2026 Kaiser Permanente HMO (Hawaii)
2026 Kaiser Permanente HMO (Hawaii) Plan Details
Group # 45041
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 - $125.50
Employee & Child(ren) - $112.96
Employee & Family - $188.26
Employee & Spouse/Registered Domestic Partner - $125.50
Employee & Child(ren) - $112.96
Employee & Family - $188.26
Part-Time Employee * Contribution Per Pay Period:
Employee Only - $224.72
Employee & Spouse/Registered Domestic Partner - $512.19
Employee & Child(ren) - $460.98
Employee & Family - $768.29
Employee & Spouse/Registered Domestic Partner - $512.19
Employee & Child(ren) - $460.98
Employee & Family - $768.29
Basics
Pre-Authorization Requirement:
In general, benefits are available only for care you receive from or arranged by your PCP, and at a KP
facility. A listing of KP providers and facilities can be found at www.kp.org.
facility. A listing of KP providers and facilities can be found at www.kp.org.
Care Management:
Health Education and Disease Management Programs
Covered, for the education in appropriate use of Health Plan services, and general health education
publications distributed by Health Plan.
Covered, for general health education services (including diabetes self-management training and
education) and disease management for members diagnosed with specific medical conditions such as
asthma, diabetes, cardiovascular disease, chronic obstructive pulmonary disease (COPD), and behavioral
health conditions (mental health and substance abuse). These programs offer services to help you learn
self-care skills to understand, monitor, manage, and/or improve your condition. Covered for tobacco
cessation classes and counseling sessions.
We also provide programs available through our Healthy Living classes and resources. These classes are
not covered benefits, but are available upon payment of reasonable class fees. Healthy living classes and
support groups include educational programs directed to members who wish to make changes in their
behavior that reduce health risks and enhance the quality of their lives or maintain their level of health.
Classes and support groups may include, but are not limited to: weight management, bariatric surgery
program, stress management, and Lamaze.
For more information, please see Healthy Living in Chapter 5:
Wellness and Other Special Features, or visit www.kp.org/classes for a list of available classes and
registration fees.
Covered, for the education in appropriate use of Health Plan services, and general health education
publications distributed by Health Plan.
Covered, for general health education services (including diabetes self-management training and
education) and disease management for members diagnosed with specific medical conditions such as
asthma, diabetes, cardiovascular disease, chronic obstructive pulmonary disease (COPD), and behavioral
health conditions (mental health and substance abuse). These programs offer services to help you learn
self-care skills to understand, monitor, manage, and/or improve your condition. Covered for tobacco
cessation classes and counseling sessions.
We also provide programs available through our Healthy Living classes and resources. These classes are
not covered benefits, but are available upon payment of reasonable class fees. Healthy living classes and
support groups include educational programs directed to members who wish to make changes in their
behavior that reduce health risks and enhance the quality of their lives or maintain their level of health.
Classes and support groups may include, but are not limited to: weight management, bariatric surgery
program, stress management, and Lamaze.
For more information, please see Healthy Living in Chapter 5:
Wellness and Other Special Features, or visit www.kp.org/classes for a list of available classes and
registration fees.
Deductible:
No deductible
Office co-pay:
$15 co-pay primary/$15 co-pay specialist
Coinsurance:
20% of applicable charges
Out-of-Pocket Maximum:
$2,500 per individual/$7,500 family (for 3 or more members)
Overall Lifetime Maximum Benefit:
No Maximum
Maternity
Maternity Hospital Stay:
100%
Baby's First Exam:
100%
Birthing Centers:
100%
Midwives:
100%
If midwife is available at Kaiser Permanente
If midwife is available at Kaiser Permanente
Doulas:
Not covered
Prenatal and Postnatal Physician Office Visits:
Network: 100%
Non-Network: Not Covered
Non-Network: Not Covered
Doctor Delivery Charge:
100%
Reproductive Health:
$15 per visit
Mental Health/Autism/Substance Abuse
Mental Health:
Outpatient: $15 per visit
Inpatient: 10% coinsurance in Total Care Services
Inpatient: 10% coinsurance in Total Care Services
Substance Abuse:
Primary and Specialty $15 per visit
Inpatient: 10% in Total Care Services
Inpatient: 10% in Total Care Services
Autism:
Primary and Specialty $15 per visit
Prescription Drugs
Pharmacy (Retail):
Generic Maintenance Drugs: $3 per prescription
Other Generic Drugs: $10 per prescription
Brand-Name Drugs: $35 per prescription
Specialty drugs: $200
Other Generic Drugs: $10 per prescription
Brand-Name Drugs: $35 per prescription
Specialty drugs: $200
Mail order drug program:
Prescription drug mail-order incentive
Two drug copayments for a 90-day consecutive supply
Two drug copayments for a 90-day consecutive supply
Birth Control Pills:
Included in Prescription Drug benefit. See summary for details.
