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2017 PLANS AND PRODUCTS | CALIFORNIA

Complete Suite™ plan comparison chartHere’s an overview of our plans that complements the quote you received in your Complete Suite Quote Proposal. You can use it to get information on a wide range of plans, including quick side-by-side comparisons of what different plans have to offer.

http://kp.org/choosebetter

Overview HMO CDHCDHMO KPIC


How to compare plansWith our Complete Suite plan comparison chart, it’s easy to compare different plans side by side. You can choose up to three plans at a time, and you can get as many comparisons as you’d like.

To get a comparison:

1. Click the “Overview” tab at the top of the page.

2. Check the box next to each plan you’d like to compare, then click the “Compare plans” button at the top-right corner of the page.

3. To remove a plan from your comparison, click the checked box to clear it. To remove all plans selected, click the “Reset” button at the bottom of the page.

You can also get more detailed information about each plan type by clicking the tabs at the top of the page — HMO, DHMO, CDHC, or KPIC. To go back to the plan comparison page at any time, simply click the “Overview” tab at the top-left corner of the page.

Are you viewing this on a mobile device?

The interactive features work best when you use a reader like PDF Expert by Readdle.


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HMO CDHCDHMO KPIC


Overview

Traditional HMO — Pay a simple copay for most covered services.

* Available with optical hardware allowance ($175 every 24 months).

HMO plan families NCAL/SCAL plan ID — office visit/hospital inpatient/out-of-pocket maximum

HMO High HMO Mid HMO Low

2017 Complete Suite plans Select the plans that you want to compare. You can choose up to three at a time.

HMO DHMO CDHC KPIC

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9961/9962 — $10/$0/$1,500

9965/9966 — $15/$0/$1,500

10003/10004 — $20/$0/$1,500

10007/10008* — $20/$0/$1,500

10011/10012 — $15/$250/$1,500

10015/10016 — $20/$250/$1,500

10044/10045* — $20/$250/$1,500

10048/10049 — $25/$250/$1,500

10052/10053 — $20/$500/$1,500

9970/9972 — $25/$500/$1,500

9975/9976* — $25/$500/$1,500

9981/9982 — $30/$500/$1,500

9983/9984 — $20/$250/$2,000

9985/9986* — $20/$250/$2,000

9987/9988 — $30/$250/$2,000

9989/9990 — $20/$500/$2,500

9930/9931 — $25/$500/$2,500

9991/9992 — $30/$500/$2,500

9994/9996* — $30/$500/$2,500

9955/9956 — $20/$250/$3,000

9957/9958 — $30/$250/$3,000

9959/9960 — $20/$500/$3,000

9967/9969 — $30/$500/$3,000

9973/9974— $30/$500/$3,000

9977/9978— $40/$500/$3,000

9979/9980 — $30/$500/$3,500

9942/9943 — $40/$500/$3,500


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HMO CDHCDHMO KPIC


Overview

Deductible HMO (DHMO) plan families NCAL/SCAL plan ID — deductible/office visit/hospital inpatient

Deductible HMO HO Deductible HMO XD Deductible HMO XP

8776/8777 — $250/$10/10% 8796/8797 — $250/$10/10% 8826/8827 — $1,000/$20/20%

8778/8779* — $250/$10/10% 8798/8799 — $500/$10/10% 9147/9158 — $4,000/$40/30%

8780/8781 — $500/$20/10% 8800/8801 — $500/$20/20% 9148/9159 — $4,500/$50/40%

8782/8783 — $750/$25/20% 8802/8803* — $500/$20/20% 9149/9160 — $4,500/40%/40%

8784/8785 — $1,000/$20/20% 8808/8809 — $750/$25/20% 9151/9163 — $5,000/$50/30%

8786/8787* — $1,000/$20/20% 8804/8805 — $1,000/$20/20% 9150/9161 — $5,500/$50/40%

8788/8789 — $1,000/$30/20% 8806/8807* — $1,000/$20/20%

8790/8791 — $1,500/$20/20% 8810/8811 — $1,000/$30/30%

8792/8793 — $1,500/$40/30% 8812/8813* — $1,000/$30/30%

8794/8795 — $2,500/$20/20% 8814/8815 — $1,500/$20/20%

8816/8817 — $1,500/$40/30%

8818/8819 — $2,000/$20/20%

8820/8821 — $2,500/$40/30%

8822/8823 — $3,000/$40/30%

8824/8825 — $3,500/$40/30%

HMO DHMO CDHC KPIC

2017 Complete Suite plans Click on the specific plan name to see your options for that plan. Plans selected:

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Deductible HMO HO — Hospital-based services, such as inpatient hospital, outpatient surgery, and emergency department services, are subject to a deductible.

