Kaiser Northern CA HMO Summary

Plan Summary: Kaiser Northern CA HMO

Kaiser Northern California
Plan Type Health Maintenance Organization (HMO)
Deductible (Ind/Fam) $500/$1,000
OOP Max (Ind/Fam) $3,000/$6,000 (includes prescription drug copays)
Annual Maximum None
Coinsurance 90%
Preventive Office Visit (OV) Covered in Full
PCP OV Copay $20
Specialist OV Copay $20
Prenatal OV Visits Covered in Full
Diagnostic Tests Covered in Full
Hospital Admission 90% after deductible
Inpatient Surgery  90% after deductible
Outpatient Surgery  90% after deductible
Emergency Room  90% after deductible
Mental Health – Inpatient  90% after deductible
Mental Health – Outpatient $20 copay
Substance Abuse – Inpatient  90% after deductible
Substance Abuse – Outpatient $20 copay
Mammograms Covered in Full
Colonoscopy Covered in Full
Physical Therapy $20 copay
Prescription Drugs
Out-of-Pocket Maximum: Combined with Medical
 Retail Copays (31-day supply)  Mail Order Copays (90-day supply)
Generic $10 $20
Preferred $30 $60
Non-Preferred $30 $60