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2026 Kaiser Permanente HMO (California)

Kaiser Permanente is a Health Maintenance Organization (HMO) that provides patient services, hospitalization, supplies, and prescription drugs through its own network of doctors, hospitals, and other Kaiser-affiliated health care facilities.

Plan Details

Group #: 7145 (Northern CA), Group #: 230178 (Southern CA)

You may use only Kaiser Permanente doctors and facilities except in emergencies. This document is a summary. 

Please refer to the plan Evidence of Coverage (EOC) for more details.

Plan Information

Plan Year:

Offered To:

Employees

Full-Time Employee * Contribution Per Pay Period:

Employee Only - $0.00
Employee & Spouse/Registered Domestic Partner - $221.00
Employee & Child(ren) - $189.50
Employee & Family - $305.50

Part-Time Employee * Contribution Per Pay Period:

Employee Only - $292.45
Employee & Spouse/Registered Domestic Partner - $724.63
Employee & Child(ren) - $621.14
Employee & Family - $1,000.83

Basics

Pre-Authorization Requirement:

Pre-authorization is required for all elective inpatient and outpatient procedures.
PENALTY for not pre-authorizing: not covered.

Care Management:

Kaiser Permanente’s Complete Care℠, is a comprehensive multidisciplinary approach to identifying and treating members with chronic conditions. It addresses a wide range of chronic and acute conditions and comorbidities with a focus on prevention, risk reduction, and self-care. The program is integrated into the patient-centered, “whole person” continuum of care provided.

Program features include: Multidisciplinary disease management and case management; sophisticated electronic health information management and disease registries; proactive, targeted screening, intervention, and outreach; extensive support for implementing best practices and improved panel management; member self-care tools for improving health and quality of life; and health education to support self-management.

Deductible:

No deductible

Office co-pay:

$30 copay primary/$50 copay specialist

Coinsurance:

100% covered after applicable copays

Out-of-Pocket Maximum:

$3,500 per individual (in single employee enrollment or in family enrollment)
$7,000 family
A single Out-of-Pocket Maximum applies to all coverage under the plan, including medical and prescription drugs. (This will cover prescriptions and medical expenses at 100% once the Out-of-Pocket Maximum is met.)

Overall Lifetime Maximum Benefit:

No Maximum

Maternity

Maternity Hospital Stay:

$150 copay per admission

Baby's First Exam:

100%

Birthing Centers:

100%

Midwives:

100% in hospital; if outpatient routine prenatal visit: No Charge
If midwife is available at Kaiser Permanente

Doulas:

11 visit limit per pregnancy:
*One initial visit.
*Up to eight additional visits that can be provided in any combination of prenatal and postpartum visits.
*Up to two additional postpartum visits may be available after the end of a pregnancy.

Support during labor and delivery, including abortions, miscarriages, or labor and delivery resulting in a stillbirth.

Prenatal and Postnatal Physician Office Visits:

Network: 100%
Non-Network: Not Covered

Doctor Delivery Charge:

100%

Reproductive Health:

$50 copay/per visit

Mental Health/Autism/Substance Abuse

Mental Health:

Kaiser Permanente must approve mental health care.

INPATIENT CARE
$150 copay per admission
No charge - Partial hospitalization

OUTPATIENT CARE
[no visit limit]
$30 copay per visit, individual
$15 copay per visit, group
No charge - Other intensive psychiatric treatment

RESIDENTIAL TREATMENT
No charge

Substance Abuse:

INPATIENT DETOXIFICATION
$150 copay per admission

OUTPATIENT CARE
[no visit limit]
$30 copay per visit, individual
$5 copay per visit, group
No charge for intensive outpatient and day treatment programs
No charge for Methadone maintenance treatment

Transitional Residential Recovery Services
$150 copay per admission

Autism:

Behavioral health treatment for pervasive developmental disorder or autism (including applied behavior analysis and evidence-based behavior intervention programs) that develops or restores, to the maximum extent practicable, the functioning of a person with pervasive developmental disorder or autism that meets Kaiser's established criteria (refer to Evidence of Coverage booklet for specifics).

Covered at 100%

Prescription Drugs

Pharmacy (Retail):

KAISER PERMANENTE PHARMACY
Generic: $10 for up to a 30-day supply; $20 for a 31- to 60-day supply; or $30 for a 61- to 100-day supply

Brand: $40 for up to a 30-day supply; $80 for a 31- to 60-day supply; or $120 for a 61- to 100-day supply

Specialty Rx 10% with a max of $200

Mail order drug program:

KAISER PERMANENTE MAIL ORDER PHARMACY
Generic: $20 for up to a 100-day supply

Brand: $80 for up to 100 day supply; Some Specialty drugs are available via mail order, but there is no incentive, as you will be paying for the full 100-day supply.