Deductible HMO XD — Provider office visits and pharmacy are covered at a copay or coinsurance. All other services, except preventive services, are subject to a deductible.

Deductible HMO XP — All services, except preventive services, are subject to a deductible. Pharmacy is excluded from the deductible on certain plans.* Available with optical hardware allowance ($175 every 24 months).


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HMO CDHCDHMO KPIC


Overview

HSA-qualified deductible HMO plans — All services, except preventive services, are subject to a deductible.Deductible HMO plans with HRA — All services, except pharmacy and preventive services, are subject to a deductible.

Consumer-directed health care (CDHC) plans NCAL/SCAL plan ID — deductible/office visit/hospital inpatient

HSA-qualified deductible HMO plans Deductible HMO plans with HRA

9153/9164 — $1,300/$20/$250 8759/8760 — $1,000/$20/20%

9155/9165 — $1,600/10%/10% 8761/8762 — $1,500/$20/20%

9156/9166 — $2,000/$30/$250 8763/8764 — $2,000/$20/20%

9157/9167 — $2,700/$30/30% 8765/8766 — $2,500/$20/20%

7871/7872 — $3,000/20%/20%

8126/8127 — $4,500/40%/40% 7823/7824 — $3,000/30%/30%

8122/8125 — $4,500/$50/40% 8767/8768 — $4,000/$20/20%

2017 Complete Suite plans Click on the specific plan name to see your options for that plan.

HMO DHMO CDHC KPIC

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10426/10427 — $3,500/$30/30%


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HMO CDHCDHMO KPIC


Overview

Kaiser Permanente Insurance Company (KPIC) NCAL/SCAL plan ID — deductible by tier/office visit by tier

Point-of-service (POS) plans PPO plans

5689/5690 — $0/$250/$500; $10/20%/40% 5700/5701 — $250/$500; $15/30%

5685/5686 — $0/$500/$1,000; $25/10%/30% 5704/5705 — $500/$1,000; $20/40%

5669/5670 — $0/$1,000/$2,000; $25/$35/30% 5702/5703 — $1,000/$2,000; $25/50%

5675/5676 — $0/$1,500/$3,000; $35/30%/50% 5698/5699 — $1,500/$3,000; $40/50%

8769/8770 — $3,000/$6,000; $40/50%

7538/7539 — $4,500/$9,000; $40/50%

2017 Complete Suite plans Click on the specific plan name to see your options for that plan.

HMO DHMO CDHC KPIC

Plans selected:

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Overview CDHCDHMO KPIC


HMO

Complete Suite category

HMO HMO High HMO High HMO High HMO High HMO High

NCAL/SCAL plan ID

Plan deductible (individual/family) None None None None None

Out-of-pocket maximum (individual/family) $1,500/$3,000 $1,500/$3,000 $1,500/$3,000 $1,500/$3,000 $1,500/$3,000

Primary and specialty care visit $10 $15 $20 $20 $15

Hospital inpatient (per admission) No charge No charge No charge No charge $250 per admit

Outpatient surgery (per procedure) $10 $15 $20 $20 $15

Emergency care $100 $100 $100 $100 $100

Prescription drugs

Generic $10 $10 $10 $10 $10

Brand $20 $20 $20 $20 $30

Specialty 20%, not to exceed $150

20%, not to exceed $150




Separate drug deductible None None None None None

Ambulance services (per trip) $50 $50 $50 $50 $50

CT/PET/MRI (per procedure) No charge No charge No charge No charge No charge

Lab/X-ray (per encounter) No charge No charge No charge No charge No charge

Durable medicalequipment 20% 20% 20% 20% 20%

Preventive care No charge No charge No charge No charge No charge

Infertility services Same as medical benefit

Same as medical benefit

Same as medical benefit

Same as medical benefit 50%

Prenatal care and well-baby visits No charge No charge No charge No charge No charge

Optical hardware Not covered Not covered Not covered $175 hardware allowance/24 months Not covered

