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Comparison Tool

2020 Plans & Contribution Rates



Medical Plans

Compare medical plans available for each of these roles:

Dental Plans

Compare dental plans available for each of these roles:

Vision Plan

Compare vision plans available for each of these roles:

Full Plan Costs

Compare the premium costs for each of these roles:

Active Employees

Retirees

Active employees may select one of two offered dental plans.
Stanford offers one dental plan for all eligible retirees.

Kaiser Permanente HMO (California) Group #7145 (Northern CA) Group #230178 (Southern CA) - 2020

Ratings
National Committee For Quality Assurance (NCQA)
Up to four stars are given for each of the following criteria:
Overall Accredition Status: 
Accredited
Access & Services: 
3
Qualified Providers: 
4
Staying Healthy: 
2
Getting Better: 
1
Living With Illness: 
4
Basics

You may use only Kaiser Permanente doctors and facilities except in emergencies.

Description: 
Kaiser
Full-Time Employee * Contribution Per Pay Period: 

Employee Only: $0 
Employee & Spouse/Registered Domestic Partner: $143.87
Employee & Children: $123.32
Employee & Family: $198.68

Part-Time Employee * Contribution Per Pay Period: 

Employee Only: $190.31
Employee & Spouse/Partner: $471.57
Employee & Children: $404.21
Employee & Family: $651.22

Pre-Authorization Requirement: 

Pre-authorization 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 co-pay primary/$50 co-pay specialist

Coinsurance: 

100% after applicable co-pays

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: 

No maximum

Maternity
Maternity Hospital Stay: 

$150 co-pay per admission

Baby's First Exam: 

100%

Birthing Centers: 

100%

Midwives: 

100% in hospital; if out-patient office visit: $30 co-pay

If midwife is available at Kaiser Permanente

Prenatal Visits: 

100%

Doctor Delivery Charge: 

100%

Pregnancy Termination: 

$50 co-pay

Mental Health/Substance Abuse
Mental Health: 

Kaiser Permanente must approve mental health care.
INPATIENT CARE
$150 co-pay per admission

OUTPATIENT CARE
[no visit limit]
$30 co-pay per visit, individual
$15 co-pay per visit, group

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 meet Kaiser's established criteria (refer to Evidence of Coverage booklet for specifics). The cost sharing for individual and group visits under this Mental Health section apply.

Substance Abuse: 

INPATIENT DETOXIFICATION
$150 co-pay per admission

OUTPATIENT CARE
[no visit limit]
$30 co-pay per visit, individual
$5 co-pay per visit, group

Transitional Residential Recovery Services
$150 co-pay per admission

Other Services (A-D)
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: 

$30 co-pay

Allergy Treatment: 

$5 co-pay for injections

Alternative Medicine: 

Not covered

Ambulance charges: 

100% after $50 co-pay

CAT Scans: 

100%

Chiropractors: 

$20 co-pay

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

Other Services (E-N)
Emergency Room: 

$200 co-pay (waived if admitted)

Urgent Care: 

$30 co-pay at Kaiser Permanente facility

Hearing Care: 

Exam 100%

Hearing aids not covered

Home Health Care: 

100%

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

Hospice Care: 

100%

Hospital Stay: 

$150 co-pay per admission

Infertility Treatment: 

50%

Fertility Drugs: Covered under drug benefits at 50%; In Vitro, GIFT, and ZIFT: Not covered.

Laboratory Charges: 

100%

Magnetic resonance imaging - MRI: 

100%

Durable Medical Equipment: 

100%

Other Services (O-Z)
Occupational Therapy: 

$30 co-pay

Organ Transplants: 

Contact Kaiser Permanente for information on transplant coverage benefits

Skilled Nursing: 

100% (Up to 100 days)

Physical Therapy: 

$30 co-pay

Surgery : Physician Services: 

INPATIENT
Covered under hospital co-pay

OUTPATIENT 
$150 co-pay per procedure

Surgery : Facility Charges: 

INPATIENT
$150 co-pay per admission

OUTPATIENT
$150 co-pay per procedure

Speech Therapy: 

$30 co-pay

Tubal Ligation: 

INPATIENT
100%

OUTPATIENT
100%

Vasectomy: 

$150 co-pay per procedure

X-rays: 

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

Mail order drug program: 

KAISER PERMANENTE MAIL ORDER PHARMACY
Generic:  $20 for up to 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.  

