Basics You may use only Kaiser Permanente doctors and facilities except in emergencies.
Full-Time Employee * Contribution Per Pay Period:
Employee Only: $0
Part-Time Employee * Contribution Per Pay Period:
Employee Only: $196.16
Pre-Authorization Requirement:
Pre-authorization required for all elective inpatient and outpatient procedures.
PENALTY for not pre-authorizing: not covered.
Care Management:
Kaiser Permanente’s Complete Care℠, is a comprehensive multidisciplinary approach to identifying and treating members with chronic conditions. It addresses a wide range of chronic and acute conditions and comorbidities with a focus on prevention, risk reduction, and self-care. The program is integrated into the patient-centered, “whole person” continuum of care provided.
Program features include: Multidisciplinary disease management and case management; sophisticated electronic health information management and disease registries; proactive, targeted screening, intervention, and outreach; extensive support for implementing best practices and improved panel management; member self-care tools for improving health and quality of life; and health education to support self-management.
Office co-pay:
$30 co-pay primary/$50 co-pay specialist
Coinsurance:
100% after applicable co-pays
Out-of-Pocket Maximum:
$3,500 per individual (in single employee enrollment or in family enrollment)
A single Out-of-Pocket Maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the Out-of-Pocket Maximum is met.)
Overall Lifetime Maximum:
Maternity Maternity Hospital Stay:
$150 co-pay per admission
Midwives:
100% in hospital; if out-patient office visit: $50 co-pay
If midwife is available at Kaiser Permanente
Mental Health/Substance Abuse Mental Health:
Kaiser Permanente must approve mental health care.
OUTPATIENT CARE
Autism:
Behavioral health treatment for pervasive developmental disorder or autism (including applied behavior analysis and evidence-based behavior intervention programs) that develops or restores, to the maximum extent practicable, the functioning of a person with pervasive developmental disorder or autism that meet Kaiser's established criteria (refer to Evidence of Coverage booklet for specifics). The cost sharing for individual and group visits under this Mental Health section apply.
Substance Abuse:
INPATIENT DETOXIFICATION
OUTPATIENT CARE
Transitional Residential Recovery Services
Other Services (A-D) Acupuncture:
At a Kaiser facility:
Using the American Specialty Health (ASH) network:
Chiropractors:
$20 co-pay
Up to 40 combined chiropractic and acupuncture visits per year
American Specialty Health (ASH) Plans Participating Chiropractors
Christian Science Practitioners:
Other Services (E-N) Emergency Room:
$200 co-pay (waived if admitted)
Urgent Care:
$30 co-pay at Kaiser Permanente facility
Hearing Care:
Exam Network: 100% as part of preventive care
Hearing aids not covered
Home Health Care:
100%
Up to 100 two-hour visits/calendar year
Hospital Stay:
$150 co-pay per admission
Infertility Treatment:
50%
Fertility Drugs: Covered under drug benefits at 50%; In Vitro, GIFT, and ZIFT: Not covered.
Magnetic resonance imaging - MRI:
Durable Medical Equipment:
Other Services (O-Z) Organ Transplants:
Contact Kaiser Permanente for information on transplant coverage benefits
Surgery : Physician Services:
INPATIENT
OUTPATIENT
Surgery : Facility Charges:
INPATIENT
OUTPATIENT
Tubal Ligation:
INPATIENT
OUTPATIENT
Vasectomy:
$150 co-pay per procedure
Prescription Drugs Pharmacy (Retail):
KAISER PERMANENTE PHARMACY
Brand: $40 for up to a 30-day supply, $80 for a 31- to 60-day supply, or $120 for a 61- to 100-day supply
Mail order drug program:
KAISER PERMANENTE MAIL ORDER PHARMACY
Brand: $80 for up to 100 day supply; Some Specialty drugs are available via mail order, but there is no incentive as you will be paying for the full 100 day supply.
Birth Control Pills:
Included in Prescription Drug benefit, covered at 100%
Preventive Care Physical exams for adults:
Physical exams for children:
Immunizations:
100%
Prostate Specific Antigen test - PSA:
Vision care:
100%
Eye exams only. Discount program available for vision hardware
Basics The Stanford Health Care Alliance ACO plan requires you designate a primary care provider to coordinate all of your care. You may visit any Stanford Health Care Alliance network doctor or hospital. Some services require prior authorization from your primary care physician.
There is no benefit if you see a Non-Network provider, except for emergency care or when clinically appropriate and prior authorized by Stanford Health Care Alliance and Outpatient mental health office visits (see Mental Health section).
