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Effective Date	1/1/2023
Annual Deductible
Individual / Family	$500 Individual / $1,000 Family (Embedded)
Individual / Family	$500 Individual / $1,000 Family (Embedded)
Maximum Out-Of-Pocket
Individual / Family	$2,000 Individual / $4,000 Family (Embedded)
Individual / Family	$2,000 Individual / $4,000 Family (Embedded)
Maximum Lifetime Benefit	Unlimited
Grandfathered Status	Not Applicable
Hospital Inpatient
Services Rendered while Hospitalized	$200 per admission after Plan Deductible
Maternity Inpatient	$200 per admission after Plan Deductible
Outpatient
Primary Care	$30 per visit (Plan Deductible does not apply)
Urgent Care	$30 per visit (Plan Deductible does not apply)

Specialist	$40 per visit (Plan Deductible does not apply)
Well-child & Preventive Care visits	No charge
Routine Prenatal Care	No charge
Outpatient Surgery	$100 per procedure after Plan Deductible
Therapies (PT/OT/ST)	$30 per visit (Plan Deductible does not apply) (Unlimited Visits)
Therapies (PT/OT/ST)
X-rays and Lab Tests	X-ray No Charge (Plan Deductible does not apply); Lab No Charge (Plan Deductible does not apply)
Advanced Imaging (CT / MRI / PET)	$100 per encounter (Plan Deductible does not apply)
Ambulance	$100 per trip (Plan Deductible does not apply)
Emergency Department Visits	$150 per visit after Plan Deductible waived if admitted
Outpatient Prescription Drugs
Generic Drugs	$10 Copay Retail (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply)
Brand Drugs	$25 Copay Retail (Plan Deductible does not apply), $50 Copay Mail Order (Plan Deductible does not apply)
Non-preferred Drugs	$25 Copay Retail (Plan Deductible does not apply), $50 Copay Mail Order (Plan Deductible does not apply)
Specialty Drugs	$250 Copay (Plan Deductible does not apply)
Pharmacy Deductible	None
Days Supply	Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 100-day supply

Outpatient Prescription Drugs - Mail Order
Generic Drugs	$20 Copay Mail Order (Plan Deductible does not apply)
Brand Drugs	$50 Copay Mail Order (Plan Deductible does not apply)
Non-preferred Drugs	$50 Copay Mail Order (Plan Deductible does not apply)
Specialty Drugs	$250 Copay (Plan Deductible does not apply)
Pharmacy Deductible	None
Days Supply	Mail Order Plan Pharmacy: up to a 100-day supply

Mental Health Services
Inpatient psychiatric care	$200 per admission after Plan Deductible
Outpatient individual therapy visits	$30 per visit (Plan Deductible does not apply)
Outpatient group therapy visits	$15 per visit (Plan Deductible does not apply)
Substance Use Services
Inpatient detoxification	$200 per admission after Plan Deductible
Outpatient individual therapy visits	$30 per visit (Plan Deductible does not apply)
Outpatient group therapy visits	$15 per visit (Plan Deductible does not apply)
Infertility Services
Covered Services Related to the Diagnosis and Treatment of Infertility	Not Covered
Infertility Drugs Included	Not Covered
Infertility Drugs Included	Not Covered
Additional Benefits
Durable Medical Equipment	20% Coinsurance (Plan Deductible does not apply)
Skilled Nursing Facility	$200 per day after Plan Deductible limited to 120 days per benefit period
Skilled Nursing Facility
Home Health	$30 per visit (Plan Deductible does not apply) limited to 100 visits per year
Home Health
Hospice Care	No Charge (Plan Deductible does not apply)
Vision Exam	No Charge (Plan Deductible does not apply)
Other Benefits
Hearing aids	$2000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply)
Chiropractic	$30 per visit / limited to 30 visits per year (Plan Deductible does not apply)
Chiropractic
Acupuncture	$30 per visit / limited to 30 visits per year (Plan Deductible does not apply)
Acupuncture
Bariatric surgery	$200 per admission after Plan Deductible
Vision Hardware	Not included


1. Please refer to EOC documents for a complete explanation of benefits.
2. Kaiser predominately uses Permanente exclusive providers. In certain instances, Kaiser will refer to out of network providers (i.e.: COEs) and benefits are paid as if in network (KP authorization is required). Worldwide emergency and urgent care are covered as if in network.
3. For questions regarding pre-authorization requirements for specific services, please consult your Certificate of Coverage or Evidence of Coverage