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 co-pay applies if provided during doctor office visit

Prostate Specific Antigen test - PSA: 

100%

Well-woman visits: 

100%

Vision care: 

100%

Eye exams only. Discount program available for vision hardware

Stanford HealthCare Alliance Plan - Group # 868025 - 2020

Ratings
National Committee For Quality Assurance (NCQA)
Up to four stars are given for each of the following criteria:
Overall Accredition Status: 
Not reported by NCQA
Access & Services: 
4
Qualified Providers: 
0
Staying Healthy: 
0
Getting Better: 
0
Living With Illness: 
0
Basics

The Stanford HealthCare Alliance ACO plan requires you designate a primary care provider to coordinate all of your care.  You may visit any Stanford HealthCare Alliance network doctor or hospital.  Some services require prior authorization from your primary care physician.

There is no benefit if you see a Non-Network provider, except for emergency care or when clinically appropriate and prior authorized by Stanford HealthCare Alliance and Outpatient mental health office visits (see Mental Health section).

Description: 
SHCA
Full-Time Employee * Contribution Per Pay Period: 

Employee Only: $40.00
Employee & Spouse/Registered Domestic Partner: $255.55
Employee & Children: $221.96
Employee & Family: $331.96

Part-Time Employee * Contribution Per Pay Period: 

Employee Only: $375.35
Employee & Spouse/Registered Domestic Partner: $860.15
Employee & Children: $737.27
Employee & Family: $1,187.81

Pre-Authorization Requirement: 

Prior authorization is required for the following services:  Advanced Imaging (CT, MRI, MRA and PET); all electively scheduled inpatient hospital admissions, all elective outpatient procedures (example – endoscopic procedures, arthroscopic procedures, epidural steroid injections, etc); other procedures and services as defined on the pre-certification requirement list.
 

Referral Requirement
Visits to a specialist will now require a referral from your designated PCP.  This includes any specialist you are currently seeing for ongoing care or for new patient visits.  Visits to a specialist without a PCP referral may be denied due to lack of referral.  Exception:  Well-woman exams with an OB/GYN do not require a referral.

Care Management: 

Participation in care management required for certain conditions and diseases.

Deductible: 

No deductible

Office co-pay: 

$30 co-pay primary/$75 co-pay specialist

Coinsurance: 

100% after applicable co-pays

Out-of-Pocket Maximum: 

$3,500 per individual/$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.) There is no benefit if you see a Non-Network provider, except for outpatient professional mental health and substance abuse care, emergency care, or when clinically appropriate and prior authorized.

Overall Lifetime Maximum: 

No maximum

Maternity
Maternity Hospital Stay: 

$150 co-pay per admission

Baby's First Exam: 

100%

Birthing Centers: 

$150 co-pay per admission

Midwives: 

100%

If the midwife is part of the Stanford HealthCare Alliance network.

Prenatal Visits: 

100%

Doctor Delivery Charge: 

100%

Pregnancy Termination: 

$125 co-pay

If hospitalized, the Hospital Stay co-payment will also apply.

Mental Health/Substance Abuse
Mental Health: 

Stanford HealthCare Alliance must approve mental health care.

INPATIENT CARE
$150 co-pay per admission

ROUTINE OUTPATIENT CARE
[no visit limit]
Network: $30 co-pay per visit
Non-Network: 80% of billed charges (up to $300 maximum allowed charges) for professional services only.

The maximum allowed amount will not exceed $300 for each office visit.  For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.

Autism: 

Behavioral health treatment (BHT) consists of professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based behavior intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorders or autism. Prior authorization for BHT or ABA services is required. Plan mental health cost sharing applies.

Substance Abuse: 

Pre-certification is required by you or your provider.

INPATIENT CARE
$150 co-pay per admission

ROUTINE OUTPATIENT CARE
[no visit limit]
Network: $30 co-pay per visit
Non-Network: 80% of billed charges (up to $300 maximum allowed charges) for professional services only.

The maximum allowed amount will not exceed $300 for each office visit.  For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.

Other Services (A-D)
Acupuncture: 

$30 co-pay

Up to 20 visits per year

Network providers only

Allergy Tests: 

100%

Office co-pay may apply.

