2016 Plan Design

Please note that CVS Caremark administers the prescription drug plan for Option 1, Option 2 and HDHP medical plans. Kaiser administers the prescription drug plan for its medical plans. For more information on the CVS Caremark prescription drug plans, click here.

Click here for a print-ready PDF.

  • Option 1

    In-Network Out-of-Network
    Annual Deductible
    Employee Only$1,000$2,000
    Family$3,000$6,000
    Annual Out-of-Pocket Maximum
    Employee Only$6,000$12,000
    Family$12,000$24,000
    Coinsurance
    70% paid by plan 30% paid by member50% paid by plan 50% paid by member
    Wellness/Preventive Services
    Well Child Exams
    7 exams in 1st 12 mos
    3 exams in 2nd 12 mos
    3 exams in 3rd 12 mos
    1 exam per 12 mos thereafter
    100% paid by plan, no deductible or copay50% paid by plan 50% paid by member after deductible
    Adult Physical Exams
    1 exam every 12 months
    100% paid by plan, no deductible or copay50% paid by plan 50% paid by member after deductible
    Routine Gynecological Exam
    Pap smear screenings for female members, no age restrictions
    1 exam every 12 months
    100% paid by plan, no deductible or copay50% paid by plan 50% paid by member after deductible
    Routine Mammogram
    1 every 12 months, no age restrictions
    100% paid by plan, no deductible or copay50% paid by plan 50% paid by member after deductible
    Routine Prostate Specific Antigen (PSA)
    1 every 12 months, no age restrictions
    100% paid by plan, no deductible or copay50% paid by plan 50% paid by member after deductible
    Routine Colonoscopies
    1 every 10 years, no age restrictions
    100% paid by plan, no deductible or copay50% paid by plan 50% paid by member after deductible
    Routine Immunizations 100% paid by plan, no deductible or copay50% paid by plan 50% paid by member after deductible
    Physician/Provider Office Services
    Primary Care Physician CopayMember pays $30 copay50% paid by plan 50% paid by member after deductible
    Specialist Physician CopayMember pays $50 copay50% paid by plan 50% paid by member after deductible
    Urgent Care CopayMember pays $50 copay50% paid by plan 50% paid by member after deductible
    Walk-In Clinic CopayMember pays $15 copay Member pays $0 copay for CVS Minute Clinic50% paid by plan 50% paid by member after deductible
    Maternity Visits70% paid by plan after deductible; member pays $30 copay for PCP visit; $50 for Specialist visit - for initial visit then 30% after deductible50% paid by plan 50% paid by member after deductible
    Diagnostic Testing
    (includes lab work, X-rays)
    Member pays applicable physician copay; otherwise subject to deductible and coinsurance50% paid by plan 50% paid by member after deductible
    Hospital and Outpatient Facility Services
    Inpatient Facility Services70% paid by plan 30% paid by member after deductible50% paid by plan and 50% paid by member after deductible and $400 copay
    Outpatient Facility Services
    (includes surgery, hemodialysis, IV therapy, chemotherapy, radiation treatment)
    70% paid by plan 30% paid by member after deductible50% paid by plan 50% paid by member after deductible
    Emergency Room Visits (Facility)70% paid by plan 30% paid by member after $250 copay70% paid by plan 30% paid by member after $250 copay
    Physical/Speech/Occupational Therapy
    60 visit combined limit
    70% paid by plan 30% paid by member after deductible50% paid by plan 50% paid by member after deductible
    Mental Health and Substance Abuse
    Inpatient Facility70% paid by plan 30% paid by member after deductible50% paid by plan and 50% paid by member after deductible and $400 copay
    Outpatient Office and Facility VisitMember pays $30 copay50% paid by plan 50% paid by member after deductible
    Note: If you have any questions regarding the benefits listed above, please contact your plan administrator.
  • Option 2