Full-Time Employee * Contribution Per Pay Period:
Employee Only: $48.00
Part-Time Employee * Contribution Per Pay Period:
Employee Only: $415.76
Pre-Authorization Requirement:
Prior authorization is required for the following services: Advanced Imaging (CT, MRI, MRA and PET); all electively scheduled inpatient hospital admissions, all elective outpatient procedures (example – endoscopic procedures, arthroscopic procedures, epidural steroid injections, etc); other procedures and services as defined on the pre-certification requirement list.
PENALTY for not pre-authorizing: the services will be considered not covered
Visits to a specialist will now require a referral from your designated PCP. This includes any specialist you are currently seeing for ongoing care or for new patient visits. Visits to a specialist without a PCP referral may be denied due to lack of referral. Exception: Well-woman exams with an OB/GYN do not require a referral.
Care Management:
Participation in care management required for certain conditions and diseases.
Office co-pay:
$30 co-pay primary/$75 co-pay specialist
Coinsurance:
100% after applicable co-pays
Out-of-Pocket Maximum:
$3,500 per individual/$7,000 family
A single Out-of-Pocket Maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the Out-of-Pocket Maximum is met.) There is no benefit if you see a Non-Network provider, except for outpatient professional mental health and substance abuse care, emergency care, or when clinically appropriate and prior authorized.
Overall Lifetime Maximum:
Maternity Maternity Hospital Stay:
$150 co-pay per admission
Birthing Centers:
$150 co-pay per admission
If the birthing center is part of the Stanford Health Care Alliance network.
Midwives:
100%
If the midwife is part of the Stanford Health Care Alliance network.
Pregnancy Termination:
$125 co-pay
If hospitalized, the Hospital Stay co-payment will also apply.
Mental Health/Substance Abuse Mental Health:
Pre-certification may be required by you or your provider.
INPATIENT CARE ** pre-authorization required
ROUTINE OUTPATIENT CARE
The maximum allowed amount will not exceed $300 for each office visit. For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.
Autism:
Behavioral health treatment (BHT) consists of professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based behavior intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorders or autism. Prior authorization for BHT or ABA services is required. Plan mental health cost sharing applies.
Substance Abuse:
Pre-certification may be required by you or your provider.
INPATIENT CARE ** pre-authorization required
ROUTINE OUTPATIENT CARE
The maximum allowed amount will not exceed $300 for each office visit. For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.
Other Services (A-D) Acupuncture:
$30 co-pay
Up to 20 visits per year
Network providers only
Allergy Tests:
100%
Office co-pay may apply.
Allergy Treatment:
100%
Office co-pay may apply.
CT Scans:
Covered at 90% with no deductible; **Pre-authorization required. 10% member coinsurance.
Chiropractors:
$30 co-pay
Up to 20 visits per year
Network providers only
Christian Science Practitioners:
Dental Treatment:
Coverage limited to certain conditions only. Contact Stanford Health Care Alliance member services for more information.
Other Services (E-N) Emergency Room:
$200 co-pay (waived if admitted)
Urgent Care:
Office visit co-payment, specialist visit co-payment, or Emergency Room co-payment, depending on the facility.
Hearing Care:
Exam $75 co-pay
Hearing aids not covered
Hospital Stay:
Pre-Certification required by you or your provider. $150 co-pay per admission
Infertility Treatment:
Network: 50% of Stanford Health Care Alliance allowed charges for professional and diagnostic services; limited to three cycles of intrauterine insemination (IUI).
In Vitro, GIFT, and ZIFT: Not covered
Fertility drugs: see Pharmacy
Magnetic resonance imaging - MRI:
Covered at 90% with no deductible; **Pre-authorization required. 10% member coinsurance.
Durable Medical Equipment:
100% **pre authorization requirement
Other Services (O-Z) Organ Transplants:
Contact Stanford Health Care Alliance member services for information on transplant coverage benefits
Skilled Nursing:
$150 co-pay per admission
Up to 100 days per calendar year
Surgery : Physician Services:
INPATIENT
OUTPATIENT
Surgery : Facility Charges:
INPATIENT
Speech Therapy:
$40 co-pay **pre authorization requirement
Tubal Ligation:
INPATIENT
OUTPATIENT
[Facility co-payments only; physician fees also apply]
Vasectomy:
$75 co-pay
[when performed in the physician office]
Prescription Drugs Pharmacy (Retail):
Stanford Health Care Alliance uses the Aetna Network pharmacy: $10 generic; $40 brand name; $100 non-formulary -- up to a 30-day supply. Specialty medication classification will have a 10% co-insurance payment applied up to a $200 max cost per prescription.