Allergy Treatment: 

100%

Office co-pay may apply.

Alternative Medicine: 

Not covered

Ambulance charges: 

100% after $50 co-pay

CAT Scans: 

10%  coinsurance **Pre authorization required

Chiropractors: 

$30 co-pay

Up to 20 visits per year

Network providers only

Christian Science Practitioners: 

Not covered

Cosmetic Surgery: 

Not covered

Dental Treatment: 

Coverage limited to certain conditions only. Contact Stanford Health Care Alliance member services for more information.

Other Services (E-N)
Emergency Room: 

$200 co-pay (waived if admitted)

Urgent Care: 

Office visit co-payment, specialist visit co-payment, or Emergency Room co-payment, depending on the facility.

Hearing Care: 

Exam $75 co-pay

Hearing aids not covered

Home Health Care: 

100%

Hospice Care: 

100%

Hospital Stay: 

Pre-Certification required by you or your provider. $150 co-pay per admission

Infertility Treatment: 

Network: 50% of Stanford Health Care Alliance allowed charges for professional and diagnostic services; limited to three cycles of intrauterine insemination (IUI).

In Vitro, GIFT, and ZIFT: Not covered

Fertility drugs: see Pharmacy

Laboratory Charges: 

100%

Magnetic resonance imaging - MRI: 

10% co-insurance.  **pre authorization required

Durable Medical Equipment: 

100% **pre authorization requirement

Other Services (O-Z)
Occupational Therapy: 

$40 co-pay

Organ Transplants: 

Contact Stanford Health Care Alliance member services for information on transplant coverage benefits

Skilled Nursing: 

$150 co-pay per admission

Up to 100 days per calendar year

Physical Therapy: 

$40 co-pay **pre authorization requirement

Surgery : Physician Services: 

INPATIENT
Covered under hospital co-pay

OUTPATIENT
Office visit co-pay may apply

Surgery : Facility Charges: 

INPATIENT
$150 co-pay per admission

OUTPATIENT
$150 co-pay per surgery

Speech Therapy: 

$40 co-pay **pre authorization requirement

Tubal Ligation: 

INPATIENT
$150 co-pay per admission

OUTPATIENT
$150 co-pay per procedure

[Facility co-payments only; physician fees also apply]

Vasectomy: 

$75 co-pay

[when performed in the physician office]

X-rays: 

100%

Prescription Drugs
Pharmacy (Retail): 

Stanford HealthCare Alliance uses the Aetna Network pharmacy: $10 generic; $40 brand name; $100 non-formulary -- up to a 30-day supply.  Specialty medication classification will have a 10% co-insurance payment applied up to a $200 max cost per presciption.

Non-Network pharmacy: Member pays co-payment plus 25% of billed charges

Fertility drugs covered at 50% (deductible does not apply); max benefit of $5,000 per lifetime

Mail order drug program: 

$20 generic; $80 brand name; $200 non-formulary -- up to a 90-day supply; Specialty drugs are not available via mail order.

Must use Aetna mail-order service

Birth Control Pills: 

Included in Prescription Drug benefit

Preventive Care
Physical exams for adults: 

100%

Physical exams for children: 

100%

Pap smears: 

100%

[as part of the office visit]

Mammograms: 

100%

Immunizations: 

100%

Travel immunizations not covered.

Prostate Specific Antigen test - PSA: 

100%

Well-woman visits: 

100%

Vision care: 

$75 co-pay

Limited to screen and refraction exams only

Healthcare + Savings Plan - Group #PPOX0004 - 2020

Ratings
National Committee For Quality Assurance (NCQA)
Up to four stars are given for each of the following criteria:
Overall Accredition Status: 
Not reported by NCQA
Access & Services: 
0
Qualified Providers: 
0
Staying Healthy: 
0
Getting Better: 
0
Living With Illness: 
0
Basics

You may visit any doctor or hospital. You receive a higher level of benefits when you use Blue Shield PPO providers. You are responsible for ensuring all providers are in the network.

When you see a Non-Network provider you are responsible for the balance of your bill that is not covered by Blue Shield. The Out-of-Pocket Maximum does not apply to the balance of the bill not covered by Blue Shield.