    In-Network In-Network Out-of-Network
    Annual Deductible
    Employee Only$1,250$2,500
    Family$3,750$7,500
    Annual Out-of-Pocket Maximum
    Employee Only$6,550$13,100
    Family$13,100$26,200
    Coinsurance
    60% paid by plan 40% paid by member50% paid by plan 50% paid by member
    Wellness/Preventive Services
    Well Child Exams
    7 exams in 1st 12 mos
    3 exams in 2nd 12 mos
    3 exams in 3rd 12 mos
    1 exam per 12 mos thereafter
    100% paid by plan, no deductible or copay50% paid by plan 50% paid by member after deductible
    Adult Physical Exams
    1 exam every 12 months
    100% paid by plan, no deductible or copay50% paid by plan 50% paid by member after deductible
    Routine Gynecological Exam
    Pap smear screenings for female members, no age restrictions
    1 exam every 12 months
    100% paid by plan, no deductible or copay50% paid by plan 50% paid by member after deductible
    Routine Mammogram
    1 every 12 months, no age restrictions
    100% paid by plan, no deductible or copay50% paid by plan 50% paid by member after deductible
    Routine Prostate Specific Antigen (PSA)
    1 every 12 months, no age restrictions
    100% paid by plan, no deductible or copay50% paid by plan 50% paid by member after deductible
    Routine Colonoscopies
    1 every 10 years, no age restrictions
    100% paid by plan, no deductible or copay50% paid by plan 50% paid by member after deductible
    Routine Immunizations 100% paid by plan, no deductible or copay50% paid by plan 50% paid by member after deductible
    Physician/Provider Office Services
    Primary Care Physician CopayMember pays $40 copay50% paid by plan 50% paid by member after deductible
    Specialist Physician CopayMember pays $60 copay50% paid by plan 50% paid by member after deductible
    Urgent Care CopayMember pays $60 copay50% paid by plan 50% paid by member after deductible
    Walk-In Clinic CopayMember pays $20 copay Member pays $0 copay for CVS Minute Clinic50% paid by plan 50% paid by member after deductible
    Maternity Visits60% paid by plan after deductible Member pays $40 copay for PCP visit; $60 for Specialist visit - for initial visit then 40% after deductible50% paid by plan 50% paid by member after deductible
    Diagnostic Testing
    (includes lab work, X-rays)
    Member pays applicable physician copay; otherwise subject to deductible and coinsurance50% paid by plan 50% paid by member after deductible
    Hospital and Outpatient Facility Services
    Inpatient Facility Services60% paid by plan 40% paid by member after deductible50% paid by plan and 50% paid by member after deductible and $400 copay
    Outpatient Facility Services
    (includes surgery, hemodialysis, IV therapy, chemotherapy, radiation treatment)
    60% paid by plan 40% paid by member after deductible50% paid by plan 50% paid by member after deductible
    Emergency Room Visits
    (Facility)
    60% paid by plan 40% paid by member after $250 copay60% paid by plan 40% paid by member after $250 copay
    Physical/Speech/Occupational Therapy
    60 visit combined limit
    60% paid by plan 40% paid by member after deductible50% paid by plan 50% paid by member after deductible
    Mental Health and Substance Abuse
    Inpatient Facility60% paid by plan 40% paid by member after deductible50% paid by plan and 50% paid by member after deductible and $400 copay
    Outpatient Office and Facility VisitMember pays $40 copay50% paid by plan 50% paid by member after deductible
    Note: If you have any questions regarding the benefits listed above, please contact your plan administrator.
  • HDHP