Prosthetics and orthotics No charge No charge No charge No charge No charge

Skilled nursing facility No charge No charge No charge No charge No charge


Plans selected:Compare plans

9961/9962 9965/9966 10003/10004 10007/10008 10011/10012


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HMO


HMO HMO High HMO High HMO High HMO High HMO High

NCAL/SCAL plan ID




Hospital inpatient (per admission) $250 per admit $250 per admit $250 per admit $500 per admit $500 per admit


Emergency care $100 $100 $100 $100 $100

Prescription drugs

Generic $10 $10 $10 $15 $15

Brand $30 $30 $30 $35 $35








CT/PET/MRI (per procedure) No charge No charge No charge $50 $50

Lab/X-ray (per encounter) No charge No charge No charge $10 $10



Infertility services 50% 50% 50% 50% 50%


Optical hardware Not covered $175 hardware allowance/24 months Not covered Not covered Not covered





10015/10016 10044/10045 10048/10049 10052/10053 9970/9972


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HMO


HMOHMO High HMO High

NCAL/SCAL plan ID




Hospital inpatient (per admission) $500 per admit $500 per admit $250 per admit $250 per admit $250 per admit


Emergency care $100 $100 $100 $100 $100

Prescription drugs

Generic $15 $15 $15 $15 $15

Brand $35 $35 $30 $30 $30








CT/PET/MRI (per procedure) $50 $50 $50 $50 $50

Lab/X-ray (per encounter) $10 $10 $10 $10 $10





Optical hardware $175 hardware allowance/24 months Not covered Not covered $175 hardware

allowance/24 months Not covered





9975/9976 9981/9982 9983/9984 9985/9986 9987/9988

HMO Mid HMO Mid HMO Mid


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HMO


HMO HMO Mid HMO Mid HMO Mid HMO Mid HMO Low

NCAL/SCAL plan ID




Hospital inpatient (per admission) $500 per admit $500 per admit $500 per admit $500 per admit $250 per day

up to 3 days


Emergency care $100 $100 $100 $100 $100

Prescription drugs

Generic $15 $15 $15 $15 $10

Brand $35 $35 $35 $35 $30














Optical hardware Not covered Not covered Not covered $175 hardware allowance/24 months Not covered





9989/9990 9930/9931 9991/9992 9994/9996 9955/9956


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HMO


HMO HMO Low HMO Low HMO Low HMO Low HMO Low

NCAL/SCAL plan ID




Hospital inpatient (per admission)

$250 per day up to 3 days

$500 per day up to 3 days

$500 per day up to 3 days $500 per day $500 per day


Emergency care $100 $150 $150 $150 $150

Prescription drugs

Generic $10 $15 $15 $15 $15

Brand $30 $35 $35 $35 $35














Optical hardware Not covered Not covered Not covered Not covered Not covered





9957/9958 9959/9960 9967/9969 9973/9974 9977/9978


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HMO


HMOHMO Low HMO Low

NCAL/SCAL plan ID

Plan deductible (individual/family) None None

Out-of-pocket maximum (individual/family) $3,500/$7,000 $3,500/$7,000

Primary and specialty care visit $30 and $50 $40 and $50

Hospital inpatient (per admission) $500 per day $500 per day

Outpatient surgery (per procedure) $250 $250

Emergency care $150 $150

Prescription drugs

Generic $15 $15

Brand $35 $35

Specialty 30%, not to exceed $150 30%, not to exceed $150

Separate drug deductible None None

Ambulance services (per trip) $150 $150

CT/PET/MRI (per procedure) $100 $100

Lab/X-ray (per encounter) $10 $10

Durable medicalequipment 50% 50%

Preventive care No charge No charge

Infertility services 50% 50%

Prenatal care and well-baby visits No charge No charge

Optical hardware Not covered Not covered

Prosthetics and orthotics No charge No charge

Skilled nursing facility No charge No charge



9979/9980 9942/9943


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Overview HMO CDHC KPIC


DHMO


DHMO

Deductible HMO HO Deductible HMO HO Deductible HMO HO Deductible HMO HO Deductible HMO HO

NCAL/SCAL plan ID 8776/8777 8778/8779 8780/8781 8782/8783 8784/8785

Plan deductible (individual/family) $250/$500 $250/$500 $500/$1,000 $750/$1,500 $1,000/$2,000

Out-of-pocket maximum (individual/family)

$3,000/$6,000 $3,000/$6,000 $3,000/$6,000 $3,000/$6,000 $3,000/$6,000


Hospital inpatient (per admission) 10% after deductible 10% after deductible 10% after deductible 20% after deductible 20% after deductible