This plan is compatible with an individual Health Savings Account (HSA), that you establish at a financial institution of your choice.

Description: 
HSA
Full-Time Employee * Contribution Per Pay Period: 

Employee Only: $40.00
Employee & Spouse/Registered Domestic Partner: $285.92
Employee & Children: $244.72
Employee & Family: $394.42

Part-Time Employee * Contribution Per Pay Period: 

Employee Only: $305.57
Employee & Spouse/Registered Domestic Partner: $713.61
Employee & Children: $611.67
Employee & Family: $985.46

Pre-Authorization Requirement: 

Pre-authorization required for all hospital stays and certain outpatient procedures.

PENALTY for not pre-authorizing:  benefit may be denied in full for failure to pre-authorize.

Care Management: 

Participation in care management optional

Our Shield Concierge program takes a comprehensive population health approach to care management.  Our multidisciplinary team of nurses, behavioral health clinicians, health coaches, dietitians, pharmacists, and customer services representatives help members live better with illness, recover from acute conditions, and have a more seamless healthcare experience.

Program features include acute and chronic condition care management, in-home visits, biometric remote monitoring (for some conditions), in-person and online self-management workshops, virtual cognitive behavioral therapy modules, proactive outreach by a clinical team, and integration with our Engagement Point digital solution for improved engagement.

Deductible: 

$1,750 per individual coverage/$3,500 per family coverage

Combined Network or Non-Network.  Up to $2,800 of an individual's claims will apply toward the family  deductible, and once that threshold is met the plan will begin sharing the costs for that individual.

Office co-pay: 

Network: 80% after deductible
Non-Network: 60% after deductible

Coinsurance: 

Network: 100% for preventive care; 80% after deductible for all other services, including prescriptions

Non-Network: 60% of allowed charges after deductible, including prescriptions

Out-of-Pocket Maximum: 

$3,750 per individual/$7,500 per family

Combined Network or Non-Network

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: 

No maximum

Maternity
Maternity Hospital Stay: 

Network: 80% after deductible
Non-Network: 60% after deductible

Baby's First Exam: 

Network: 80% after deductible
Non-Network: 60% after deductible

Birthing Centers: 

Network: 80% after deductible
Non-Network: 60% after deductible

Midwives: 

Network: 80% after deductible
Non-Network: 60% after deductible

Prenatal Visits: 

Network: 80% after deductible
Non-Network: 60% after deductible

Doctor Delivery Charge: 

Covered the same as all other inpatient surgery

Pregnancy Termination: 

Network: 80% after deductible
Non-Network: 60% after deductible

Mental Health/Substance Abuse
Mental Health: 

INPATIENT CARE
Pre-Certification is required by you or your provider.
Network: 80% after deductible
Non-Network: 60% of billed charges

ROUTINE OUTPATIENT CARE
[no visit limit]
Network: 80% after deductible.
Non-Network: 80% of billed charges (up to $300 maximum allowed charges) for professional services only.

The maximum allowed amount will not exceed $300 for each office visit.  For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.

Autism: 

Behavioral health treatment (BHT) consists of professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based behavior intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorders or autism. Prior authorization for BHT or ABA services is required. Plan mental health cost sharing applies.

Substance Abuse: 

Pre-certification is required by you or your provider.

INPATIENT CARE
Network: 80% after deductible
Non-Network: 60% after deductible

ROUTINE OUTPATIENT CARE
[no visit limit]
Network: 80% after deductible
Non-Network: 80% of billed charges (up to $300 maximum allowed charges) for professional services only.  

The maximum allowed amount will not exceed $300 for each office visit.  For example, if the billed charge is $350, the plan will pay 80% of {the lesser of $300 or the billed charge} = 80% x $300 = $240.

Other Services (A-D)
Acupuncture: 

Network: 80% after deductible
Non-Network: 60% after deductible
Up to 20 combined Network and Non-Network visits per year

Allergy Tests: 

Network: 80% after deductible
Non-Network: 60% after deductible

Allergy Treatment: 

Network: 80% after deductible
Non-Network: 60% after deductible

Alternative Medicine: 

Not covered

Ambulance charges: 

Network: 80% after deductible
Non-Network: 60% after deductible

CAT Scans: 

100% **Pre authorization requirement

Chiropractors: 

Network: 80% after deductible
Non-Network: 60% after deductible
Up to 20 combined Network and Non-Network visits per year

Christian Science Practitioners: 

Not covered

Cosmetic Surgery: 

Not covered

Dental Treatment: 

Coverage limited to certain conditions only. Contact Blue Shield for more information.

