Kaiser - Traditional

For Actives and Retirees not eligible for Medicare

The Services described below are covered only if all the following conditions are satisfied:

The Services are Medically Necessary
The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive the Services from Plan Providers inside our Northern California Region Service Area (your Home Region), except where specifically noted to the contrary in the Evidence of Coverage for authorized referrals, hospice care, Emergency Care, Post-stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services

Plan Summary

ANNUAL OUT-OF-POCKET MAXIMUMS
For any one Member in the same Family Unit	$3,000 per calendar year
For an entire Family Unit of two or more Members	$6,000 per calendar year
Copayments and Coinsurance for most Services and all Deductible payments count toward this maximum as described in the Evidence of Coverage.
DEDUCTIBLES
For any one Member in the same Family Unit	$300 per calendar year
For an entire Family Unit of two or more Members	$600 per calendar year
Lifetime Maximum	None
Coordination of Benefits	Included
PROFESSIONAL SERVICES (Plan Provider office visits)
Primary and specialty care visits (includes routine and Urgent Care appointments)	$20 per visit (Deductible doesn't apply)
Routine preventive physical exams	$20 per visit (Deductible doesn't apply)
Well-child preventive care visits (0–23 months)	$10 per visit (Deductible doesn't apply)
Family planning visits	$20 per visit (Deductible doesn't apply)
Scheduled prenatal care and first postpartum visit	$10 per visit (Deductible doesn't apply)
Eye exams	$20 per visit (Deductible doesn't apply)
Hearing tests	$20 per visit (Deductible doesn't apply)
Physical, occupational, and speech therapy visits	$20 per visit (Deductible doesn't apply)
OUTPATIENT SERVICES
Outpatient surgery	10% Coinsurance after Deductible
Allergy injection visits	No charge (Deductible doesn't apply)
Allergy testing visits	$20 per visit (Deductible doesn't apply)
Vaccines (immunizations)	No charge (Deductible doesn't apply)
X-rays and lab tests	$10 per encounter (except that MRI, CT, and PET are $50 per procedure) (Deductible doesn't apply)
Health education	$20 per individual visit (Deductible doesn't apply)
Health education	No charge for group visits (Deductible doesn't apply)
HOSPITILIZATION SERVICES
Room and board, surgery, anesthesia, X-rays, lab tests, and drugs	10% Coinsurance after Deductible
EMERGENCY HEALTH COVERAGE
Emergency Department visits	10% Coinsurance after Deductible
AMBULANCE SERVICES
Ambulance Services	$150 per trip (Deductible doesn't apply)
PRESCRIPTION DRUG COVERAGE
Most covered outpatient items in accord with our drug formulary from Plan Pharmacies:
Generic items from a Plan Pharmacy	$10 for up to a 30 day supply, $20 for a 31–60 day supply, or $30 for a 61–100 day supply (Deductible doesn't apply)
Refills from our mail order program	$20 for up to a 100 day supply (Deductible doesn't apply)
Brand name items from a Plan Pharmacy	$20 for up to a 30 day supply, $40 for a 31–60 day supply, or $60 for a 61–100 day supply (Deductible doesn't apply)
Refills from our mail order program	$40 for up to a 100 day supply (Deductible doesn't apply)
DURABLE MEDICAL EQUIPMENT
Most covered durable medical equipment for home use in accord with our DME formulary	20% Coinsurance (Deductible doesn't apply)
MENTAL HEALTH SERVICES
Inpatient psychiatric care (up to 30 days per calendar year)	10% Coinsurance after Deductible
Outpatient visits:
Up to a total of 20 individual and group therapy visits per calendar year	$20 per individual therapy visit (Deductible doesn't apply)
	$10 per group therapy visit (Deductible doesn't apply)
Up to 20 additional group therapy visits that meet the Medical Group criteria in the same calendar year	$10 per group therapy visit (Deductible doesn't apply)
Note: Visit and day limits do not apply to serious emotional disturbances of children and severe mental illnesses as described in the Evidence of Coverage.
CHEMICAL DEPENDENCY SERVICES
Inpatient detoxification	10% Coinsurance after Deductible
Outpatient individual therapy visits	$20 per visit (Deductible doesn't apply)
Outpatient group therapy visits	$5 per visit (Deductible doesn't apply)
Transitional residential recovery Services (up to 60 days per calendar year, not to exceed 120 days in any five-year period)	$100 per admission (Deductible doesn't apply)
HOME HEALTH SERVICES
Home health care (up to 100 two-hour visits per calendar year)	No charge (Deductible doesn't apply)
OTHER
Skilled nursing facility care (up to 100 days per benefit period)	10% Coinsurance (Deductible doesn't apply)
Covered infertility inpatient care and outpatient surgery	50% Coinsurance after Deductible
All other covered Services related to infertility treatment	50% Coinsurance (Deductible doesn't apply)
Hospice care	No charge (Deductible doesn't apply)
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Deductibles, exclusions, or limitations, and it does not list all benefits, Copayments, and Coinsurance. For a complete explanation, please refer to the Evidence of Coverage. Please note that we provide all benefits required by law (for example, diabetes testing supplies).

This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Deductibles, exclusions, or limitations, and it does not list all benefits, Copayments, and Coinsurance. For a complete explanation, please refer to the Evidence of Coverage. Please note that we provide all benefits required by law (for example, diabetes testing supplies).

Contact Information

www.kaiserpermanente.org

Find a Provider

KAISER Member Service Call Center
800.464.4000 (ENGLISH)
800.788.0616 (SPANISH)

Plan Documents

Enrollment/Change Form (English)
Enrollment/Change Form (Spanish)

Benefits Booklet