Plan Year 2027

KAISER PERMANENTE HMO

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

KAISER PERMANENTE HMO

Plan Details

Carrier: Kaiser Permanente
Plan Type: HMO
Network: Kaiser Permanente
Out-of-Network Coverage: No

Your Contributions

Coverage Tier	MONTHLY CONTRIBUTIONS
Employee Only	$268.02
Employee + Spouse	$708.82
Employee + Child(Ren)	$536.13
Employee + Family	$942.01

Coverage Tier: Employee Only
MONTHLY CONTRIBUTIONS: $268.02

Coverage Tier: Employee + Spouse
MONTHLY CONTRIBUTIONS: $708.82

Coverage Tier: Employee + Child(Ren)
MONTHLY CONTRIBUTIONS: $536.13

Coverage Tier: Employee + Family
MONTHLY CONTRIBUTIONS: $942.01

Covered Services

Coverage Details

Services	IN-NETWORK ONLY
Calendar Year Deductible - Individual	$750
Calendar Year Deductible - Family	$1,500¹
Coinsurance (Plan Pays)	N/A
Calendar Year Out-Of-Pocket Maximum (Includes Deductible And Medical And Rx Copays) - Individual	$4,000
Calendar Year Out-Of-Pocket Maximum (Includes Deductible And Medical And Rx Copays) - Family	$8,000
Preventive Care	No charge
Primary Care	$30
Specialist Services	$40
Urgent Care	$30
Diagnostic Care	No charge
Medical Transportation	$250*
Emergency Room	$250*

Services: Calendar Year Deductible - Individual
IN-NETWORK ONLY: $750

Services: Calendar Year Deductible - Family
IN-NETWORK ONLY: $1,500¹

Services: Coinsurance (Plan Pays)
IN-NETWORK ONLY: N/A

Services: Calendar Year Out-Of-Pocket Maximum (Includes Deductible And Medical And Rx Copays) - Individual
IN-NETWORK ONLY: $4,000

Services: Calendar Year Out-Of-Pocket Maximum (Includes Deductible And Medical And Rx Copays) - Family
IN-NETWORK ONLY: $8,000

Services: Preventive Care
IN-NETWORK ONLY: No charge

Services: Primary Care
IN-NETWORK ONLY: $30

Services: Specialist Services
IN-NETWORK ONLY: $40

Services: Urgent Care
IN-NETWORK ONLY: $30

Services: Diagnostic Care
IN-NETWORK ONLY: No charge

Services: Medical Transportation
IN-NETWORK ONLY: $250*

Services: Emergency Room
IN-NETWORK ONLY: $250*

*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	$15
Preferred	$35
Non-Preferred	$35
Specialty Rx	20% to $250 Max

Tier: Generic
IN-NETWORK ONLY: $15

Tier: Preferred
IN-NETWORK ONLY: $35

Tier: Non-Preferred
IN-NETWORK ONLY: $35

Tier: Specialty Rx
IN-NETWORK ONLY: 20% to $250 Max

**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.
For both Kaiser and EHN Network only there are NO Out-of-Network Benefits or benefits provided outside of the service area.
90-day supply through mail order is available at 2x the retail copay for Kaiser plans.