Outpatient surgery (per procedure) 10% after deductible 10% after deductible 10% after deductible 20% after deductible 20% after deductible

Emergency care 10% after deductible 10% after deductible 10% after deductible 20% after deductible 20% after deductible

Prescription drugs

Generic $10 $10 $10 $10 $10

Brand $30 $30 $30 $30 $30














Optical hardware Not covered $175 hardware allowance/24 months Not covered Not covered Not covered


Skilled nursing facility 10% 10% 10% 20% 20%




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DHMO


DHMO

Deductible HMO HO Deductible HMO HO Deductible HMO HO Deductible HMO HO Deductible HMO HO

NCAL/SCAL plan ID 8786/8787 8788/8789 8790/8791 8792/8793 8794/8795

Plan deductible (individual/family) $1,000/$2,000 $1,000/$2,000 $1,500/$3,000 $1,500/$3,000 $2,500/$5,000



Hospital inpatient (per admission) 20% after deductible 20% after deductible 20% after deductible 30% after deductible 20% after deductible

Outpatient surgery (per procedure) 20% after deductible 20% after deductible 20% after deductible 30% after deductible 20% after deductible

Emergency care 20% after deductible 20% after deductible 20% after deductible 30% after deductible 20% after deductible

Prescription drugs

Generic $10 $10 $10 $10 $10

Brand $30 $30 after drug deductible $30 $30 $30



after drug deductible




Separate drug deductible None $250 None None None








Optical hardware $175 hardware allowance/24 months Not covered Not covered Not covered Not covered


Skilled nursing facility 20% 20% 20% 30% 20%




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DHMO


DHMODeductible HMO XD Deductible HMO XD Deductible HMO XD

NCAL/SCAL plan ID 8796/8797 8798/8799 8800/8801

Plan deductible (individual/family) $250/$500 $500/$1,000 $500/$1,000

Out-of-pocket maximum (individual/family) $2,500/$5,000 $3,000/$6,000 $3,000/$6,000

Primary and specialty care visit $10 $10 $20

Hospital inpatient (per admission) 10% after deductible 10% after deductible 20% after deductible

Outpatient surgery (per procedure) 10% after deductible 10% after deductible 20% after deductible

Emergency care 10% after deductible 10% after deductible 20% after deductible

Prescription drugs

Generic $10 $10 $10

Brand $30 $30 $30 after drug deductible

Specialty 20%, not to exceed $150 20%, not to exceed $150 20%, not to exceed $150 after drug deductible

Separate drug deductible None None $100

Ambulance services (per trip) $150 after deductible $150 after deductible $150 after deductible

CT/PET/MRI (per procedure) $150 after deductible $150 after deductible $150 after deductible

Lab/X-ray (per encounter) $10 after deductible $10 after deductible $10 after deductible

Durable medicalequipment 20% 20% 20%

Preventive care No charge No charge No charge

Infertility services 50% 50% 50%

Prenatal care and well-baby visits No charge No charge No charge

Optical hardware Not covered Not covered Not covered

Prosthetics and orthotics No charge No charge No charge

Skilled nursing facility 10% after deductible 10% after deductible 20% after deductible




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DHMO


DHMO Deductible HMO XD Deductible HMO XD Deductible HMO XD Deductible HMO XD

NCAL/SCAL plan ID 8802/8803 8808/8809 8804/8805 8806/8807

Plan deductible (individual/family) $500/$1,000 $750/$1,500 $1,000/$2,000 $1,000/$2,000

Out-of-pocket maximum (individual/family) $3,000/$6,000 $3,000/$6,000 $3,000/$6,000 $3,000/$6,000

Primary and specialty care visit $20 $25 $20 $20

Hospital inpatient (per admission) 20% after deductible 20% after deductible 20% after deductible 20% after deductible

Outpatient surgery (per procedure) 20% after deductible 20% after deductible 20% after deductible 20% after deductible

Emergency care 20% after deductible 20% after deductible 20% after deductible 20% after deductible

Prescription drugs

Generic $10 $10 $10 $10

Brand $30 after drug deductible $30 $30 $30

Specialty 20%, not to exceed $150 after $100 drug deductible 20%, not to exceed $150 20%, not to exceed $150 20%, not to exceed $150

