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Plan Highlights

Kaiser Deductible HMO Plan C

Annual Calendar Year DeductibleIn-Network

Maximum Calendar Year Out-of-PocketIn-Network

Lifetime MaximumIn-Network

Professional ServicesIn-Network
Primary Care Physician (PCP)$15 Copay (1)
Specialist$15 Copay (1)
Preventive Care ExamNo Charge (1)
Well-baby Care (First 23 months)No Charge (1)
Diagnostic X-Ray and Lab$10 Copay
Complex Diagnostics (MRI/CT Scan)5% up to $50 Copay per procedure
Therapy (Physical, Occupational and Speech)$15 Copay

Hospital ServicesIn-Network
Outpatient Surgery5%
Emergency Room5%
Urgent Care$15 Copay (1)

Maternity CareIn-Network
Physician Services (prenatal or postnatal)No Charge (1)
Hospital Services5%

Mental Health & Substance AbuseIn-Network
OutpatientIndividual visit: $15 Copay (1)
Group visit: $7 Copay (Mental Health) (1) / $5 Copay (Substance Abuse) (1)

Vision CareIn-Network
Routine Eye Exams with a Plan OptometristNo Charge
Eyeglasses or contact lenses every 24 monthsAllowance up to $175 (1)

Retail Prescription Drugs (up to a 30-day supply)In-Network
Generic Drugs$10 Copay
Preferred Brand Name Drugs$35 Copay

Mail Order Prescription Drugs (Up to a 100-day supply)In-Network
Generic Drugs$20 Copay
Preferred Brand Name Drugs$70 Copay

(1) Deductible Waived

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