Other Services (E-N)
Emergency Room: 

Network: 80% after deductible
Non-Network: 80% after deductible

Lab/ancillary/professional charges paid at 80% after deductible for Network or Non-Network

Urgent Care: 

Network or Non-Network: 80% after deductible

Hearing Care: 

Exam:  Network:  100% as part of preventive care
Non-Network: Not covered

Hearing aids not covered

Home Health Care: 

Network: 80% after deductible
Non-Network: 60% after deductible

Hospice Care: 

Network: 80% after deductible
Non-Network: 60% after deductible

Hospital Stay: 

Pre-Certification required by you or your provider.
Network: 80% after deductible
Non-Network: 60% after deductible

Infertility Treatment: 

Network: 50% of Blue Shield allowed charges after deductible for professional and lab services; limited to three cycles of intrauterine insemination (IUI).
Non-Network: Not covered

In Vitro, GIFT, and ZIFT:  Not covered

Fertility drugs:  see Pharmacy

Laboratory Charges: 

Network: 80% after deductible
Non-Network: 60% after deductible

Magnetic resonance imaging - MRI: 

Pre-Certification required by you or your provider.
Network: 80% after deductible
Non-Network: 60% after deductible

Durable Medical Equipment: 

Network: 80% after deductible
Non-Network: 60% after deductible

Other Services (O-Z)
Occupational Therapy: 

Network: 80% after deductible
Non-Network: 60% after deductible

Organ Transplants: 

Contact Blue Shield for information on transplant coverage benefits

Skilled Nursing: 

Network:80% after deductible
Non-Network: 80% after deductible (pre-certification required)

Up to a 120-day annual maximum Network and Non-Network combined.

Physical Therapy: 

Network: 80% after deductible
Non-Network: 60% after deductible

Surgery : Physician Services: 

Network: 80% after deductible
Non-Network: 60% after deductible

Surgery : Facility Charges: 

Network: 80% after deductible

Non-Network (non-ambulatory surgery centers): 60% of billed charges after deductible

Non-Network (ambulatory surgery centers): 60% of allowed charges after deductible up to the maximum allowed charges of $4,000 per visit

For example, if the non-network allowed charge is $4500, the plan will pay 60% of {the lesser of $4,000 or the allowed charge} = 60% x $4,000 = $2,400.

Speech Therapy: 

Network: 80% after deductible
Non-Network: 60% after deductible

Tubal Ligation: 

Network: 80% after deductible
Non-Network: 60% after deductible

Vasectomy: 

Network: 80% after deductible
Non-Network: 60% after deductible

X-rays: 

Network: 80% after deductible
Non-Network: 60% after deductible

Prescription Drugs
Pharmacy (Retail): 

Network or Non-Network: 80% after deductible

Fertility drugs:  covered at 50% after deductible; max benefit of $5,000 per lifetime

Mail order drug program: 

80% after deductible; Specialty drugs are not available via mail order.

Must use Blue Shield mail-order service

Birth Control Pills: 

Included in Prescription Drug benefit

Preventive Care
Physical exams for adults: 

Network: 100%
Non-Network: Not covered

Physical exams for children: 

Network: 100%
Non-Network: Not covered

Pap smears: 

Network: 100% if part of annual preventive
Non-Network: Not covered

Mammograms: 

Network: 100% if part of annual preventive
Non-Network: Not covered

Immunizations: 

Network: 100%
Non-Network: Not covered; travel immunizations not covered.

Prostate Specific Antigen test - PSA: 

Network: 100%
Non-Network: Not covered

Well-woman visits: 

Network: 100%
Non-Network: Not covered

Vision care: 

Network: 100%
Non-Network: Not covered

Limited to screen and refraction exams only

ACA Basic High Deductible Plan - Group #PPOX0007 - 2020

Ratings
National Committee For Quality Assurance (NCQA)
Up to four stars are given for each of the following criteria:
Overall Accredition Status: 
Not reported by NCQA
Access & Services: 
0
Qualified Providers: 
0
Staying Healthy: 
0
Getting Better: 
0
Living With Illness: 
0
Basics

You may visit any doctor or hospital. You receive a higher level of benefits when you use Blue Shield PPO providers. You are responsible for ensuring all providers are in the network.