    In-Network Out-of-Network
    Annual Deductible
    Employee Only$1,750$3,500
    Family$3,500$7,000
    Annual Out-of-Pocket Maximum
    Employee Only$6,550$13,100
    Family$13,100$26,200
    Coinsurance
    50% paid by plan 50% paid by member40% paid by plan 60% paid by member
    Wellness/Preventive Services
    Well Child Exams
    7 exams in 1st 12 mos
    3 exams in 2nd 12 mos
    3 exams in 3rd 12 mos
    1 exam per 12 mos thereafter
    100% paid by plan No deductible or copay40% paid by plan 60% paid by member after deductible
    Adult Physical Exams
    1 exam every 12 months
    100% paid by plan No deductible or copay40% paid by plan 60% paid by member after deductible
    Routine Gynecological Exam
    Pap smear screenings for female members, no age restrictions
    1 exam every 12 months
    100% paid by plan No deductible or copay40% paid by plan 60% paid by member after deductible
    Routine Mammogram
    1 every 12 months, no age restrictions
    100% paid by plan No deductible or copay40% paid by plan 60% paid by member after deductible
    Routine Prostate Specific Antigen (PSA)
    1 every 12 months, no age restrictions
    100% paid by plan No deductible or copay40% paid by plan 60% paid by member after deductible
    Routine Colonoscopies
    1 every 10 years, no age restrictions
    100% paid by plan No deductible or copay40% paid by plan 60% paid by member after deductible
    Routine Immunizations 100% paid by plan No deductible or copay40% paid by plan 60% paid by member after deductible
    Physician/Provider Office Services
    Primary Care Physician50% paid by plan 50% paid by member after deductible40% paid by plan 60% paid by member after deductible
    Specialist Physician 50% paid by plan 50% paid by member after deductible40% paid by plan 60% paid by member after deductible
    Urgent Care50% paid by plan 50% paid by member after deductible40% paid by plan 60% paid by member after deductible
    Walk-In Clinic50% paid by plan 50% paid by member after deductible40% paid by plan 60% paid by member after deductible
    Maternity Visits50% paid by plan 50% paid by member after deductible40% paid by plan 60% paid by member after deductible
    Diagnostic Testing
    (includes lab work, X-rays)
    50% paid by plan 50% paid by member after deductible40% paid by plan 60% paid by member after deductible
    Hospital and Outpatient Facility Services
    Inpatient Facility Services50% paid by plan 50% paid by member after deductible40% paid by plan 60% paid by member after deductible
    Outpatient Facility Services
    (includes surgery, hemodialysis, IV therapy, chemotherapy, radiation treatment)
    50% paid by plan 50% paid by member after deductible40% paid by plan 60% paid by member after deductible
    Emergency Room Visits
    (Facility)
    50% paid by plan 50% paid by member after deductible50% paid by plan 50% paid by member after deductible
    Physical/Speech/Occupational Therapy
    60 visit combined limit
    50% paid by plan 50% paid by member after deductible40% paid by plan 60% paid by member after deductible
    Mental Health and Substance Abuse
    Inpatient Facility50% paid by plan 50% paid by member after deductible40% paid by plan 60% paid by member after deductible
    Outpatient Office and Facility Visit50% paid by plan 50% paid by member after deductible40% paid by plan 60% paid by member after deductible
    Note: If you have any questions regarding the benefits listed above, please contact your plan administrator.
  • Kaiser California

    Additional Plan Information (North)

    Additional Plan Information (South)

    In-Network
    Annual Deductible
    Employee Only$1,000
    Family$3,000
    Annual Out-of-Pocket Maximum
    Employee Only$6,000
    Family$12,000
    Coinsurance
    70% paid by plan 30% paid by member
    Wellness/Preventive Services
    Well Child Exams (through 17 years)100% paid by plan, no deductible or copay
    Adult Physical Exams (beginning at age 18)100% paid by plan, no deductible or copay
    Routine Gynecological Exam (typically beginning at age 21; consult your physician)100% paid by plan, no deductible or copay
    Routine Mammogram (typically beginning at age 40; consult your physician)100% paid by plan, no deductible or copay
    Routine Prostate Specific Antigen (PSA) (typically beginning at age 50; consult your physician)100% paid by plan, no deductible or copay
    Routine Colorectal Cancer Screening (typically beginning at age 50; consult your physician)100% paid by plan, no deductible or copay
    Routine Developmental Screening (determined by physician)100% paid by plan, no deductible or copay
    Routine Immunizations (determined by Age; consult your physician)100% paid by plan, no deductible or copay
    Physician/Provider Office Services
    Primary Care Physician CopayMember pays $35 copay (deductible doesn't apply)
    Specialist Physician CopayMember pays $50 copay (deductible doesn't apply)
    Urgent Care CopayMember pays $35 copay (deductible doesn't apply)
    Maternity Visits100% paid by plan, no deductible or copay
    Diagnostic Testing (includes lab work, X-rays)Member pays $10 per encounter after deductible
    Hospital and Outpatient Facility Services
    Inpatient Facility Services70% paid by plan 30% paid by member after deductible
    Outpatient Facility Services (includes surgery, hemodialysis, IV therapy, chemotherapy, radiation treatment)70% paid by plan 30% paid by member after deductible
    Emergency Room Visits (Facility)70% paid by plan 30% paid by member after deductible
    Physical/Speech Therapy Member pays $35 copay after deductible
    Mental Health and Substance Abuse
    Inpatient70% paid by plan 30% paid by member after deductible
    OutpatientMember pays $35 copay for individual visit, $17 for group visit (deductible doesn't apply)
    Prescription Drugs
    Pharmacy/Retail: Generic (30 day supply)$15 for up to a 30-day supply (Deductible doesn't apply)
    Pharmacy/Retail: Brand (30 day supply)$35 for up to a 30-day supply (Deductible doesn't apply)
    Pharmacy/Retail: Specialty (30 day supply)Member pays 20% per prescription up to $150 maximum for 1-100 days
    Mail Order - Generic (90 day supply)$30 per prescription for up to a 100-day supply (Deductible doesn't apply)
    Mail Order - Brand (90 day supply)$70 per prescription for up to a 100-day supply (Deductible doesn't apply)
  • Kaiser Colorado