Preventive Care
Physical exams for adults:
100%
Physical exams for children:
100%
Pap smears:
100%
Mammograms:
100%
Immunizations:
Office visit for (CDC) Immunizations 100%
Office visit for Travel Immunization
Primary Care $15 per visit
Specialty Care $15 per visit
Office visit for Travel Immunization
Primary Care $15 per visit
Specialty Care $15 per visit
Prostate Specific Antigen test - PSA:
Prostate Specific Antigen (screening) $15 per visit
Vasectomy
Primary Care $15 per visit
Specialty Care $15 per visit
Total Care Settings Included in Total Care Settings
Vasectomy
Primary Care $15 per visit
Specialty Care $15 per visit
Total Care Settings Included in Total Care Settings
Well-woman visits:
Preventive Care
Annual Gynecological Exam 100%
Mammography (screening) 100%
Pap Smears (cervical cancer screening) 100%
Annual Gynecological Exam 100%
Mammography (screening) 100%
Pap Smears (cervical cancer screening) 100%
Other Services
Acupuncture:
Not covered
Allergy Tests:
Primary and Specialty $15 per visit
Allergy Treatment:
Skilled-Administered Drugs: 20% of applicable charges
Alternative Medicine:
Not covered
Ambulance charges:
Air Ambulance 20% of applicable charges
Ground Ambulance 20% of applicable charges
Ground Ambulance 20% of applicable charges
CT and PET Scans (Complex Imaging):
Specialty 20% of applicable charges
Chiropractors:
Not covered
Christian Science Practitioners:
Not covered
Cosmetic Surgery:
Not covered
Dental Treatment:
Not covered (Adults)
Covered for children: Primary and Specialty care $15/visit
Covered for children: Primary and Specialty care $15/visit
Emergency Room:
Emergency Services $100 per visit in area
$100 per visit out of area
$100 per visit out of area
Urgent Care:
Within Service Area (Primary Care) $15 per visit
Outside Service Area 20% of Applicable Charges
Outside Service Area 20% of Applicable Charges
Hearing Care:
"Hearing Exam (for correction)
Primary Care $15 per visit
Specialty Care $15 per visit
Hearing Test
Primary Care $15 per visit
Specialty Care $15 per visit
Appliances: 80% of applicable charges covered for the lowest priced model, per ear, every 36 months. Hearing aids must be prescribed by a Kaiser physician or audiologist and obtained from Kaiser-designated sources.
Primary Care $15 per visit
Specialty Care $15 per visit
Hearing Test
Primary Care $15 per visit
Specialty Care $15 per visit
Appliances: 80% of applicable charges covered for the lowest priced model, per ear, every 36 months. Hearing aids must be prescribed by a Kaiser physician or audiologist and obtained from Kaiser-designated sources.
Home Health Care:
100%
Hospice Care:
100%
Hospital Stay:
Inpatient Hospital Services 10% of applicable charges
Infertility Treatment:
Infertility Consultation
Primary Care $15 per visit
Specialty Care $15 per visit
In Vitro Fertilization 20% of applicable charges
*Artificial insemination and ovulation induction are covered regardless of partner status and without a diagnosis of infertility.
Primary Care $15 per visit
Specialty Care $15 per visit
In Vitro Fertilization 20% of applicable charges
*Artificial insemination and ovulation induction are covered regardless of partner status and without a diagnosis of infertility.
Laboratory Charges:
Basic $15 per day
Specialty 20% of applicable charges
Specialty 20% of applicable charges
Magnetic Resonance Imaging (MRI) (Complex Imaging):
Specialty 20% of applicable charges
Durable Medical Equipment:
Outpatient 20% of applicable charges
Total Care Settings Included in Total Care Services
Total Care Settings Included in Total Care Services
Occupational Therapy:
Medical Office $15 per visit
Organ Transplants:
Transplant Care for Transplant Recipients:
Primary Care $15 per visit
Specialty Care $15 per visit
Total Care Settings Included in Total Care Services
Transplant Care for Transplant Donors (based on
health plan approval):
Primary Care $15 per visit
Specialty Care $15 per visit
Total Care Settings Included in Total Care Services
Primary Care $15 per visit
Specialty Care $15 per visit
Total Care Settings Included in Total Care Services
Transplant Care for Transplant Donors (based on
health plan approval):
Primary Care $15 per visit
Specialty Care $15 per visit
Total Care Settings Included in Total Care Services
Skilled Nursing:
Skilled Nursing Facility -10% of applicable charges up to 120 days per
calendar year
calendar year
Physical Therapy:
Medical Office $15 per visit
Prosthetic & Orthotic Devices:
Covered base formulary only at 20%
Speech Therapy:
Medical Office $15 per visit
Surgery : Facility Charges:
Inpatient Hospital Services -10% of applicable charges
Outpatient Surgery and Procedures in a Hospital-Based Setting or Ambulatory Surgery Center (ASC) -10% of applicable charges
Outpatient Surgery and Procedures in a Hospital-Based Setting or Ambulatory Surgery Center (ASC) -10% of applicable charges
Surgery : Physician Services:
Inpatient Hospital Services 10% of applicable charges
Outpatient Surgery and Procedures in a Hospital-Based Setting or Ambulatory Surgery Center (ASC)
10% of applicable charges
Outpatient Surgery and Procedures in a Hospital-Based Setting or Ambulatory Surgery Center (ASC)
10% of applicable charges
Transgender Services:
Call Kaiser Hawaii 808-432-7263 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)
• 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:
Voluntary Sterilization (including tubal ligation)
Medical Office 100%
Total Care Settings Included in Total Care Settings
Medical Office 100%
Total Care Settings Included in Total Care Settings
Vasectomy:
Prostate Specific Antigen (screening) $15 per visit
Vasectomy: $15 per visit
Primary Care $15 per visit
Specialty Care $15 per visit
Total Care Settings Included in Total Care Settings
Vasectomy: $15 per visit
Primary Care $15 per visit
Specialty Care $15 per visit
Total Care Settings Included in Total Care Settings
Vision care:
Vision Exam (for glasses)
Primary Care $15 per visit
Specialty Care $15 per visit
Primary Care $15 per visit
Specialty Care $15 per visit
X-rays (Basic Imaging):
Basic $15 per day
Specialty 20% of applicable charges
Specialty 20% of applicable charges