When you see a Non-Network provider you are responsible for the balance of your bill that is not covered by Blue Shield. The Out-of-Pocket Maximum does not apply to the balance of the bill not covered by Blue Shield.

This plan is compatible with an individual Health Savings Account (HSA), that you establish at a financial institution of your choice.

Description: 
ACA
Full-Time Employee * Contribution Per Pay Period: 

Employee Only: $24.26
Employee & Spouse/Registered Domestic Partner: $175.32
Employee & Children: $150.29
Employee & Family: $242.10

Part-Time Employee * Contribution Per Pay Period: 

Employee Only: $178.75
Employee & Spouse/Registered Domestic Partner: $437.55
Employee & Children: $375.05
Employee & Family: $604.23

Pre-Authorization Requirement: 

Pre-authorization required for all hospital stays and certain outpatient procedures.

PENALTY for not pre-authorizing:  benefit may be denied in full for failure to pre-authorize.

Care Management: 

Participation in care management optional

Our Shield Concierge program takes a comprehensive population health approach to care management.  Our multidisciplinary team of nurses, behavioral health clinicians, health coaches, dietitians, pharmacists, and customer services representatives help members live better with illness, recover from acute conditions, and have a more seamless healthcare experience.

Program features include acute and chronic condition care management, in-home visits, biometric remote monitoring (for some conditions), in-person and online self-management workshops, virtual cognitive behavioral therapy modules, proactive outreach by a clinical team, and integration with our Engagement Point digital solution for improved engagement.

Deductible: 

$3,250 per individual coverage/$6,500 per family coverage in-network

$6,500 per individual coverage/$13,000 out-of-network.  The individual deductible will apply to each covered family member's claims.  If met, the plan would begin sharing costs for the family member that met the individual deductible.

Office co-pay: 

Network: Plan pays 60% after deductible
Non-Network: Plan pays 50% after deductible

Coinsurance: 

Network: 100% for preventive care; 60% after deductible for all other services, including prescriptions
Non-Network: 50% of allowed charges after deductible, including prescriptions

Out-of-Pocket Maximum: 

$6,500 per individual/$13,000 per family In-network
$13,000 per individual/$26,000 per family Out-of-network

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: 

No maximum

Maternity
Maternity Hospital Stay: 

Network: 60% after deductible
Non-Network: 50% after deductible

Baby's First Exam: 

Network: 60% after deductible
Non-Network: 50% after deductible

Birthing Centers: 

Network: 60% after deductible
Non-Network: 50% after deductible

Midwives: 

Network: 60% after deductible
Non-Network: 50% after deductible

Prenatal Visits: 

Network: 60% after deductible
Non-Network: 50% after deductible

Doctor Delivery Charge: 

Covered the same as all other inpatient surgery

Pregnancy Termination: 

Network: 60% after deductible
Non-Network: 50% after deductible

Mental Health/Substance Abuse
Mental Health: 

INPATIENT CARE
Pre-Certification is required by you or your provider.
Network: 60% after deductible
Non-Network: 50% of the allowed amount after deductible

OUTPATIENT CARE
[no visit limit]
Network: 60% after deductible.
Non-Network: 50% of the allowed amount after deductible    

Autism: 

Behavioral health treatment (BHT) consists of professional services and treatment programs, including applied behavior analysis (ABA) and evidence-based behavior intervention programs that develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorders or autism. Prior authorization for BHT or ABA services is required. Plan mental health cost sharing applies.

Substance Abuse: 

Pre-certification is required by you or your provider.

