Under this Kaiser-administered plan, you can choose any healthcare provider within one single statewide network. It is recommended that you select a Primary Care Physician to direct your care. In most cases, referrals are required. However, you may self-refer to certain specialists. In place of a deductible, enrollees will be responsible for a copay for medical visits, diagnostic testing and hospital/facilities services.

Out-of-network care is not covered except for emergency and/or urgent care.

  Plan details

  Covered providers and medications

Out-of-area benefit for dependents only

This benefit applies to services listed in the Summary Chart (page 128 of Benefits Booklet).

Office visit
Primary care, Specialty, Mental Health/Chemical Dependency, Well Child prevention, Gynocological and Allergy injection visits are covered. All other visits are not covered. 
Office visit limits (procedures and labs are excluded) 5 visits per plan year
Diagnostic X-ray service limits (X-ray and Ultrasound only) 20% coinsurance
5 per plan year
Prescription Drug  Brand/Generic
Physical, Occupational & Speech Therapies 5 combined visits per plan year




Features and considerations
Plan type EPO - Kaiser network
Deductible $0
Out-of-pocket limit $7,900/Individual; $15,800/Family
Office visit PCP - $30/visit
Specialist - $40/visit
Urgent Care - $30/visit
Emergency care $250 (waived if admitted)
Prescription drug (Rx)
30-day supply

Generic: $15
Non-Preferred Brand: Not Covered

Preferred Brand: $35
Specialty: 20% of cost up to $75
Mail Order (Rx)
90-day supply
Cost Savings: 90-day supply for the prices of a 60-day supply