    Additional Plan Information

    In-Network
    Annual Deductible
    Employee Only$1,000
    Family$3,000
    Annual Out-of-Pocket Maximum
    Employee Only$6,000
    Family$12,000
    Coinsurance
    70% paid by plan 30% paid by member
    Wellness/Preventive Services
    Well Child Exams (through 17 years)100% paid by plan, no deductible or copay
    Adult Physical Exams (beginning at age 18)100% paid by plan, no deductible or copay
    Routine Gynecological Exam (typically beginning at age 21; consult your physician)100% paid by plan, no deductible or copay
    Routine Mammogram (typically beginning at age 40; consult your physician)100% paid by plan, no deductible or copay
    Routine Prostate Specific Antigen (PSA) (typically beginning at age 50; consult your physician)100% paid by plan, no deductible or copay
    Routine Colorectal Cancer Screening (typically beginning at age 50; consult your physician)100% paid by plan, no deductible or copay
    Routine Developmental Screening (determined by physician)100% paid by plan, no deductible or copay
    Routine Immunizations (determined by Age; consult your physician)100% paid by plan, no deductible or copay
    Physician/Provider Office Services
    Primary Care Physician CopayMember pays $35 copay (deductible doesn't apply)
    Specialist Physician CopayMember pays $50 copay (deductible doesn't apply)
    Urgent Care CopayMember pays $50 copay (deductible doesn't apply)
    Maternity Visits70% paid by plan 30% paid by member after deductible
    Diagnostic Testing (includes lab work, X-rays)Labs covered at 100%; Radiology 30% after deductible
    Hospital and Outpatient Facility Services
    Inpatient Facility Services70% paid by plan 30% paid by member after deductible
    Outpatient Facility Services (includes surgery, hemodialysis, IV therapy, chemotherapy, radiation treatment)70% paid by plan 30% paid by member after deductible
    Emergency Room Visits (Facility)70% paid by plan 30% paid by member after deductible
    Physical/Speech Therapy Member pays $35 per visit up to 20 visits per therapy per year
    Mental Health and Substance Abuse
    Inpatient70% paid by plan 30% paid by member after deductible
    OutpatientMember pays $35 copay per visit; group visits are 50% of the individual visit (deductible doesn't apply)
    Prescription Drugs
    Pharmacy/Retail: Generic (30 day supply)$15 for up to a 30-day supply (Deductible doesn't apply)
    Pharmacy/Retail: Brand (30 day supply)$35 for up to a 30-day supply (Deductible doesn't apply)
    Pharmacy/Retail: Specialty (30 day supply)Member pays 20% per prescription up to $150 maximum for 1-100 days (deductible doesn't apply)
    Mail Order - Generic (90 day supply)$30 per prescription for up to a 100-day supply (Deductible doesn't apply)
    Mail Order - Brand (90 day supply)$70 per prescription for up to a 100-day supply (Deductible doesn't apply)
  • Kaiser Georgia