Specialty drugs are not available via mail order.

Birth Control Pills:

Included in Prescription Drug benefit, covered at 100%

Preventive Care

Physical exams for adults:

100%

Physical exams for children:

100%

Pap smears:

100%

Mammograms:

100%

Immunizations:

100%
Office visit copay applies if provided during doctor's office visit

Prostate Specific Antigen test - PSA:

100%

Well-woman visits:

100%

Other Services

Acupuncture:

At a Kaiser facility:
$30 copay/visit
Referral required - limited basis by referral only as part of a comprehensive pain management program or for the treatment of nausea.

Using the American Specialty Health (ASH) network:
$20 copay/visit for up to 40 combined chiropractic and acupuncture visits per year.
No referral required.

Allergy Tests:

$50 copay specialist

Allergy Treatment:

$5 copay for injections

Alternative Medicine:

Not covered

Ambulance charges:

100% after $50 copay/per trip

CT and PET Scans (Complex Imaging):

100%

Chiropractors:

$20 copay

Up to 40 combined chiropractic and acupuncture visits per year.

American Specialty Health (ASH) Plans Participating Chiropractors

Christian Science Practitioners:

Not covered

Cosmetic Surgery:

Not covered

Dental Treatment:

Not covered

Emergency Room:

$200 copay (waived if admitted)
Out-of-Network: $200

Urgent Care:

$30 copay at Kaiser Permanente facility
Not covered at non-Kaiser facilities, but can be covered only for medically necessary services.

Hearing Care:

Exam: Hearing exams with an audiologist to determine the need for hearing correction - $30 copay

Physician Specialist Visits to diagnose and treat hearing problems - $50 Copay

Hearing Aid: $3000 limit per ear every 36 months

Home Health Care:

100%
Up to 100 two-hour visits/calendar year
[3 visits per day max]

Hospice Care:

100%

Hospital Stay:

$150 copay per admission

Infertility Treatment:

Diagnosis and treatment of Infertility:
Office Visits: $30 per visit
Outpatient: $150 per procedure
Inpatient: $150 per hospitalization
Fertility Drugs: Covered under drug benefits
Oocyte retrievals limited to three per lifetime
Transfer of fresh and cryopreserved embryo(s)

*Artificial insemination and ovulation induction are covered regardless of partner status and without a diagnosis of infertility.

Kaiser Permanente complies with Senate Bill 729, which mandates coverage of the diagnosis and treatment of infertility and fertility services. See the addendum EOC for more details including cryopreservation and storage benefits as part of covered Fertility Services.

Laboratory Charges:

100%

Magnetic Resonance Imaging (MRI) (Complex Imaging):

100%

Durable Medical Equipment:

100%

Occupational Therapy:

$30 copay

Organ Transplants:

Contact Kaiser Permanente for information on transplant coverage benefits.

Skilled Nursing:

100% (Up to 100 days)

Physical Therapy:

$30 copay

Prosthetic & Orthotic Devices:

Base formulary and special footwear covered at no charge upon referral. See Evidence of Coverage or contact Kaiser for more details.

Speech Therapy:

$30 copay

Surgery : Facility Charges:

INPATIENT
$150 copay per admission

OUTPATIENT
$150 copay per procedure

Surgery : Physician Services:

INPATIENT
Covered under hospital copay

OUTPATIENT
$150 copay per procedure

Transgender Services:

Call Kaiser Nor CA 510-752-7149 or So CA 323-857-3818 for resources.
Kaiser offers a broad range of covered gender-affirming care services:
• Mental health care
• Office visits
• Lab and imaging services
• Hormone therapy visits and administration
• Pharmacy services
• Preoperative and postoperative exams
• Facial hair removal
• Vocal therapy
• Tracheal shave
• Mastectomy with chest reconstruction and gender-affirming chest surgery
• Gender-affirming facial surgery
• Gender-affirming genital surgeries
• Inpatient hospital care
• Outpatient care
• Treatment for medical complications
• Travel and lodging (when referred by Kaiser Permanente to a facility outside your region)

Travel and Lodging:

Contact the plan for details

Tubal Ligation:

INPATIENT
100%

OUTPATIENT
100%

Vasectomy:

$150 copay per procedure

Vision care:

100%
Eye exams only

X-rays (Basic Imaging):

100%

Plan Documents

Additional Plan Resources and Services

Your Kaiser HMO CA plan provides services in California only. The Kaiser HMO HI plan provides services for those living in Hawaii. You may also visit Kaiser locations in other states we are not contracted with on a guest basis. You receive no coverage for routine services outside the service area. Kaiser provides “Emergency Care” coverage anywhere you may experience an emergency that is life-threatening in nature. 

If you need to file a claim for emergency care received while overseas, download the Kaiser emergency claim form or contact Kaiser to have an emergency claim form sent to you.