INPATIENT CARE
Network: 60% after deductible
Non-Network: 50% of the allowed amount after deductible

OUTPATIENT CARE
[no visit limit]
Network: 60% after deductible
Non-Network: 50% of the allowed amount after deductible

Other Services (A-D)
Acupuncture: 

Network: 60% after deductible
Non-Network: 50% after deductible
Up to 20 combined Network and Non-Network visits per year

Allergy Tests: 

Network: 60% after deductible
Non-Network: 50% after deductible

Allergy Treatment: 

Network: 60% after deductible
Non-Network: 50% after deductible

Alternative Medicine: 

Not covered

Ambulance charges: 

Network or Non-Network: 60% after deductible (if medically approved)

CAT Scans: 

Network: 60% after deductible
Non-Network: 50% after deductible

Chiropractors: 

Network: 60% after deductible
Non-Network: 50% after deductible
Up to 20 combined Network and Non-Network visits per year

Christian Science Practitioners: 

Not covered

Cosmetic Surgery: 

Not covered

Dental Treatment: 

Coverage limited to certain conditions only. Contact Blue Shield for more information.

Other Services (E-N)
Emergency Room: 

Network: 60% after deductible
Non-Network: 60% after deductible

Lab/ancillary/professional charges paid at 60% after deductible for Network or Non-Network

Urgent Care: 

Network or Non-Network: 60% after deductible

Hearing Care: 

Exam:  Network:  100% as part of preventive care
Non-Network: Not covered

Hearing aids not covered

Home Health Care: 

Network: 60% after deductible
Non-Network: 50% after deductible

Hospice Care: 

Network: 60% after deductible
Non-Network: 50% after deductible

Hospital Stay: 

Pre-Certification required by you or your provider.
Network: 60% after deductible
Non-Network: 50% after deductible

 

Infertility Treatment: 

Network: 50% of Blue Shield allowed charges after deductible for professional and lab services; limited to three cycles of intrauterine insemination (IUI).
Non-Network: Not covered

In Vitro, GIFT, and ZIFT:  Not covered

Fertility drugs:  see Pharmacy

Laboratory Charges: 

Network: 60% after deductible
Non-Network: 50% after deductible

Magnetic resonance imaging - MRI: 

Pre-Certification required by you or your provider.
Network: 60% after deductible
Non-Network: 50% after deductible

Durable Medical Equipment: 

Network: 60% after deductible
Non-Network: 50% after deductible

Other Services (O-Z)
Occupational Therapy: 

Network: 60% after deductible
Non-Network: 50% after deductible

Organ Transplants: 

Contact Blue Shield for information on transplant coverage benefits

Skilled Nursing: 

Network: 60% after deductible
Non-Network: 50% after deductible (pre-certification required)

Up to a 120-day annual maximum Network and Non-Network combined.

Physical Therapy: 

Network: 60% after deductible
Non-Network: 50% after deductible

Surgery : Physician Services: 

Network: 60% after deductible
Non-Network: 50% after deductible

Surgery : Facility Charges: 

Network: 60% after deductible

Non-Network (non-ambulatory surgery centers): 50% of billed charges after deductible

Non-Network (ambulatory surgery centers): 50% of allowed charges after deductible up to the maximum allowed charges of $4,000 per visit

For example, if the non-network allowed charge is $4000, the plan will pay 50% of {the lesser of $4,000 or the allowed charge} = 50% x $4,000 = $2,000.

Speech Therapy: 

Network: 60% after deductible
Non-Network: 50% after deductible (pre-certification required)

Tubal Ligation: 

Network: 60% after deductible
Non-Network: 50% after deductible

Vasectomy: 

Network: 60% after deductible
Non-Network: 50% after deductible

X-rays: 

Network: 60% after deductible
Non-Network: 50% after deductible

Prescription Drugs
Pharmacy (Retail): 

Network or Non-Network: 60% after deductible

Fertility drugs:  covered at 50% after deductible; max benefit of $5,000 per lifetime

Mail order drug program: 

60% after deductible; Specialty drugs are not available via mail order.

Must use Blue Shield mail-order service

Birth Control Pills: 

Included in Prescription Drug benefit

Preventive Care
Physical exams for adults: 

Network: 100%
Non-Network: Not covered

Physical exams for children: 

Network: 100%
Non-Network: Not covered

Pap smears: 

Network: 100% if part of annual preventive
Non-Network: Not covered

Mammograms: 

Network: 100% if part of annual preventive
Non-Network: Not covered

Immunizations: 

Network: 100% if part of annual preventive
Non-Network: Not covered

Prostate Specific Antigen test - PSA: 

Network: 100%
Non-Network: Not covered

Well-woman visits: 

Network: 100%
Non-Network: Not covered

Vision care: 

Network: 100%
Non-Network: Not covered

Limited to screen and refraction exams only

Kaiser Permanente HMO (California) Group #7145 (Northern CA) Group #230178 (Southern CA) - 2020

Ratings
National Committee For Quality Assurance (NCQA)
Up to four stars are given for each of the following criteria:
Overall Accredition Status: 
Excellent
Access & Services: 
4
Qualified Providers: 
4
Staying Healthy: 
4
Getting Better: 
4
Living With Illness: 
4
Basics

You may use only Kaiser Permanente doctors and facilities except in emergencies.