    Additional Plan Information

    In-Network
    Annual Deductible
    Employee Only$1,000
    Family$3,000
    Annual Out-of-Pocket Maximum
    Employee Only$6,000
    Family$12,000
    Coinsurance
    70% paid by plan 30% paid by member
    Wellness/Preventive Services
    Well Child Exams (through 17 years)100% paid by plan, no deductible or copay
    Adult Physical Exams (beginning at age 18)100% paid by plan, no deductible or copay
    Routine Gynecological Exam (typically beginning at age 21; consult your physician)100% paid by plan, no deductible or copay
    Routine Mammogram (typically beginning at age 40; consult your physician)100% paid by plan, no deductible or copay
    Routine Prostate Specific Antigen (PSA) (typically beginning at age 50; consult your physician)100% paid by plan, no deductible or copay
    Routine Colorectal Cancer Screening (typically beginning at age 50; consult your physician)100% paid by plan, no deductible or copay
    Routine Developmental Screening (determined by physician)100% paid by plan, no deductible or copay
    Routine Immunizations (determined by Age; consult your physician)100% paid by plan, no deductible or copay
    Physician/Provider Office Services
    Primary Care Physician CopayMember pays $35 copay (deductible doesn't apply)
    Specialist Physician CopayMember pays $50 copay (deductible doesn't apply)
    Urgent Care CopayMember pays $50 copay (deductible doesn't apply)
    Maternity Visits100% paid by plan, no deductible or copay
    Diagnostic Testing (includes lab work, X-rays)No charge in office visit setting; 70% paid by plan, 30% paid by member (after deductible) outpatient setting.
    Hospital and Outpatient Facility Services
    Inpatient Facility Services70% paid by plan 30% paid by member after deductible
    Outpatient Facility Services (includes surgery, hemodialysis, IV therapy, chemotherapy, radiation treatment)70% paid by plan 30% paid by member after deductible
    Emergency Room Visits (Facility)70% paid by plan 30% paid by member after deductible
    Physical/Speech Therapy 70% paid by plan, 30% paid by member after deductible. Coverage is limited to 20 outpatient visits per year combined for Occupational and Physical therapy. Speech therapy is limited to 20 outpatient visits per year.
    Mental Health and Substance Abuse
    Inpatient70% paid by plan 30% paid by member after deductible
    OutpatientMember pays $35 copay for individual or group (deductible doesn't apply); 30% paid by member (after deductible) outpatient setting
    Prescription Drugs
    Pharmacy/Retail: Generic (30 day supply)$15 per prescription (retail), $25 per prescription (network pharmacies); Network Pharmacies limited to one time fill (deductible doesn't apply)
    Pharmacy/Retail: Brand (30 day supply)$35 per prescription (retail), $45 per prescription (network pharmacies); Network Pharmacies limited to one time fill (Deductible doesn't apply)
    Mail Order - Generic (90 day supply)$30 per prescription for a 31 to 90-day supply (Deductible doesn't apply)
    Mail Order - Brand (90 day supply)$70 per prescription for a 31 to 90-day supply (Deductible doesn't apply)
    Pharmacy/Retail: Specialty (30 day supply)Member pays 20% per prescription up to $150 maximum
  • Kaiser Oregon