Separate drug deductible $100 None None None

Ambulance services (per trip) $150 after deductible $150 after deductible $150 after deductible $150 after deductible

CT/PET/MRI (per procedure) $150 after deductible $150 after deductible $150 after deductible $150 after deductible

Lab/X-ray (per encounter) $10 after deductible $10 after deductible $10 after deductible $10 after deductible

Durable medicalequipment 20% 20% 20% 20%

Preventive care No charge No charge No charge No charge

Infertility services 50% 50% 50% 50%

Prenatal care and well-baby visits No charge No charge No charge No charge

Optical hardware $175 hardware allowance/24 months Not covered Not covered $175 hardware

allowance/24 months

Prosthetics and orthotics No charge No charge No charge No charge

Skilled nursing facility 20% after deductible 20% after deductible 20% after deductible 20% after deductible




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DHMO



NCAL/SCAL plan ID 8810/8811 8812/8813 8814/8815 8816/8817

Plan deductible (individual/family) $1,000/$2,000 $1,000/$2,000 $1,500/$3,000 $1,500/$3,000






Prescription drugs

Generic $10 $10 $10 $10

Brand $30 after drug deductible $30 after drug deductible $30 $30

Specialty 20%, not to exceed $150after drug deductible

20%, not to exceed $150 after drug deductible 20%, not to exceed $150 20%, not to exceed $150

Separate drug deductible $100 $100 None None








Optical hardware Not covered $175 hardware allowance/24 months Not covered Not covered






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DHMO



NCAL/SCAL plan ID 8818/8819 8820/8821 8822/8823 8824/8825







Prescription drugs

Generic $10 $10 $10 $10

Brand $30 $30 $30 $30

Specialty 20%, not to exceed $150 20%, not to exceed $150 20%, not to exceed $150 20%, not to exceed $150

Separate drug deductible None None None None








Optical hardware Not covered Not covered Not covered Not covered






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DHMO


DHMO Deductible HMO XP Deductible HMO XP Deductible HMO XP Deductible HMO XP

NCAL/SCAL plan ID 8826/8827 9147/9158 9148/9159 9149/9160



Primary and specialty care visit $20 after deductible $40 after deductible* $50 after deductible 40% after deductible



Emergency care 20% after deductible 30% after deductible $250 after deductible 40% after deductible

Prescription drugs

Generic $10 $15 $15 30%, not to exceed $50

Brand $30 after drug deductible $35 $35 40%, not to exceed $100

Specialty 20%, not to exceed $150 after drug deductible 30%, not to exceed $150 30%, not to exceed $150 40%, not to exceed $200

Separate drug deductible $250 None None None

Ambulance services (per trip) $150 after deductible $150 after deductible 40% after deductible 40% after deductible

CT/PET/MRI (per procedure) $150 after deductible $150 after deductible $150 after deductible 40% after deductible

Lab/X-ray (per encounter) $10 after deductible 40% after deductible 40% after deductible



Infertility services 50% Not covered Not covered Not covered





Deductible HMO XP — All services, except preventive services, are subject to a deductible. Pharmacy is excluded from the deductible on certain plans.* Plan deductible doesn’t apply to the first 3 visits combined for primary care, urgent care, mental health, and chemical dependency.


$10 after deductible


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DHMO


DHMODeductible HMO XP Deductible HMO XP

NCAL/SCAL plan ID 9151/9163 9150/9161

Plan deductible (individual/family) $5,000/$10,000 $5,500/$11,000

Out-of-pocket maximum (individual/family) $6,850/$13,700 $6,850/$13,700

Primary and specialty care visit $50 after deductible* $50 after deductible*

Hospital inpatient (per admission) 30% after deductible 40% after deductible

Outpatient surgery (per procedure) 30% after deductible 40% after deductible

Emergency care 30% after deductible 40% after deductible

Prescription drugs†

Generic $15 after plan deductible $15 after plan deductible

Brand $50 after plan deductible 40%, not to exceed $100after plan deductible

Specialty 30%, not to exceed $150 after plan deductible 40%, not to exceed $200 after plan deductible

Separate drug deductible None None

Ambulance services (per trip) 30% after deductible 40% after deductible

CT/PET/MRI (per procedure) 30% after deductible 40% after deductible

Lab/X-ray (per encounter) 30% after deductible 40% after deductible

Durable medicalequipment 30% 40%

Preventive care No charge No charge

Infertility services Not covered Not covered

Prenatal care and well-baby visits No charge No charge

Optical hardware Not covered Not covered

Prosthetics and orthotics No charge No charge

Skilled nursing facility 30% after deductible 40% after deductible

Deductible HMO XP — All services, except preventive services, are subject to a deductible. Pharmacy is excluded from the deductible on certain plans.* Plan deductible doesn’t apply to the first 3 visits combined for primary care, urgent care, mental health, and chemical dependency.† Supplemental preventive drugs available at a lower cost share and before plan deductible.

