$2,000 Deductible Plan with HSA Option (80%)

$2,000 Deductible Plan

with Health Savings Account (HSA) Option (80%)

Annual deductible

Features		Member pays
Individual		$2,000¹

Family		$4,000¹
The deductible applies to all services unless otherwise noted.

Out-of-pocket annual maximum

Features		Member pays
Individual		$5,000

Family		$10,000
The out-of-pocket maximum includes deductible and coinsurance.

Lifetime maximum

Features		Member pays
Lifetime maximum paid by the Plan for all care		No lifetime maximum

Routine medical office visits

Features		Member pays
Primary care office visit		20% coinsurance per visit

Specialist office visit		20% coinsurance per visit

In-office procedures

Features		Member pays
Procedures received during office visits		20% coinsurance per procedure

Preventive services²

Features		Member pays
Children's services		No charge³

Adults' services		No charge³

Maternity

Features		Member pays
Prenatal care		Not covered

Delivery and inpatient well-baby care		Not covered

Prescription drugs

Features		Member pays
Prescription drugs		Not covered⁴

Inpatient hospital

Features		Member pays
Inpatient hospital		20% coinsurance per admission

Inpatient professional visits		20% coinsurance per visit

Outpatient/ambulatory surgery

Features		Member pays
Outpatient/ambulatory surgery		20% coinsurance per admission

Laboratory and X-ray

Features		Member pays
Diagnostic lab		20% coinsurance

X-ray, including therapeutic		20% coinsurance

MRI/CT/PET		20% coinsurance per procedure

Emergency care

Features		Member pays
Emergency care		20% coinsurance per visit at a designated Kaiser Permanente emergency room or a non-Plan emergency room

Ambulance

Features		Member pays
Ambulance		20% coinsurance per trip

Urgent, nonroutine, and after-hours care

Features		Member pays
Office hours visit		20% coinsurance per visit at a Kaiser Permanente medical office during office hours

After-hours visit		20% coinsurance per after-hours visit at a designated Kaiser Permanente after-hours medical office

Procedures received during urgent, nonroutine, and after-hours care

Features		Member pays
Procedures received during urgent, nonroutine, and after-hours care		20% coinsurance per procedure

¹Deductible applies toward out-of-pocket maximum.

²Preventive services include adult preventive care exams, adult preventive care screenings, well-woman care, immunizations, and well-child care.

³Not subject to the deductible.

⁴Kaiser Permanente uses a list of preferred drugs referred to as our formulary. You may purchase preferred drugs prescribed by your doctor at our pharmacies at competitive rates. To learn more about preferred drugs in our formulary, contact our Clinical Pharmacy Call Center at 303-338-4503.

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