Effective Date	1/1/2023
Annual Deductible
Individual / Family	$500 Individual / $1,000 Family (Embedded)
Individual / Family	$500 Individual / $1,000 Family (Embedded)
Maximum Out-Of-Pocket
Individual / Family	$2,000 Individual / $4,000 Family (Embedded)
Individual / Family	$2,000 Individual / $4,000 Family (Embedded)
Maximum Lifetime Benefit	Unlimited
Grandfathered Status	Not Applicable
Hospital Inpatient
Services Rendered while Hospitalized	$200 per admission after Plan Deductible
Maternity Inpatient	$200 per admission after Plan Deductible
Outpatient
Primary Care	$30 per visit (Plan Deductible does not apply)
Urgent Care	$30 per visit (Plan Deductible does not apply)

Specialist	$40 per visit (Plan Deductible does not apply)
Well-child & Preventive Care visits	No Charge (Plan Deductible does not apply)
Routine Prenatal Care	No Charge (Plan Deductible does not apply)
Outpatient Surgery	$100 per procedure after Plan Deductible
Therapies (PT/OT/ST)	$30 per visit (Plan Deductible does not apply) (Unlimited Visits)
Therapies (PT/OT/ST)
X-rays and Lab Tests	X-ray No Charge (Plan Deductible does not apply); Lab No Charge (Plan Deductible does not apply)
Advanced Imaging (CT / MRI / PET)	$100 per encounter (Plan Deductible does not apply)
Ambulance	$100 per trip (Plan Deductible does not apply)
Emergency Department Visits	$150 per visit after Plan Deductible waived if admitted
Outpatient Prescription Drugs
Generic Drugs	$10 Copay Retail (Plan Deductible does not apply), $20 Copay Mail Order (Plan Deductible does not apply)
Brand Drugs	$25 Copay Retail (Plan Deductible does not apply), $50 Copay Mail Order (Plan Deductible does not apply)
Non-preferred Drugs	$25 Copay Retail (Plan Deductible does not apply), $50 Copay Mail Order (Plan Deductible does not apply)
Specialty Drugs	$250 Copay (Plan Deductible does not apply)
Pharmacy Deductible	None
Days Supply	Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 100-day supply

Outpatient Prescription Drugs - Mail Order
Generic Drugs	$20 Copay Mail Order (Plan Deductible does not apply)
Brand Drugs	$50 Copay Mail Order (Plan Deductible does not apply)
Non-preferred Drugs	$50 Copay Mail Order (Plan Deductible does not apply)
Specialty Drugs	$250 Copay (Plan Deductible does not apply)
Pharmacy Deductible	None
Days Supply	Mail Order Plan Pharmacy: up to a 100-day supply

Mental Health Services
Inpatient psychiatric care	$200 per admission after Plan Deductible
Outpatient individual therapy visits	$30 per visit (Plan Deductible does not apply)
Outpatient group therapy visits	$15 per visit (Plan Deductible does not apply)
Substance Use Services
Inpatient detoxification	$200 per admission after Plan Deductible
Outpatient individual therapy visits	$30 per visit (Plan Deductible does not apply)
Outpatient group therapy visits	$15 per visit (Plan Deductible does not apply)
Infertility Services
Covered Services Related to the Diagnosis and Treatment of Infertility	Not Covered
Infertility Drugs Included	Not Covered
Infertility Drugs Included	Not Covered
Additional Benefits
Durable Medical Equipment	20% Coinsurance (Plan Deductible does not apply)
Skilled Nursing Facility	$200 per day after Plan Deductible limited to 120 days per benefit period
Skilled Nursing Facility
Home Health	$30 per visit (Plan Deductible does not apply) limited to 100 visits per year
Home Health
Hospice Care	No charge
Vision Exam	No charge
Other Benefits
Hearing aids	$2000 allowance / 1 device per ear / every 36 months (Plan Deductible does not apply)
Chiropractic	$30 per visit / limited to 30 visits per year (Plan Deductible does not apply)
Chiropractic
Acupuncture	$30 per visit / limited to 30 visits per year (Plan Deductible does not apply)
Acupuncture
Bariatric surgery	$200 per admission after Plan Deductible
Vision Hardware	Not included


