Plan Details
Plan Name	Kaiser HDHP
Effective Dates	Jan 01, 2024 to Jan 01, 2025
Benefits	In-Network
Annual Deductible/Individual	$1,600 $3200 for any one member within a family enrollment
Annual Deductible/Family	$3,200
Coinsurance	0%
Office Visit/Exam	$20 after deductible
Outpatient Specialist Visit	$20 after deductible
Annual Out-of-Pocket Limit/Individual	$3,200 $3200 for any one member within a family enrollment
Annual Out-of-Pocket Limit/Family	$6,400
Preventive Care	0%
Inpatient Hospitalization	$250 /admission after deductible
Surgical Services Outpatient Facility Charge	$150 /procedure after deductible
Emergency Room	$100 after deductible
Urgent Care Facility	$20 after deductible
Prescription Drug Deductible	combined with medical deductible
Prescription Drugs - Generic	$10 after deductible
Prescription Drugs - Brand (Formulary/Preferred)	$30 after deductible
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	$30 after deductible
Prescription Drugs - Specialty	30% up to $100 after deductible
Chiropractic Services	$15 20 visits per year
Acupuncture	Referral required