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2025 Northern California Plan Summary
2025 Southern California Plan Summary
2025 Hawaii Plan Summary
| Effective Date | 1/1/2025 |
| Annual Deductible | |
| Individual / Family | $500 Individual / $1,000 Family (Embedded) |
| Maximum Out-Of-Pocket | |
| 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) |
| 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) |
| Brand Drugs | $25 Copay Retail (Plan Deductible does not apply) |
| Non-preferred Drugs | $25 Copay Retail (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 |
| 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 |
| Home Health | No Charge (Plan Deductible does not apply) limited to 100 visits per accumulation period |
| 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) |
| Acupuncture | $30 per visit / limited to 30 visits per year (Plan Deductible does not apply) |
| 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 | 1/1/2025 |
| Annual Deductible | |
| Individual / Family | $500 Individual / $1,000 Family (Embedded) |
| Maximum Out-Of-Pocket | |
| 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) |
| 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) |
| Brand Drugs | $25 Copay Retail (Plan Deductible does not apply) |
| Non-preferred Drugs | $25 Copay Retail (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 |
| 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 |
| Home Health | No Charge (Plan Deductible does not apply) limited to 100 visits per accumulation period |
| 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) |
| Acupuncture | $30 per visit / limited to 30 visits per year (Plan Deductible does not apply) |
| 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 | 1/1/2025 |
| Annual Deductible | |
| Individual / Family | None |
| Maximum Out-Of-Pocket | |
| 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) |
| 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, Maintenance Drugs: $3 Copay Retail |
| Brand Drugs | $45 Copay Retail |
| Non-preferred Drugs | $45 Copay Retail |
| 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: $6 Copay Mail Order |
| Brand Drugs | $90 Copay Mail Order |
| Non-preferred Drugs | $90 Copay Mail Order |
| Specialty Drugs | $200 Copay |
| 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 per visit |
| Outpatient group therapy visits | $15 per visit |
| Substance Use Services | |
| Inpatient detoxification | 10% coinsurance |
| Outpatient individual therapy visits | $15 per visit |
| Outpatient group therapy visits | $15 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 |
| Infertility Drugs Included | Drugs at Pharmacy cost shares. |
| Additional Benefits | |
| Durable Medical Equipment | 20% coinsurance |
| Skilled Nursing Facility | 10% coinsurance limited to 120 days per year |
| Home Health | No Charge |
| Hospice Care | No charge |
| Vision Exam | No Charge |
| Other Benefits | |
| Hearing aids | 20% Coinsurance / 1 device per ear / every 36 months |
| Chiropractic | Not included |
| Acupuncture | Not included |
| Bariatric surgery | 10% Coinsurance |
| Vision Hardware | $150 allowance / every 12 months and Pediatric $0 allowance / every 12 months |
| Dental | 100/70/50 |
| 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 | |