Kaiser HMO N. CA

The Kaiser Health Maintenance Organization (HMO) Plan is only available to employees who live within Kaiser’s Northern California region service area. With the Kaiser HMO N. CA plan, you must see providers within the Kaiser network (except in an emergency). The plan requires that you select a Primary Care Physician (PCP) to coordinate all your healthcare needs, including arranging for hospitalization and referrals to specialists. Visit Find a Doctor to see if your provider is in-network.

With the Kaiser HMO N. CA plan, you are eligible to enroll in the General Purpose Flexible Spending Account (GPFSA) for your out-of-pocket expenses.

Kaiser HMO N. CA Plan Details

In-Network Out-of-Network
Annual Deductible No deductible No deductible
Annual Out-of-Pocket (OOP) Maximum1 Individual: $1,500
Family: $3,000
Not Covered
Employee Coinsurance Applies to certain medical procedures only Not Covered
Preventive (Annual Physicals, Well Care Exams) 100% covered, not subject to co-pay Not Covered
Physician Visits $15 per visit Not Covered
Lab and X-Ray 100% if part of office visit Not Covered
Emergency Room $50 per visit $50 per visit
Ambulance $50 per trip $50 per trip
Hospitalization $250 co-pay per admit Not Covered
Chiropractic $15 co-pay per visit
Up to 30 visits per year
Not Covered
Acupuncture $15 co-pay per visit
Referral required
Not Covered
Speech Therapy2 $15 co-pay per visit for covered cases Not Covered
Infertility/Fertility Preservation 50% coinsurance per visit
(Does not include GIFT, ZIFT or IVF)3
Not Covered

1 OOP maximum includes Prescription Rx.
2 Available to those with conditions of medical necessity.
3 GIFT is a gamete intrafallopian transfer. ZIFT is a zygote intrafallopian transfer. IVF is in-vitro fertilization.

Prescription Rx

Coverage for prescription drugs is included when you enroll in the Kaiser HMO N. CA plan. In general, generic and brand name prescriptions filled at a retail pharmacy are limited to a 30-day supply. Prescriptions filled through the mail order program may be up to a 100-day supply. However, mail order may be reduced to a 30-day supply for specific drugs.

Prescription Plan Details

In-Network Pharmacy Out-of-Network Pharmacy
Retail (30-day supply)
Generic/Brand/Non-Formulary
$10/$20/$20 co-pay Not Covered
Mail Order (100-day supply)
Generic/Brand/Non-Formulary
$20/$40/$40 co-pay Not Covered

 

Employee Contributions for 2018

Per Paycheck Rates

Plan Employee Only Employee +
Spouse/Domestic Partner
Employee + Child(ren) Employee + Family
Kaiser HMO N. CA $72.38 $159.23 $137.52 $231.61

Per paycheck contributions are 24 times per year.

Dependent Eligibility

  • Your spouse or domestic partner. Please note: after tax contributions and imputed income may apply when covering a domestic partner. See the Domestic Partner Imputed Income Rate Table for details
  • Your child(ren), your spouse’s / domestic partner’s child(ren), your foster child(ren), the minor(s) you have legal guardianship of are eligible for medical coverage until age 26, regardless of marital or student status.

For more details see the Kaiser HMO N.CA Summary of Benefits and Coverage (SBC).

Contact Us

HR Source
Phone: 1-888-VMWARE8, option ‘US Benefits’
ASK HR [VMware network access required]
HRSource@vmware.com


Kaiser
Phone: 1-800-464-4000
Visit website

Resources

Benefits Contact Quick Reference Guide
Domestic Partner Imputed Income Rate Table
Kaiser HMO N. CA Benefit Summary 2017
Kaiser HMO N. CA Chiropractic Benefit 2017
Kaiser HMO N. CA Chiropractic Evidence of Coverage (EOC) 2018
Kaiser HMO N. CA Emergency Claim Form
Kaiser HMO N. CA Evidence of Coverage (EOC) 2018
Kaiser HMO N. CA Pharmacy Refill Form
Kaiser HMO N. CA Summary of Benefits and Coverage (SBC) 2017
Kaiser HMO N. CA Summary of Benefits and Coverage (SBC) 2018
Kaiser Mobile Health Vehicle
Kaiser Mobile Health Vehicle Location
Kaiser Mobile Health Vehicle Q&A
Kaiser Pharmacy Refill Form
Travel Outside Kaiser Areas