Non-Network pharmacy: Member pays co-payment plus 25% of billed charges
Fertility drugs covered at 50% (deductible does not apply); max benefit of $5,000 per lifetime
Mail order drug program:
$20 generic; $80 brand name; $200 non-formulary -- up to a 90-day supply; Specialty drugs are not available via mail order.
Must use Aetna mail-order service
Birth Control Pills:
Included in Prescription Drug benefit
Preventive Care Physical exams for adults:
Physical exams for children:
Pap smears:
100%
[as part of the office visit]
Immunizations:
100%
Travel immunizations not covered.
Prostate Specific Antigen test - PSA:
Vision care:
Up to age 22 - 100%
Limited to screen and refraction exams only
Basics You may visit any doctor or hospital. You receive a higher level of benefits when you use Blue Shield PPO providers. You are responsible for ensuring all providers are in the network.
When you see a Non-Network provider you are responsible for the balance of your bill that is not covered by Blue Shield. The Out-of-Pocket Maximum does not apply to the balance of the bill not covered by Blue Shield.
This plan is compatible with an individual Health Savings Account (HSA), that you establish at a financial institution of your choice.
Full-Time Employee * Contribution Per Pay Period:
Employee Only: $40.00
Out of Area Plan (Full-Time Employee * Contribution Per Pay Period)
Part-Time Employee * Contribution Per Pay Period:
Employee Only: $282.60
Out of Area Plan (Part-Time Employee * Contribution Per Pay Period)
Pre-Authorization Requirement:
Pre-authorization required for all hospital stays and certain outpatient procedures.
PENALTY for not pre-authorizing: benefit may be denied in full for failure to pre-authorize.
Care Management:
Participation in care management optional
Our Shield Concierge program takes a comprehensive population health approach to care management. Our multidisciplinary team of nurses, behavioral health clinicians, health coaches, dietitians, pharmacists, and customer services representatives help members live better with illness, recover from acute conditions, and have a more seamless healthcare experience.
Program features include acute and chronic condition care management, in-home visits, biometric remote monitoring (for some conditions), in-person and online self-management workshops, virtual cognitive behavioral therapy modules, proactive outreach by a clinical team, and integration with our Engagement Point digital solution for improved engagement.
Deductible:
$1,750 per individual coverage/$3,500 per family coverage
Combined Network or Non-Network. Up to $2,800 of an individual's claims will apply toward the family deductible, and once that threshold is met the plan will begin sharing the costs for that individual.
Office co-pay:
Network: 80% after deductible
Non-Network: 60% after deductible
Coinsurance:
Network: 100% for preventive care; 80% after deductible for all other services, including prescriptions
Non-Network: 60% of allowed charges after deductible, including prescriptions
Out-of-Pocket Maximum:
$3,750 per individual/$7,500 per family
Combined Network or Non-Network
A single Out-of-Pocket Maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the Out-of-Pocket Maximum is met.)
Overall Lifetime Maximum:
Maternity Maternity Hospital Stay:
Network: 80% after deductible
Baby's First Exam:
Network: 80% after deductible
Birthing Centers:
Network: 80% after deductible
Midwives:
Network: 80% after deductible
Non-Network: 60% after deductible
Prenatal Visits:
Network: 80% after deductible
Non-Network: 60% after deductible
Doctor Delivery Charge:
Covered the same as all other inpatient surgery
Pregnancy Termination:
Network: 80% after deductible
Non-Network: 60% after deductible
Mental Health/Substance Abuse Mental Health:
INPATIENT CARE
ROUTINE OUTPATIENT CARE
The maximum allowed amount will not exceed $300 for each office visit. For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.
Autism:
Behavioral health treatment (BHT) consists of professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based behavior intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorders or autism. Prior authorization for BHT or ABA services is required. Plan mental health cost sharing applies.
Substance Abuse:
Pre-certification is required by you or your provider.
INPATIENT CARE
ROUTINE OUTPATIENT CARE
The maximum allowed amount will not exceed $300 for each office visit. For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.