Description: 
Kaiser
Full-Time Employee * Contribution Per Pay Period: 

Employee Only: $0 
Employee & Spouse/Registered Domestic Partner: $143.87
Employee & Children: $123.32
Employee & Family: $198.68

Part-Time Employee * Contribution Per Pay Period: 

Employee Only: $190.31
Employee & Spouse/Partner: $471.57
Employee & Children: $404.21
Employee & Family: $651.22

Pre-Authorization Requirement: 

Pre-authorization 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 co-pay primary/$50 co-pay specialist

Coinsurance: 

100% after applicable co-pays

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: 

No maximum

Maternity
Maternity Hospital Stay: 

$150 co-pay per admission

Baby's First Exam: 

100%

Birthing Centers: 

100%

Midwives: 

100% in hospital; if out-patient office visit: $30 co-pay

If midwife is available at Kaiser Permanente

Prenatal Visits: 

100%

Doctor Delivery Charge: 

100%

Pregnancy Termination: 

$50 co-pay

Mental Health/Substance Abuse
Mental Health: 

Kaiser Permanente must approve mental health care.
INPATIENT CARE
$150 co-pay per admission

OUTPATIENT CARE
[no visit limit]
$30 co-pay per visit, individual
$15 co-pay per visit, group

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 meet Kaiser's established criteria (refer to Evidence of Coverage booklet for specifics). The cost sharing for individual and group visits under this Mental Health section apply.

Substance Abuse: 

INPATIENT DETOXIFICATION
$150 co-pay per admission

OUTPATIENT CARE
[no visit limit]
$30 co-pay per visit, individual
$5 co-pay per visit, group

Transitional Residential Recovery Services
$150 co-pay per admission

Other Services (A-D)
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: 

$30 co-pay

Allergy Treatment: 

$5 co-pay for injections

Alternative Medicine: 

Not covered

Ambulance charges: 

100% after $50 co-pay

CAT Scans: 

100%

Chiropractors: 

$20 co-pay

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

Other Services (E-N)
Emergency Room: 

$200 co-pay (waived if admitted)

Urgent Care: 

$30 co-pay at Kaiser Permanente facility

Hearing Care: 

Exam 100%

Hearing aids not covered

Home Health Care: 

100%

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

Hospice Care: 

100%

Hospital Stay: 

$150 co-pay per admission

Infertility Treatment: 

50%

Fertility Drugs: Covered under drug benefits at 50%; In Vitro, GIFT, and ZIFT: Not covered.

Laboratory Charges: 

100%

Magnetic resonance imaging - MRI: 

100%

Durable Medical Equipment: 

100%

Other Services (O-Z)
Occupational Therapy: 

$30 co-pay

Organ Transplants: 

Contact Kaiser Permanente for information on transplant coverage benefits

Skilled Nursing: 

100% (Up to 100 days)

Physical Therapy: 

$30 co-pay

Surgery : Physician Services: 

INPATIENT
Covered under hospital co-pay

OUTPATIENT 
$150 co-pay per procedure

Surgery : Facility Charges: 

INPATIENT
$150 co-pay per admission

OUTPATIENT
$150 co-pay per procedure

Speech Therapy: 

$30 co-pay

Tubal Ligation: 

INPATIENT
100%

OUTPATIENT
100%

Vasectomy: 

$150 co-pay per procedure

X-rays: 

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

Mail order drug program: 

KAISER PERMANENTE MAIL ORDER PHARMACY
Generic:  $20 for up to 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.

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 co-pay applies if provided during doctor office visit

Prostate Specific Antigen test - PSA: 

100%

Well-woman visits: 

100%

Vision care: 

100%

Eye exams only. Discount program available for vision hardware