinsurance of the plan:
- Kaiser HMO (Northern California Only)
- Kaiser HDHP HMO with HSA (Northern California Only)
Northern California Only Plans
| Kaiser | HMO (Northern California Only) | HDHP HMO with HSA (Northern California Only) |
|---|---|---|
| Key Features | In-Network | In-Network |
| Annual Calendar Year Deductible | ||
| Individual | None | $2,800 |
| Family | None | $2,800 (each member in a family of two or more) $5,600 (entire family of two or more) |
| Out-of-Pocket Maximum | ||
| Individual (includes deductible) | $1,500 per individual | $2,800 (each member in a family of two or more) |
| Family (includes deductible) | $3,000 | $5,600 |
| Physician Services | ||
| Office Visit | $30 | No charge after deductible |
| Preventive Care | No charge | No charge (deductible waived) |
| Diagnostic Lab and X-Ray | No charge | No charge after deductible |
| Complex Lab and X-Ray | No charge | No charge after deductible |
| Hospital Services | ||
| Inpatient (per admission) | No charge | No charge after deductible |
| Outpatient Surgery | $30 | No charge after deductible |
| Emergency Treatment | ||
| Emergency Room (waived if admitted) | $100 | No charge after deductible |
| Retail Prescriptions¹ (30-day supply) | ||
| Tier 1 | $10 | No charge after deductible |
| Tier 2 | $25 | No charge after deductible |
| Mail-Order Prescriptions¹ (100-day supply) | ||
| Tier 1 | $20 | No charge after deductible |
| Tier 2 | $50 | No charge after deductible |
1 For prescription drug formulary information, visit the carrier website or contact Members Services via the toll-free number on your ID card. |
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