Supplemental preventive drug list available on account.kp.org/completesuite.



https://account.kp.org/broker-employer/poc?uri=center:large-business&article=434EF1F4-69CE-11E4-86A9-95F6381FB8B9&region=CA

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Overview HMO DHMO KPIC


CDHC


CDHC HSA-qualified DHMO HSA-qualified DHMO HSA-qualified DHMO HSA-qualified DHMO

NCAL/SCAL plan ID 9153/9164 9155/9165 9156/9166 9157/9167

Plan deductible

Self-only $1,300 $1,600 $2,000 $2,700

Family member/family $2,600/$2,600 $2,600/$3,200 $2,600/$4,000 $2,700/$5,450

Out-of-pocket maximum

Self-only $3,000 $3,200 $3,500 $5,250

Family member/family $3,000/$6,000 $3,200/$6,400 $3,500/$7,000 $5,250/$10,500

Primary and specialty care visit $20 after plan deductible 10% after plan deductible $30 after plan deductible $30 after plan deductible

Hospital inpatient (per admission) $250 after plan deductible 10% after plan deductible $250 after plan deductible 30% after plan deductible

Outpatient surgery (per procedure) $150 after plan deductible 10% after plan deductible $150 after plan deductible 30% after plan deductible

Emergency care $100 after plan deductible 10% after plan deductible $100 after plan

deductible 30% after plan deductible

Prescription drugs

Generic $10 after plan deductible $10 after plan deductible $10 after plan deductible $15 after plan deductible

Brand $30 after plan deductible $30 after plan deductible $30 after plan deductible $30 after plan deductible

Specialty 20%, not to exceed $150 after plan deductible

20%, not to exceed $150 after plan deductible




Ambulance services (per trip)

$100 after plan deductible 10% after plan deductible $100 after plan

deductible$100 after plan

deductible

CT/PET/MRI (per procedure)

$150 after plan deductible 10% after plan deductible $150 after plan

deductible$150 after plan

deductible

Lab/X-ray (per encounter) $10 after plan deductible 10% after plan deductible $10 after plan deductible $10 after plan deductible

Durable medical equipment 20% after plan deductible 10% after plan deductible 20% after plan deductible 20% after plan deductible


Infertility services Not covered Not covered Not covered Not covered



Prosthetics and orthotics No charge after plan deductible

No charge after plan deductible



Skilled nursing facility $250 after plan deductible 10% after plan deductible $250 after plan

deductible 30% after plan deductible

HSA-qualified deductible HMO plans — All services, except preventive services, are subject to a deductible.



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CDHC


CDHCHSA-qualified DHMO HSA-qualified DHMO HSA-qualified DHMO

NCAL/SCAL plan ID 8126/8127 8122/8125

Plan deductible

Self-only $3,500 $4,500 $4,500

Family member/family $3,500/$7,000 $4,500/$9,000 $4,500/$9,000

Out-of-pocket maximum

Self-only $6,000 $6,250 $6,250

Family member/family $6,000/$12,000 $6,250/$12,500 $6,250/$12,500

Primary and specialty care visit $30 after plan deductible 40% after plan deductible $50 after plan deductible

Hospital inpatient (per admission) 30% after plan deductible 40% after plan deductible 40% after plan deductible

Outpatient surgery (per procedure) 30% after plan deductible 40% after plan deductible 40% after plan deductible

Emergency care 30% after plan deductible 40% after plan deductible $250 after plan deductible

Prescription drugs

Generic $15 after plan deductible 30% after plan deductible $15 after plan deductible

Brand $35 after plan deductible 40% after plan deductible $35 after plan deductible

Specialty 30%, not to exceed $200 after plan deductible



Separate drug deductible None None None

Ambulance services (per trip) 30% after plan deductible 40% after plan deductible 40% after plan deductible

CT/PET/MRI (per procedure) 30% after plan deductible 40% after plan deductible $150 after plan deductible

Lab/X-ray (per encounter) 40% after plan deductible 40% after plan deductible

Durable medical equipment 30% after plan deductible 40% after plan deductible 40% after plan deductible


Infertility services Not covered Not covered Not covered



Prosthetics and orthotics No charge after plan deductible No charge after plan deductible No charge after plan deductible

Skilled nursing facility 30% after plan deductible 40% after plan deductible 40% after plan deductible

HSA-qualified deductible HMO plans — All services, except preventive services, are subject to a deductible.


