| Plan Details | ||
|---|---|---|
| Plan Name | Kaiser HI HMO | |
| Effective Dates | Jan 01, 2026 to Jan 01, 2027 | |
| Benefits | In-Network | |
| Annual Deductible/Individual | $0 | |
| Annual Deductible/Family | $0 | |
| Coinsurance | 10% | |
| Office Visit/Exam | $15 | |
| Outpatient Specialist Visit | $15 | |
| Annual Out-of-Pocket Limit/Individual | $2,500 | |
| Annual Out-of-Pocket Limit/Family | $7,500 | |
| Preventive Care | 0% | |
| Inpatient Hospitalization | 10% | |
| Surgical Services Outpatient Facility Charge | 10% | |
| Emergency Room | $100 | |
| Urgent Care Facility | $15 | |
| Prescription Drug Deductible | N/A | |
| Prescription Drugs - Generic | $10 | |
| Prescription Drugs - Brand (Formulary/Preferred) | $35 | |
| Prescription Drugs - Brand (Non-Formulary/Non-preferred) | $35 | |
| Prescription Drugs - Specialty | $200 | |
| Chiropractic Services | Not covered | |
| Acupuncture | Not covered | |