Plan Year 2027

WEBTPA EHN NETWORK ONLY

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

Plan Details

Carrier: WebTPA
Network: EHN
Out-of-Network Coverage: No

Your Contributions

Coverage Tier	MONTHLY CONTRIBUTIONS
Employee Only	$151.00
Employee + Spouse	$448.00
Employee + Child(Ren)	$400.00
Employee + Family	$727.00

Coverage Tier: Employee Only
MONTHLY CONTRIBUTIONS: $151.00

Coverage Tier: Employee + Spouse
MONTHLY CONTRIBUTIONS: $448.00

Coverage Tier: Employee + Child(Ren)
MONTHLY CONTRIBUTIONS: $400.00

Coverage Tier: Employee + Family
MONTHLY CONTRIBUTIONS: $727.00

Covered Services

Coverage Details

Services	IN-NETWORK ONLY
Calendar Year Deductible - Individual	$1,500
Calendar Year Deductible - Family	$3,000
Coinsurance (Plan Pays)	80%
Calendar Year Out-Of-Pocket Maximum (Includes Deductible And Medical And Rx Copays) - Individual	$5,000
Calendar Year Out-Of-Pocket Maximum (Includes Deductible And Medical And Rx Copays) - Family	$10,000
Preventive Care	No charge
Primary Care	$5
Specialist Services	$50
Urgent Care	$100
Diagnostic Care	20%*
Medical Transportation	20%*
Emergency Room	$250 Copay + 20%

Services: Calendar Year Deductible - Individual
IN-NETWORK ONLY: $1,500

Services: Calendar Year Deductible - Family
IN-NETWORK ONLY: $3,000

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: $5,000

Services: Calendar Year Out-Of-Pocket Maximum (Includes Deductible And Medical And Rx Copays) - Family
IN-NETWORK ONLY: $10,000

Services: Preventive Care
IN-NETWORK ONLY: No charge

Services: Primary Care
IN-NETWORK ONLY: $5

Services: Specialist Services
IN-NETWORK ONLY: $50

Services: Urgent Care
IN-NETWORK ONLY: $100

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

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

Services: Emergency Room
IN-NETWORK ONLY: $250 Copay + 20%

*After Deductible

Pharmacy Benefits

Coverage Details

Tier	IN-NETWORK ONLY
Generic	$5
Preferred	$50
Non-Preferred	$100
Specialty Rx	$100

Tier: Generic
IN-NETWORK ONLY: $5

Tier: Preferred
IN-NETWORK ONLY: $50

Tier: Non-Preferred
IN-NETWORK ONLY: $100

Tier: Specialty Rx
IN-NETWORK ONLY: $100

**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

New for 2027: For employees in the EHN Zip codes of Texas, you have the option of selecting the EHN Network only plan administered by Web TPA.
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 2.5x the retail copay for the EHN Network Only Plan.