$10 after deductible

10426/10427


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CDHC


CDHCDHMO with HRA DHMO with HRA DHMO with HRA DHMO with HRA

NCAL/SCAL plan ID 8759/8760 8761/8762 8763/8764 8765/8766



Primary and specialty care visit $20 after plan deductible $20 after plan deductible $20 after plan deductible $20 after plan deductible

Hospital inpatient (per admission) 20% after plan deductible 20% after plan deductible 20% after plan deductible 20% after plan deductible

Outpatient surgery (per procedure) 20% after plan deductible 20% after plan deductible 20% after plan deductible 20% after plan deductible

Emergency care 20% after plan deductible 20% after plan deductible 20% after plan deductible 20% after plan deductible

Prescription drugs

Generic $10 $10 $10 $10

Brand $30 $30 $30 $30

Specialty 20%, not to exceed $150 20%, not to exceed $150 20%, not to exceed $150 20%, not to exceed $150



$150 after plan deductible









Lab/X-ray (per encounter) $10 after plan deductible $10 after plan deductible $10 after plan deductible $10 after plan deductible







Skilled nursing facility 20% after plan deductible 20% after plan deductible 20% after plan deductible 20% after plan deductible

Deductible HMO plans with HRA — All services, except pharmacy and preventive services, are subject to a deductible.



##



CDHC


CDHCDHMO with HRA DHMO with HRA DHMO with HRA

NCAL/SCAL plan ID 7871/7872 7823/7824 8767/8768

Plan deductible (individual/family) $3,000/$6,000 $3,000/$6,000 $4,000/$8,000


Primary and specialty care visit 20% after plan deductible 30% after plan deductible $20 after plan deductible

Hospital inpatient (per admission) 20% after plan deductible 30% after plan deductible 20% after plan deductible

Outpatient surgery (per procedure) 20% after plan deductible 30% after plan deductible 20% after plan deductible

Emergency care 20% after plan deductible 30% after plan deductible 20% after plan deductible

Prescription drugs

Generic 20% 30% $10

Brand 20% 30% $30

Specialty 20%, not to exceed $150 30%, not to exceed $150 20%, not to exceed $150


Ambulance services (per trip) 20% after plan deductible 30% after plan deductible $150 after plan deductible

CT/PET/MRI (per procedure) 20% after plan deductible 30% after plan deductible $150 after plan deductible

Lab/X-ray (per encounter) 20% after plan deductible 30% after plan deductible $10 after plan deductible

Durable medicalequipment 20% 30% 20%


Infertility services 50% 50% 50%



Prosthetics and orthotics No charge No charge No charge

Skilled nursing facility 20% after plan deductible 30% after plan deductible 20% after plan deductible

Deductible HMO plans with HRA — All services, except pharmacy and preventive services, are subject to a deductible.



##

Overview HMO CDHCDHMO


KPIC


KPICPOS

NCAL/SCAL plan ID 5689/5690

Tier Tier 1 Tier 2 Tier 3

Plan deductible (individual/family) $0/$0 $250/$500 $500/$1,000


Primary and specialty care visit $10 20% after plan deductible 40% after plan deductible

Hospital inpatient (per admission) $200 $250 + 20% after plan deductible $500 + 40% after plan deductible

Outpatient surgery (per procedure) $100 20% after plan deductible 40% after plan deductible

Emergency care $100 Covered as HMO benefit Covered as HMO benefit

Prescription drugs

Generic $10 $20 preferred, $50 nonpreferred Not covered

Brand $30 $40 preferred, $50 nonpreferred Not covered

Specialty 20%, not to exceed $150 30%, not to exceed $250 Not covered


Ambulance services (per trip) $150 40% after plan deductible 40% after plan deductible

CT/PET/MRI (per procedure) No charge 20% after plan deductible 40% after plan deductible

Lab/X-ray (per encounter) No charge 20% after plan deductible 40% after plan deductible