Other Services (A-D) Acupuncture:
Network: 80% after deductible
Allergy Tests:
Network: 80% after deductible
Allergy Treatment:
Network: 80% after deductible
Ambulance charges:
Network: 80% after deductible
CT Scans:
100% **Pre authorization requirement
Chiropractors:
Network: 80% after deductible
Christian Science Practitioners:
Dental Treatment:
Coverage limited to certain conditions only. Contact Blue Shield for more information.
Other Services (E-N) Emergency Room:
Network: 80% after deductible
Lab/ancillary/professional charges paid at 80% after deductible for Network or Non-Network
Urgent Care:
Network or Non-Network: 80% after deductible
Hearing Care:
Exam: Network: 100% as part of preventive care
Hearing aids not covered
Home Health Care:
Network: 80% after deductible - 100 days per calendar year. Prior authorization required.
Hospice Care:
Network: 80% after deductible
Hospital Stay:
Pre-Certification required by you or your provider.
Infertility Treatment:
Network: 50% of Blue Shield allowed charges after deductible for professional and lab services; limited to three cycles of intrauterine insemination (IUI).
In Vitro, GIFT, and ZIFT: Not covered
Fertility drugs: see Pharmacy
Laboratory Charges:
Network: 80% after deductible
Magnetic resonance imaging - MRI:
Pre-Certification required by you or your provider.
Durable Medical Equipment:
Network: 80% after deductible
Other Services (O-Z) Occupational Therapy:
Network: 80% after deductible
Organ Transplants:
Contact Blue Shield for information on transplant coverage benefits
Skilled Nursing:
Network: 80% after deductible
Up to a 120-day annual maximum Network and Non-Network combined.
Physical Therapy:
Network: 80% after deductible
Surgery : Physician Services:
Network: 80% after deductible
Surgery : Facility Charges:
Network: 80% after deductible
Non-Network (non-ambulatory surgery centers): 60% of billed charges after deductible
Non-Network (ambulatory surgery centers): 60% of allowed charges after deductible up to the maximum allowed charges of $4,000 per visit
For example, if the non-network allowed charge is $4,500, the plan will pay 60% of {the lesser of $4,000 or the allowed charge} = 60% x $4,000 = $2,400.
Speech Therapy:
Network: 80% after deductible
Tubal Ligation:
Network: 80% after deductible
Vasectomy:
Network: 80% after deductible
X-rays:
Network: 80% after deductible
Prescription Drugs Pharmacy (Retail):
Network or Non-Network: 80% after deductible
*Note per federal regulations certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required
Fertility drugs: covered at 50% after deductible; max benefit of $5,000 per lifetime
Mail order drug program:
80% after deductible; Specialty drugs are not available via mail order.
*Note per federal regulations certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required
Must use Blue Shield mail-order service.
Birth Control Pills:
Included in Prescription Drug benefit
Preventive Care Physical exams for adults:
Network: 100%
Physical exams for children:
Network: 100%
Pap smears:
Network: 100% if part of annual preventive
Mammograms:
Network: 100% if part of annual preventive
Immunizations:
Network: 100%
Non-Network: not covered;
Travel immunizations are covered both in-network and out of network at no charge
Prostate Specific Antigen test - PSA:
Network: 100%
Well-woman visits:
Network: 100%
Vision care:
Network: 100%
Limited to screen and refraction exams only
Basics You may visit any doctor or hospital. You receive a higher level of benefits when you use Blue Shield PPO providers. You are responsible for ensuring all providers are in the network.
When you see a Non-Network provider you are responsible for the balance of your bill that is not covered by Blue Shield. The Out-of-Pocket Maximum does not apply to the balance of the bill not covered by Blue Shield.
This plan is compatible with an individual Health Savings Account (HSA), that you establish at a financial institution of your choice.
Full-Time Employee * Contribution Per Pay Period:
Employee Only: $24.26
Part-Time Employee * Contribution Per Pay Period:
Employee Only: $154.94
Pre-Authorization Requirement:
Pre-authorization required for all hospital stays and certain outpatient procedures.
PENALTY for not pre-authorizing: benefit may be denied in full for failure to pre-authorize.
Care Management:
Participation in care management optional
Our Shield Concierge program takes a comprehensive population health approach to care management. Our multidisciplinary team of nurses, behavioral health clinicians, health coaches, dietitians, pharmacists, and customer services representatives help members live better with illness, recover from acute conditions, and have a more seamless healthcare experience.
Program features include acute and chronic condition care management, in-home visits, biometric remote monitoring (for some conditions), in-person and online self-management workshops, virtual cognitive behavioral therapy modules, proactive outreach by a clinical team, and integration with our Engagement Point digital solution for improved engagement.