    Additional Plan Information

    In-Network
    Annual Deductible
    Employee Only$1,000
    Family$3,000
    Annual Out-of-Pocket Maximum
    Employee Only$6,000
    Family$12,000
    Coinsurance
    70% paid by plan 30% paid by member
    Wellness/Preventive Services
    Well Child Exams (through 17 years)100% paid by plan, no deductible or copay
    Adult Physical Exams (beginning at age 18)100% paid by plan, no deductible or copay
    Routine Gynecological Exam (typically beginning at age 21; consult your physician)100% paid by plan, no deductible or copay
    Routine Mammogram (typically beginning at age 40; consult your physician)100% paid by plan, no deductible or copay
    Routine Prostate Specific Antigen (PSA) (typically beginning at age 50; consult your physician)100% paid by plan, no deductible or copay
    Routine Colorectal Cancer Screening (typically beginning at age 50; consult your physician)100% paid by plan, no deductible or copay
    Routine Developmental Screening (determined by physician)100% paid by plan, no deductible or copay
    Routine Immunizations (determined by Age; consult your physician)100% paid by plan, no deductible or copay
    Physician/Provider Office Services
    Primary Care Physician CopayMember pays $35 copay (deductible doesn't apply)
    Specialist Physician CopayMember pays $50 copay (deductible doesn't apply)
    Urgent Care CopayMember pays $50 copay (deductible doesn't apply)
    Maternity Visits100% paid by plan, no deductible or copay
    Diagnostic Testing (includes lab work, X-rays)Member pays $10 copay (deductible doesn't apply)
    Hospital and Outpatient Facility Services
    Inpatient Facility Services70% paid by plan 30% paid by member after deductible
    Outpatient Facility Services (includes surgery, hemodialysis, IV therapy, chemotherapy, radiation treatment)70% paid by plan 30% paid by member after deductible
    Emergency Room Visits (Facility)70% paid by plan 30% paid by member after deductible
    Physical/Speech Therapy $50 Copay per outpatient visit after deductible; for inpatient, member pays 30% after deductible; limited to 20 visits per therapy per calendar year
    Mental Health and Substance Abuse
    Inpatient70% paid by plan 30% paid by member after deductible
    OutpatientMember pays $35 copay for individual visit, $17 for group visit (deductible doesn't apply)
    Prescription Drugs
    Pharmacy/Retail: Generic (30 day supply)$15 Copay
    Pharmacy/Retail: Brand (30 day supply)$35 Copay
    Pharmacy/Retail: Specialty (30 day supply)Member pays 20% per prescription up to $150 maximum
    Mail Order - Generic (90 day supply)$30 Copay
    Mail Order - Brand (90 day supply)$70 Copay
  • Kaiser Mid-Atlantic

    Additional Plan Information

    In-Network
    Annual Deductible
    Employee Only$1,000
    Family$3,000
    Annual Out-of-Pocket Maximum
    Employee Only$6,000
    Family$12,000
    Coinsurance
    70% paid by plan 30% paid by member
    Wellness/Preventive Services
    Well Child Exams (through 17 years)100% paid by plan, no deductible or copay
    Adult Physical Exams (beginning at age 18)100% paid by plan, no deductible or copay
    Routine Gynecological Exam (typically beginning at age 21; consult your physician)100% paid by plan, no deductible or copay
    Routine Mammogram (typically beginning at age 50; consult your physician)100% paid by plan, no deductible or copay
    Routine Prostate Specific Antigen (PSA) (typically beginning at age 50; consult your physician)100% paid by plan, no deductible or copay
    Routine Colorectal Cancer Screening (typically beginning at age 50; consult your physician)100% paid by plan, no deductible or copay
    Routine Developmental Screening (determined by physician)100% paid by plan, no deductible or copay
    Routine Immunizations (determined by Age; consult your physician)100% paid by plan, no deductible or copay
    Physician/Provider Office Services
    Primary Care Physician CopayMember pays $35 copay (deductible doesn't apply)
    Specialist Physician CopayMember pays $50 copay (deductible doesn't apply)
    Urgent Care CopayMember pays $50 copay (deductible doesn't apply)
    Maternity VisitsNo Charge after confirmation of pregnancy
    Diagnostic Testing (includes lab work, X-rays)70% paid by plan 30% paid by member after deductible
    Hospital and Outpatient Facility Services
    Inpatient Facility Services70% paid by plan 30% paid by member after deductible
    Outpatient Facility Services (includes surgery, hemodialysis, IV therapy, chemotherapy, radiation treatment)70% paid by plan 30% paid by member after deductible
    Emergency Room Visits (Facility)Member pays $150 Copay (deductible doesn't apply)
    Physical/Speech Therapy Member pays $50 copay for outpatient visit (deductible doesn't apply); member pays 30% for inpatient visits (after deductible)
    Mental Health and Substance Abuse
    Inpatient70% paid by plan 30% paid by member after deductible
    OutpatientMember pays $35 copay for individual visit, $17 for group visit (deductible doesn't apply)
    Prescription Drugs
    Pharmacy/Retail: Generic$15 copay (Plan Pharmacy) $25 copay (Network Pharmacy)
    Pharmacy/Retail: Brand$35 copay (Plan Pharmacy) $45 copay (Network Pharmacy)
    Pharmacy/Retail: Non-Formulary Brand$35 copay (Plan Pharmacy) $45 copay (Network Pharmacy)
    Pharmacy/Retail: SpecialtyMember pays 20% per prescription up to $150 maximum
    Mail Order - Generic$30 copay (deductible doesn't apply)
    Mail Order - Brand$70 copay (deductible doesn't apply)
    Mail Order - Non-Formulary Brand$70 copay (deductible doesn't apply)
  • Kaiser Hawaii HMO

