What you need to know
In a health maintenance organization (HMO), you and each covered dependent must choose a primary care physician (PCP) within the HMO network. The PCP coordinates all your care with providers within the HMO network.
How the Kaiser HMO plan works
Pay nothing for preventive care in the HMO network. That includes services like screenings, immunizations, and exams.
You pay only copays when you get care. And there’s no coinsurance to pay, either.
Care outside the HMO network isn’t covered. Unless it’s an emergency situation.
Copays count toward the out-of-pocket maximum. Once you meet the out-of-pocket maximum, the plan pays 100% of covered services for the rest of the year.
Pharmacy benefits are provided by the HMO. You pay a copay for generic, brand, and non-brand prescriptions at in-network pharmacies. But prescriptions filled at an out-of-network pharmacy aren’t covered by the plan.
Certain medications cost nothing for Kaiser HMO members. Prescriptions for medications to treat diabetes, high blood pressure, and high cholesterol are provided at no cost to Kaiser HMO members when they are filled by in-network pharmacies.
Kaiser HMO plan at a glance
You can enroll in the Kaiser HMO if you live in California. Find out more about what this plan has to offer.
Kaiser HMO (CA)
Network: Kaiser facilities and physicians only
Annual deductible: None
Out-of-pocket maximum: $1,500 individual/$3,000 family (includes office visit and prescription copays)
Coinsurance (plan pays): None
Emergency room: $100 copay (waived if admitted)*
Doctor office or MinuteClinic visits**: $20 copay
Specialist office visits: $35 copay
Annual physical exams: $0
Diagnostic X-ray/lab: $0
*If services are not a true emergency, applicable hospital benefits apply based on the provider’s network status.
**MinuteClinics can treat minor illnesses and injuries, including the flu, ear infections, pink eye, small wounds, abrasions, and sprains. To find a MinuteClinic, visit minuteclinic.com.