Plan Year 2027

KAISER PERMANENTE HDHP

For both Kaiser and EHN Network only there are NO Out-of-Network Benefits or benefits provided outside of the service area.

KAISER PERMANENTE HDHP

Plan Details

Carrier: Kaiser Permanente
Plan Type: HDHP
Network: Kaiser Permanente
Out-of-Network Coverage: No
HSA Eligible: Yes

Your Contributions

Coverage Tier	MONTHLY CONTRIBUTIONS
Employee Only	$214.37
Employee + Spouse	$562.46
Employee + Child(Ren)	$415.88
Employee + Family	$743.24

Coverage Tier: Employee Only
MONTHLY CONTRIBUTIONS: $214.37

Coverage Tier: Employee + Spouse
MONTHLY CONTRIBUTIONS: $562.46

Coverage Tier: Employee + Child(Ren)
MONTHLY CONTRIBUTIONS: $415.88

Coverage Tier: Employee + Family
MONTHLY CONTRIBUTIONS: $743.24

Covered Services

Coverage Details

Services	IN-NETWORK ONLY
Calendar Year Deductible - Individual	$3,500
Calendar Year Deductible - Family	$7,000¹
Coinsurance (Plan Pays)	80%
Calendar Year Out-Of-Pocket Maximum (Includes Deductible And Medical And Rx Copays) - Individual	$6,200
Calendar Year Out-Of-Pocket Maximum (Includes Deductible And Medical And Rx Copays) - Family	$12,400
Preventive Care	No charge
Primary Care	20%*
Specialist Services	20%*
Urgent Care	20%*
Diagnostic Care	20%*
Medical Transportation	20%*
Emergency Room	20%*

Services: Calendar Year Deductible - Individual
IN-NETWORK ONLY: $3,500

Services: Calendar Year Deductible - Family
IN-NETWORK ONLY: $7,000¹

Services: Coinsurance (Plan Pays)
IN-NETWORK ONLY: 80%

Services: Calendar Year Out-Of-Pocket Maximum (Includes Deductible And Medical And Rx Copays) - Individual
IN-NETWORK ONLY: $6,200

Services: Calendar Year Out-Of-Pocket Maximum (Includes Deductible And Medical And Rx Copays) - Family
IN-NETWORK ONLY: $12,400

Services: Preventive Care
IN-NETWORK ONLY: No charge

Services: Primary Care
IN-NETWORK ONLY: 20%*

Services: Specialist Services
IN-NETWORK ONLY: 20%*

Services: Urgent Care
IN-NETWORK ONLY: 20%*

Services: Diagnostic Care
IN-NETWORK ONLY: 20%*

Services: Medical Transportation
IN-NETWORK ONLY: 20%*

Services: Emergency Room
IN-NETWORK ONLY: 20%*

*After Deductible
1If you choose to enroll you and your dependents in the Kaiser plans, a family member can meet the individual deductible and the plan will begin paying benefits for that individual only. Once two or more covered family members’ combined expenses meet the family deductible, the plan will begin paying benefits for any covered family member; 13

Pharmacy Benefits

Coverage Details

Tier	IN-NETWORK ONLY
Generic	$10*
Preferred	$30*
Non-Preferred	$30*
Specialty Rx	$30*

Tier: Generic
IN-NETWORK ONLY: $10*

Tier: Preferred
IN-NETWORK ONLY: $30*

Tier: Non-Preferred
IN-NETWORK ONLY: $30*

Tier: Specialty Rx
IN-NETWORK ONLY: $30*

*After Deductible
**90-day supply through mail order is available at 2x the retail copay for Kaiser plans and 2.5x retail copay for the EHN Network Only Plan

Plan Notes

Medical benefits are provided through Kaiser Permanente for California residents only.
ACE’s HSA employer contribution is a dollar-for-dollar match, up to $300 (Employee) or $600 (Family). You must make an employee contribution in order to receive the employer contribution.
For both Kaiser and EHN Network only there are NO Out-of-Network Benefits or benefits provided outside of the service area.