$2,600 Deductible/Rx Plan with HSA Option

Hospital care
(including maternity care)
Office visits
Outpatient Rx drugs

Laboratory
X-rays and other special procedures
Emergency care

Features		Member pays
Annual deductible (per calendar year)		$2,600 member $5,200 per family

Annual out-of-pocket maximum (per calendar year)		$5,000 member $10,000 per family

Lifetime benefit maximum		$2 million

Hospital care (including maternity care)*

Features		Member pays
All inpatient care is covered after payment of applicable copayments. There are no limits on prescribed hospital days.		20% coinsurance (after deductible)

Office visits*

Features		Member pays
For diagnosis and treatment by primary care providers, consultation and treatment by specialists, routine physical and hearing exams, well-baby visits through age 2, prenatal care, eye exams, and urgent care.		20% coinsurance per primary care visit^† 20% coinsurance per specialty care visit

Outpatient Rx drugs

Features		Member pays
When prescribed by a Kaiser Permanente physician or a licensed dentist in accordance with our formulary process.		$15 generic prescription $30 brand-name prescription (30-day supply) Mail order: 2 copayments for 90-day supply of maintenance drugs

Laboratory

Features		Member pays
Inpatient		Included under hospital care 20% coinsurance^‡

Outpatient		Included under hospital care 20% coinsurance^‡

X-rays and other special procedures

Features		Member pays
Inpatient		Included under hospital care 20% coinsurance^‡

Outpatient		Included under hospital care 20% coinsurance^‡

Emergency care*

Features		Member pays
Within and outside Kaiser Permanente service area		20% coinsurance (after deductible)**

* Plus any copayments or coinsurance for lab or X-ray

** The emergency care copay will be waived and the hospital copay will apply if admitted directly to hospital from an emergency room. Additional copayments or coinsurance may apply for lab, X-ray, etc.

† (After deductible) Deductible waived for well-baby visits, prenatal care, and certain preventive procedures.

‡ (After deductible) No deductible for preventive tests or preventive procedures.

With the Deductible Plans with HSA Option you may qualify to establish a health savings account (HSA). While you can choose to set up an HSA with any HSA-qualified trustee, for your convenience Kaiser Permanente has selected Wells Fargo as our preferred provider for HSA services. Learn more about the advantages of an HSA from Wells Fargo.

Need more information about HSAs? See our frequently asked questions.

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