Deductible:
$3,250 per individual coverage/$6,500 per family coverage in-network
$6,500 per individual coverage/$13,000 out-of-network. The individual deductible will apply to each covered family member's claims. If met, the plan would begin sharing costs for the family member that met the individual deductible.
Office co-pay:
Network: Plan pays 60% after deductible
Coinsurance:
Network: 100% for preventive care; 60% after deductible for all other services, including prescriptions
Non-Network: 50% of allowed charges after deductible, including prescriptions
Out-of-Pocket Maximum:
$6,500 per individual/$13,000 per family In-network
A single Out-of-Pocket Maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the Out-of-Pocket Maximum is met.)
Overall Lifetime Maximum:
Maternity Maternity Hospital Stay:
Network: 60% after deductible
Baby's First Exam:
Network: 60% after deductible
Birthing Centers:
Network: 60% after deductible
Midwives:
Network: 60% after deductible
Prenatal Visits:
Network: 60% after deductible
Doctor Delivery Charge:
Covered the same as all other inpatient surgery
Pregnancy Termination:
Network: 60% after deductible
Mental Health/Substance Abuse Mental Health:
INPATIENT CARE
OUTPATIENT CARE
Autism:
Behavioral health treatment (BHT) consists of professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based behavior intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorders or autism. Prior authorization for BHT or ABA services is required. Plan mental health cost sharing applies.
Substance Abuse:
Pre-certification is required by you or your provider.
INPATIENT CARE
OUTPATIENT CARE
Other Services (A-D) Acupuncture:
Network: 60% after deductible
Allergy Tests:
Network: 60% after deductible
Allergy Treatment:
Network: 60% after deductible
Ambulance charges:
Network or Non-Network: 60% after deductible (if medically approved)
CT Scans:
Network: 60% after deductible
Chiropractors:
Network: 60% after deductible
Christian Science Practitioners:
Dental Treatment:
Coverage limited to certain conditions only. Contact Blue Shield for more information.
Other Services (E-N) Emergency Room:
Network: 60% after deductible
Lab/ancillary/professional charges paid at 60% after deductible for Network or Non-Network
Urgent Care:
Network or Non-Network: 60% after deductible
Hearing Care:
Exam Network: 100% As part of preventive care
Hearing aids not covered
Home Health Care:
Network: 60% after deductible
Hospice Care:
Network: 60% after deductible
Hospital Stay:
Pre-Certification required by you or your provider.
Infertility Treatment:
Network: 50% of Blue Shield allowed charges after deductible for professional and lab services; limited to three cycles of intrauterine insemination (IUI).
In Vitro, GIFT, and ZIFT: Not covered
Fertility drugs: see Pharmacy
Laboratory Charges:
Network: 60% after deductible
Magnetic resonance imaging - MRI:
Pre-Certification required by you or your provider.
Durable Medical Equipment:
Network: 60% after deductible
Other Services (O-Z) Occupational Therapy:
Network: 60% after deductible
Organ Transplants:
Contact Blue Shield for information on transplant coverage benefits
Skilled Nursing:
Network: 60% after deductible
Up to a 120-day annual maximum Network and Non-Network combined.
Physical Therapy:
Network: 60% after deductible
Surgery : Physician Services:
Network: 60% after deductible
Surgery : Facility Charges:
Network: 60% after deductible
Non-Network (non-ambulatory surgery centers): 50% of billed charges after deductible
Non-Network (ambulatory surgery centers): 50% of allowed charges after deductible up to the maximum allowed charges of $4,000 per visit
For example, if the non-network allowed charge is $4,000, the plan will pay 50% of {the lesser of $4,000 or the allowed charge} = 50% x $4,000 = $2,000.
Speech Therapy:
Network: 60% after deductible
Tubal Ligation:
Network: 60% after deductible
Vasectomy:
Network: 60% after deductible
X-rays:
Network: 60% after deductible
Prescription Drugs Pharmacy (Retail):
Network or Non-Network: 60% after deductible
*Note per federal regulations certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required
Fertility drugs: covered at 50% after deductible; max benefit of $5,000 per lifetime
Mail order drug program:
60% after deductible; Specialty drugs are not available via mail order.