1. Please refer to EOC documents for a complete explanation of benefits.
2. Kaiser predominately uses Permanente exclusive providers. In certain instances, Kaiser will refer to out of network providers (i.e.: COEs) and benefits are paid as if in network (KP authorization is required). Worldwide emergency and urgent care are covered as if in network.
3. For questions regarding pre-authorization requirements for specific services, please consult your Certificate of Coverage or Evidence of Coverage

Effective Date	1/1/2023
Annual Deductible
Individual / Family	None
Individual / Family	None
Maximum Out-Of-Pocket
Individual / Family	$2,500 Individual / $7,500 Family (Embedded)
Individual / Family	$2,500 Individual / $7,500 Family (Embedded)
Maximum Lifetime Benefit	Unlimited
Grandfathered Status	Not Applicable
Hospital Inpatient
Services Rendered while Hospitalized	10% coinsurance
Maternity Inpatient	No Charge
Outpatient
Primary Care	$15 per visit; No charge for children 0-17
Urgent Care	$15 per visit (within service area); 20% of applicable charges (outside of service area)

Specialist	$15 per visit
Well-child & Preventive Care visits	No charge
Routine Prenatal Care	No charge
Outpatient Surgery	10% coinsurance
Therapies (PT/OT/ST)	$15 per visit (unlimited visits)
Therapies (PT/OT/ST)	$15 per visit (unlimited visits)
X-rays and Lab Tests	$15 per encounter, Lab $15 per encounter,
Advanced Imaging (CT / MRI / PET)	20% coinsurance
Ambulance	20% coinsurance
Emergency Department Visits	$100 per visit; waived if admitted
Outpatient Prescription Drugs
Generic Drugs	$10 copay retail, $20 copay mail order, maintenance drugs: $3 copay retail, $6 copay mail order
Brand Drugs	$45 copay retail, $90 copay mail order
Non-preferred Drugs	$45 copay retail, $90 copay mail order
Specialty Drugs	$200 copay
Pharmacy Deductible	None
Days Supply	Retail Plan Pharmacy: up to a 30-day supply, Mail Order Plan Pharmacy: up to a 90-day supply

Outpatient Prescription Drugs - Mail Order
Generic Drugs	$20 copay mail order, maintenance drugs
Brand Drugs	$90
Non-preferred Drugs	$90
Specialty Drugs	$200
Pharmacy Deductible	None
Days Supply	Mail Order Plan Pharmacy: up to a 90-day supply

Mental Health Services
Inpatient psychiatric care	10% coinsurance
Outpatient individual therapy visits	$15
Outpatient group therapy visits	$15 per visit
Substance Use Services
Inpatient detoxification	$250 per admission
Outpatient individual therapy visits	$25 per visit
Outpatient group therapy visits	$12 per visit
Infertility Services
Covered Services Related to the Diagnosis and Treatment of Infertility	$15 per visit; 20% Coinsurance IVF limited to 1 cycle per lifetime. Includes Infertility drugs.
Infertility Drugs Included	Includes Infertility drugs
Infertility Drugs Included	Includes Infertility drugs
Additional Benefits
Durable Medical Equipment	20% coinsurance
Skilled Nursing Facility	10% coinsurance limited to 120 days per benefit period
Skilled Nursing Facility	10% coinsurance limited to 120 days per benefit period
Home Health	No Charge
Home Health	No Charge
Hospice Care	No charge
Vision Exam	$15 per visit
Other Benefits
Hearing aids	60% Coinsurance/1 device per ear/every 36 months
Chiropractic	Not included
Chiropractic	Not included
Acupuncture	Not included
Acupuncture	Not included
Bariatric surgery	10% Coinsurance
Vision Hardware	$150 allowance/every 12 months and pediatric $0 allowance/every 12 months
Dental	Not included

1. Please refer to EOC documents for a complete explanation of benefits.
2. Kaiser predominately uses Permanente exclusive providers. In certain instances, Kaiser will refer to out of network providers (i.e.: COEs) and benefits are paid as if in network (KP authorization is required). Worldwide emergency and urgent care are covered as if in network.
3. For questions regarding pre-authorization requirements for specific services, please consult your Certificate of Coverage or Evidence of Coverage

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