Durable medicalequipment 20% 30% after plan deductible 50% after plan deductible

Preventive care No charge No charge 40%

Infertility services $10 20% 40%

Prenatal care and well-baby visits No charge No charge 40%


Prosthetics and orthotics No charge Covered by HMO In-Network only Covered by HMO In-Network only

Skilled nursing facility $200 $250 + 20% after plan deductible $500 + 40% after plan deductible

The Kaiser Permanente provider option of the POS plan is underwritten by Kaiser Foundation Health Plan, Inc. (KFHP). The PHCS Network and nonparticipating provider options of the POS plan are underwritten by Kaiser Permanente Insurance Company (KPIC). KPIC is a subsidiary of KFHP.



##



KPIC


KPICPOS



Plan deductible (individual/family) $0/$0 $500/$1,000 $1,000/$2,000






Prescription drugs


















##



KPIC


KPICPOS



Plan deductible (individual/family) $0/$0 $1,000/$2,000 $2,000/$4,000


Primary and specialty care visit $25 $35 30% after plan deductible




Prescription drugs






CT/PET/MRI (per procedure) No charge $35 30% after plan deductible

Lab/X-ray (per encounter) No charge $35 30% after plan deductible

Durable medicalequipment 20% 30% 50% after plan deductible










##



KPIC


KPICPOS



Plan deductible (individual/family) $0/$0 $1,500/$3,000 $3,000/$6,000






Prescription drugs


















##



KPIC


KPICPPO

NCAL/SCAL plan ID 5700/5701 5704/5705

Tier Tier 1 Tier 2 Tier 1 Tier 2

Plan deductible (individual/family) $250/$500 $500/$1,000 $500/$1,000 $1,000/$2,000


Primary and specialty care visit $15 30% $20 40%


$250 + 10% after plan deductible




Outpatient surgery (per procedure)

$100 +10% after plan deductible




Emergency care $100 + 10% after plan deductible




Prescription drugs

Generic $15 Not covered $15 Not covered

Brand $40 Not covered $40 Not covered

Specialty 30%, not to exceed $200 Not covered 30%, not to exceed $200 Not covered


Ambulance services (per trip) 30% after plan deductible 30% after plan deductible 40% after plan deductible 40% after plan deductible

CT/PET/MRI (per procedure) 10% after plan deductible 30% after plan deductible 20% after plan deductible 40% after plan deductible

Lab/X-ray (per encounter) 10% after plan deductible 30% after plan deductible 20% after plan deductible 40% after plan deductible

Durable medicalequipment 30% after plan deductible 50% after plan deductible 20% after plan deductible 40% after plan deductible

Preventive care No charge 30% No charge 40%


Prenatal care and well-baby visits No charge 30% No charge 40%


Prosthetics and orthotics 10% after plan deductible 30% after plan deductible 20% after plan deductible 40% after plan deductible

Skilled nursing facility $250 +10% after plan deductible




The Kaiser Permanente PPO Insurance Plan is underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc.



##



KPIC


KPICPPO

NCAL/SCAL plan ID 5702/5703 5698/5699







$1,000 + 50% after plan deductible












Prescription drugs








Durable medicalequipment 30% after plan deductible 50% after plan deductible 30% after plan deductible 50% after plan deductible






Skilled nursing facility $500 + 30% after plan deductible







##



KPIC


KPICPPO

NCAL/SCAL plan ID 8769/8770 7538/7539



















Prescription drugs








Durable medical equipment 30% after plan deductible 50% after plan deductible 30% after plan deductible 50% after plan deductible






Skilled nursing facility $1,000 + 30% after plan deductible







# 32 kp.org/choosebetter

Overview HMO CDHCDHMO KPIC


NCAL/SCAL plan ID

Plan deductible Individual (Self-only)/ Family member/Family

Out-of-pocket maximum Individual (Self-only)/ Family member/Family

Primary and specialty care visit



Emergency care

Prescription drugs

Generic

Brand

Specialty

Separate drug deductible



Lab/X-ray (per encounter)

Durable medicalequipment

Preventive care

Infertility services

Prenatal care and well-baby visits

Optical hardware

Prosthetics and orthotics

Skilled nursing facility

The plan summary highlights the most frequently asked-about benefits and is for illustration purposes only. For a complete description, please refer to the appropriate Certificate of Insurance or contact your broker or Kaiser Permanente account manager.

Information may have changed since publication.

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