2026 Kaiser Permanente HMO (California)
2026 Kaiser Permanente HMO (California) 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
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
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.
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.
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.)
$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
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.
*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
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
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
$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%
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
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.
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
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.
$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
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
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.
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
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]
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 will comply with Senate Bill 729, which mandates coverage of the diagnosis and treatment of infertility and fertility services.
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 will comply with Senate Bill 729, which mandates coverage of the diagnosis and treatment of infertility and 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
$150 copay per admission
OUTPATIENT
$150 copay per procedure
Surgery : Physician Services:
INPATIENT
Covered under hospital copay
OUTPATIENT
$150 copay per procedure
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)
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%
100%
OUTPATIENT
100%
Vasectomy:
$150 copay per procedure
Vision care:
100%
Eye exams only
Eye exams only
X-rays (Basic Imaging):
100%