    Additional Plan Information

    In-Network
    Annual Deductible
    Employee Only$0
    Family$0
    Annual Out-of-Pocket Maximum
    Employee Only$2,500
    Family (3 or more members)$7,500
    Coinsurance
    90% paid by plan 10% paid by member
    Wellness/Preventive Services
    Well Child Exams (through age 21)Plan pays 100% Member pays 0%
    Adult Physical Exams (beginning at age 22)Plan pays 100% Member pays 0%
    Routine Gynecological Exam (no age restriction)Plan pays 100% Member pays 0%
    Routine Mammogram (one for women 35-39, then annually beginning at 40)Plan pays 100% Member pays 0%
    Routine Prostate Specific Antigen (PSA) (one per calendar year after 50)Member pays $10
    Routine Colorectal Cancer Screening (for adults over 50)Plan pays 100% Member pays 0%
    Routine Developmental ScreeningNot Covered
    Routine Immunizations (no age restrictions)Plan pays 100% Member pays 0%
    Physician/Provider Office Services
    Primary Care Physician CopayMember pays $20 copay
    Specialist Physician CopayMember pays $20 copay
    Urgent Care CopayMember pays $20 copay
    Out-of-Area Urgent CareMember pays 20% of applicable charges at a non-Kaiser Permanente facility outside the Hawaii service area
    Maternity VisitsNo charge per confirmed pregnancy
    Diagnostic Testing (includes lab work, X-rays)Member pays $10 per day for basic labs / 20% for complex, outpatient labs
    Hospital and Outpatient Facility Services
    Inpatient Facility ServicesPlay pays 90% Member pays 10%
    Outpatient Facility Services (includes surgery, hemodialysis, IV therapy, chemotherapy, radiation treatment)Play pays 90% Member pays 10%
    Emergency Room Visits (Facility)Member pays $100 copay / visit
    Physical/Speech Therapy Member pays $20 copay per outpatient visit; member pays 10% for inpatient visit
    Mental Health and Substance Abuse
    InpatientPlay pays 90% Member pays 10%
    OutpatientMember pays $20 copay per visit
    Prescription Drugs
    Pharmacy/Retail: Generic Maintenance Medication$5
    Pharmacy/Retail: Other Generic$15
    Pharmacy/Retail: Brand$50
    Pharmacy/Retail: Specialty$75
    Mail Order - Generic Maintenance Medication (90 day supply)$10
    Mail Order - Other Generic (90 day supply)$30
    Mail Order - Brand (90 day supply)$100
  • Kaiser Hawaii POS

