Kaiser HMO N. CA
The Kaiser Health Maintenance Organization (HMO) Plan is only available to employees who work or 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
|Annual Deductible||No deductible||No deductible|
|Annual Out-of-Pocket (OOP) Maximum1||Individual: $1,500
|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||Not Covered|
|Ambulance||$50 per trip||Not Covered|
|Hospitalization||$250 co-pay per admit||Not Covered|
|Chiropractic||$15 co-pay per visit
Up to 30 visits per year
|Acupuncture||$15 co-pay per visit
|Physical Therapy||100% if inpatient
$15 per visit if outpatient
|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
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.
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)
|$10/$20/$20 co-pay||Not Covered|
|Mail Order (100-day supply)
|100 day supply
Employee Contributions for 2017
Per Paycheck Rates
|Plan||Employee Only||Employee +
|Employee + Child(ren)||Employee + Family|
|Kaiser HMO N. CA||$46.06||$119.76||$101.33||$181.17|
Per paycheck contributions are 24 times per year.
- 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) and your spouse’s / domestic partner’s child(ren), your foster child(ren) are eligible for medical coverage until age 26, regardless of student status.
For more details see the Kaiser HMO N.CA Summary of Benefits and Coverage (SBC).
1-888-VMWARE8, option ‘US Benefits’
Benefits Contact Quick Reference Guide
Domestic Partner Imputed Income Rate Table
Kaiser HMO N. CA 2016 Documents
Kaiser HMO N. CA Benefit Summary 2017
Kaiser HMO N. CA Chiropractic Benefit 2017
Kaiser HMO N. CA Emergency Claim Form
Kaiser HMO N. CA Pharmacy Refill Form
Kaiser HMO N. CA Summary of Benefits and Coverage (SBC) 2017
Kaiser Mobile Health Vehicle
Kaiser Mobile Health Vehicle Q&A
Kaiser Pharmacy Refill Form