*Note per federal regulations certain preventive drugs (if covered by your plan) pay at first dollar coverage - no deductible required
Must use Blue Shield mail-order service
Birth Control Pills:
Included in Prescription Drug benefit
Preventive Care Physical exams for adults:
Network: 100%
Physical exams for children:
Network: 100%
Pap smears:
Network: 100% if part of annual preventive
Mammograms:
Network: 100% if part of annual preventive
Immunizations:
Network: 100%
Travel immunizations are covered both in-network and out of network at no charge
Prostate Specific Antigen test - PSA:
Network: 100%
Well-woman visits:
Network: 100%
Vision care:
Network: 100%
Limited to screen and refraction exams only
Basics You may use only Kaiser Permanente doctors and facilities except in emergencies.
Pre-Authorization Requirement:
Pre-authorization required for all elective inpatient and outpatient procedures.
PENALTY for not pre-authorizing: not covered.
Care Management:
Kaiser Permanente’s Complete Care℠, is a comprehensive multidisciplinary approach to identifying and treating members with chronic conditions. It addresses a wide range of chronic and acute conditions and comorbidities with a focus on prevention, risk reduction, and self-care. The program is integrated into the patient-centered, “whole person” continuum of care provided.
Program features include: Multidisciplinary disease management and case management; sophisticated electronic health information management and disease registries; proactive, targeted screening, intervention, and outreach; extensive support for implementing best practices and improved panel management; member self-care tools for improving health and quality of life; and health education to support self-management.
Office co-pay:
$30 co-pay primary/$50 co-pay specialist
Coinsurance:
100% after applicable co-pays
Out-of-Pocket Maximum:
$3,500 per individual (in single employee enrollment or in family enrollment)
A single Out-of-Pocket Maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the Out-of-Pocket Maximum is met.)
Overall Lifetime Maximum:
Maternity Maternity Hospital Stay:
$150 co-pay per admission
Midwives:
100% in hospital; if out-patient office visit: $50 co-pay
If midwife is available at Kaiser Permanente
Mental Health/Substance Abuse Mental Health:
Kaiser Permanente must approve mental health care.
OUTPATIENT CARE
Autism:
Behavioral health treatment for pervasive developmental disorder or autism (including applied behavior analysis and evidence-based behavior intervention programs) that develops or restores, to the maximum extent practicable, the functioning of a person with pervasive developmental disorder or autism that meet Kaiser's established criteria (refer to Evidence of Coverage booklet for specifics). The cost sharing for individual and group visits under this Mental Health section apply.
Substance Abuse:
INPATIENT DETOXIFICATION
OUTPATIENT CARE
Transitional Residential Recovery Services
Other Services (A-D) Acupuncture:
At a Kaiser facility:
Using the American Specialty Health (ASH) network:
Chiropractors:
$20 co-pay
Up to 40 combined chiropractic and acupuncture visits per year
American Specialty Health (ASH) Plans Participating Chiropractors
Christian Science Practitioners:
Other Services (E-N) Emergency Room:
$200 co-pay (waived if admitted)
Urgent Care:
$30 co-pay at Kaiser Permanente facility
Hearing Care:
Exam Network: 100% as part of preventive care
Hearing aids not covered
Home Health Care:
100%
Up to 100 two-hour visits/calendar year
Hospital Stay:
$150 co-pay per admission
Infertility Treatment:
50%
Fertility Drugs: Covered under drug benefits at 50%; In Vitro, GIFT, and ZIFT: Not covered.
Magnetic resonance imaging - MRI:
Durable Medical Equipment:
Other Services (O-Z) Organ Transplants:
Contact Kaiser Permanente for information on transplant coverage benefits
Surgery : Physician Services:
INPATIENT
OUTPATIENT
Surgery : Facility Charges:
INPATIENT
OUTPATIENT
Tubal Ligation:
INPATIENT
OUTPATIENT
Vasectomy:
$150 co-pay per procedure
Prescription Drugs Pharmacy (Retail):
KAISER PERMANENTE PHARMACY
Brand: $40 for up to a 30-day supply, $80 for a 31- to 60-day supply, or $120 for a 61- to 100-day supply
Mail order drug program:
KAISER PERMANENTE MAIL ORDER PHARMACY
Brand: $80 for up to 100 day supply; Some Specialty drugs are available via mail order, but there is no incentive as you will be paying for the full 100 day supply.
Birth Control Pills:
Included in Prescription Drug benefit, covered at 100%
Preventive Care Physical exams for adults:
Physical exams for children:
Immunizations:
100%
Prostate Specific Antigen test - PSA:
Vision care:
100%
Eye exams only. Discount program available for vision hardware