    Additional Plan Information

    KP Plan Provider (HMO) Contracted Provider (CON) Noncontracted Provider (NonCON)
    Annual Deductible
    Employee Only$0$100$100
    Family$0$300$300
    Annual Out-of-Pocket Maximum
    Employee Only$2,000$2,000$2,000
    Family$6,000$6,000$6,000
    Coinsurance
    Plan pays 90% Member pays 10% Plan pays 80% Member pays 20% ; of Maximum Allowable ChargePlan pays 80% Member pays 20% ; of Maximum Allowable Charge
    Wellness/Preventive Services
    Well Child Exams (through age 21)Plan pays 100% Member pays 0%Plan pays 100% Member pays 0%Plan pays 100% Member pays 0%
    Adult Physical Exams (beginning at age 22)Plan pays 100% Member pays 0%Plan pays 100% Member pays 0%Plan pays 100% Member pays 0%
    Routine Gynecological Exam (no age restriction)Plan pays 100% Member pays 0%Plan pays 100% Member pays 0%Plan pays 100% Member pays 0%
    Routine Mammogram (one for women 35-39, then annually beginning at 40)Plan pays 100% Member pays 0%Plan pays 100% Member pays 0%Plan pays 100% Member pays 0%
    Routine Prostate Specific Antigen (PSA) (one per calendar year after 50)Member pays $10Plan pays 100% Member pays 0%Plan pays 100% Member pays 0%
    Routine Colorectal Cancer Screening (for adults over 50)Plan pays 100% Member pays 0%Plan pays 100% Member pays 0%Plan pays 100% Member pays 0%
    Routine Developmental ScreeningNot CoveredNot CoveredNot Covered
    Routine Immunizations (no age restrictions)Plan pays 100% Member pays 0%Plan pays 100% Member pays 0%Plan pays 100% Member pays 0%
    Physician/Provider Office Services
    Primary Care Physician CopayMember pays $20 copayPlan pays 80% Member pays 20% after deductiblePlan pays 80% Member pays 20% after deductible
    Specialist Physician CopayMember pays $20 copayPlan pays 80% Member pays 20% after deductiblePlan pays 80% Member pays 20% after deductible
    Urgent Care Copay$20 copay at Kaiser within Hawaii region/ 20% at non-Kaiser facility outside of HICovered under HMO benefitCovered under HMO benefit
    Maternity VisitsPlan pays 100% for routine maternity visitsPlan pays 100% for routine maternity visitsPlan pays 100% for routine maternity visits
    Diagnostic Testing (includes lab work, X-rays)Member pays $10 per day for basic / 20% for complexPlan pays 80% Member pays 20% after deductiblePlan pays 80% Member pays 20% after deductible
    Hospital and Outpatient Facility Services
    Inpatient Facility ServicesPlan pays 90% Member pays 10% Plan pays 80% Member pays 20% after deductiblePlan pays 80% Member pays 20% after deductible
    Outpatient Facility Services (includes surgery, hemodialysis, IV therapy, chemotherapy, radiation treatment)Member pays $50 copayPlan pays 80% Member pays 20% after deductiblePlan pays 80% Member pays 20% after deductible
    Emergency Room Visits (Facility)Member pays $100 copayCovered under HMO benefitCovered under HMO benefit
    Physical/Speech Therapy Member pays 10% for inpatient visits; member pays $20 per outpatient visitPlan pays 80% Member pays 20% after deductiblePlan pays 80% Member pays 20% after deductible
    Mental Health and Substance Abuse
    InpatientPlan pays 90% Member pays 10% Plan pays 80% Member pays 20% after deductiblePlan pays 80% Member pays 20% after deductible
    OutpatientMember pays $20 per visitPlan pays 80% Member pays 20% after deductiblePlan pays 80% Member pays 20% after deductible
    Prescription Drugs
    Pharmacy/Retail: Generic Maintenance Medication$520% of charge but not less than stated copay value per prescription of each given category (mail order n/a)not covered
    Pharmacy/Retail: Other Generic$1520% of charge but not less than stated copay value per prescription of each given category (mail order n/a)not covered
    Pharmacy/Retail: Brand$5020% of charge but not less than stated copay value per prescription of each given category (mail order n/a)not covered
    Pharmacy/Retail: Specialty$7520% of charge but not less than stated copay value per prescription of each given category (mail order n/a)not covered
    Mail Order - Generic Maintenance Medication (90 day supply)$1020% of charge but not less than stated copay value per prescription of each given category (mail order n/a)not covered
    Mail Order - Other Generic (90 day supply)$3020% of charge but not less than stated copay value per prescription of each given category (mail order n/a)not covered
    Mail Order - Brand (90 day supply)$10020% of charge but not less than stated copay value per prescription of each given category (mail order n/a)not covered