Kaiser HMO Plan Highlights

Annual Calendar Year Deductible	In-Network
Individual	$250
Family	$500

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Maximum Calendar Year Out-of-Pocket	In-Network
Individual	$2,500
Family	$2,500

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Lifetime Maximum	In-Network
Individual	Unlimited

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Professional Services	In-Network
Primary Care Physician (PCP)	$15 Copay (1)
Specialist	$15 Copay (1)
Preventive Care Exam	No 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

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Hospital Services	In-Network
Inpatient	5%
Outpatient Surgery	5%
Emergency Room	5%
Urgent Care	$15 Copay (1)

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Maternity Care	In-Network
Physician Services (prenatal or postnatal)	No Charge (1)
Hospital Services	5%

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Mental Health & Substance Abuse	In-Network
Inpatient	5%
Outpatient	Individual visit: $15 Copay (1) Group visit: $7 Copay (Mental Health) (1) / $5 Copay (Substance Abuse) (1)

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Vision Care	In-Network
Routine Eye Exams with a Plan Optometrist	No Charge
Eyeglasses or contact lenses every 24 months	Allowance up to $175 (1)

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

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

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(1) Deductible Waived

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