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Intuit

Effective Date	8/1/2024
Annual Deductible
Individual / Family	Not Applicable
Maximum Out-Of-Pocket
Individual / Family	$1,500 Individual / $3,000 Family (Embedded)
Maximum Lifetime Benefit	Unlimited
Hospital Inpatient
Services Rendered while Hospitalized	$100 per admission
Maternity Inpatient	$100 per admission
Outpatient
Primary Care	$20 per visit
Urgent Care	$20 per visit
Virtual Care	No charge
Specialist	$20 per visit
Well-child & Preventive Care visits	No charge
Routine Prenatal Care	No charge
Outpatient Surgery	$20 per procedure
Therapies (PT/OT/ST)	$20 per visit Unlimited visits
X-rays and Lab Tests	X-ray No Charge; Lab No Charge
Advanced Imaging (CT / MRI / PET)	No Charge
Ambulance	$50 per trip
Emergency Department Visits	$100 per visit; waived if admitted
Outpatient Prescription Drugs
Generic Drugs	$10 Copay Retail
Brand Name Drugs	$20 Copay Retail
Non-preferred Brand Drugs	$30 Copay Retail
Specialty Drugs	$20 Copay
Pharmacy Deductible	This plan does not have a drug deductible
Days Supply	Up to a 30-day supply
Outpatient Prescription Drugs - Mail Order
Generic Drugs	$20 copay
Brand Drugs	$40 Copay
Non-preferred Drugs	$60 Copay
Specialty Drugs	$20 Copay
Pharmacy Deductible	This plan does not have a drug deductible
Days Supply	Up to a 90-day Supply
Mental Health Services
Inpatient psychiatric care	$100 per admission
Outpatient individual therapy visits	$20 per visit
Outpatient group therapy visits	$10 per visit
Substance Use Services
Inpatient detoxification	$100 per admission
Outpatient individual therapy visits	$20 per visit
Outpatient group therapy visits	$10 per visit
Infertility Services
Covered Services Related to the Diagnosis and Treatment of Infertility	$20 per visit. Includes IVF, GIFT & ZIFT. Includes Infertility drugs at applicable Pharmacy Cost Shares
	1 cycle per lifetime. (GIFT, ZIFT, IVF)
Infertility Drugs Included	Covered at applicable generic/brand/specialty cost shares.
Infertility Drugs Included
Additional Benefits
Durable Medical Equipment	20% coinsurance
Skilled Nursing Facility	No Charge limited to 100 days per benefit period
Home Health	No Charge limited to 100 visits per accumulation period
Hospice Care	No charge (unlimited visits)
Vision Exam	No charge
Other Benefits
Hearing aids	$3000 allowance / 1 device per ear / 36 months; Under 19 every 48 months
Chiropractic	$15 per visit / 20 visit limit per accumulation period
Acupuncture	$20 per visit / limited to provider referral
Bariatric surgery	$100 per admission
Vision Hardware	Not included
Dental	Not included
1. Please refer to EOC documents for a complete explanation of benefits.
2. Kaiser predominately uses Permanente exclusive providers. In certain instances, Kaiser will refer to out of network providers (i.e.: COEs) and benefits are paid as if in network (KP authorization is required). Worldwide emergency and urgent care are covered as if in network.
3. For questions regarding pre-authorization requirements for specific services, please consult your Certificate of Coverage or Evidence of Coverage

Effective Date	8/1/2024
Annual Deductible
Individual / Family	None
Individual / Family	None
Maximum Out-Of-Pocket
Individual / Family	$2,500 / $7,500
Individual / Family	$2,500 / $7,500
Maximum Lifetime Benefit	Unlimited
Grandfathered Status	None
Hospital Inpatient
Services Rendered while Hospitalized	10% of applicable charges
Maternity Inpatient	No Charge
Outpatient
Primary Care	$15 per visit; No Charge for Children 0-17 years
Urgent Care	$15 per visit within service area (Primary Care); 20% of applicable charges outside service area
Virtual Care	No charge
Specialist	$15 per visit
Well-child & Preventive Care visits	No charge
Routine Prenatal Care	No charge
Outpatient Surgery	10% Coinsurance
Therapies (PT/OT/ST)	$15 per visit (Unlimited Visits)
Therapies (PT/OT/ST)	$15 per visit (Unlimited Visits)
X-rays and Lab Tests	X-ray $15 per day; Lab $15 per day
Advanced Imaging (CT / MRI / PET)	20% of applicable charges
Ambulance	20% of applicable charges
Emergency Department Visits	$100 per visit
Outpatient Prescription Drugs
Generic Drugs	$10
Brand Drugs	$35
Non-preferred Drugs	$35
Specialty Drugs	$200
Pharmacy Deductible	None
Days Supply	30-day supply
Outpatient Prescription Drugs - Mail Order
Generic Drugs	$20
Brand Drugs	$70
Non-preferred Drugs	$70
Pharmacy Deductible	None
Days Supply	90-day supply
Mental Health Services
Total Care Setting	Included in Total Care Services
Outpatient individual therapy visits	$15 per visit
Substance Use Services
Total Care Setting	Included in Total Care Services
Outpatient individual therapy visits	$15 per visit
Infertility Services
Infertility Consultation	$15 per visit. 20% Coinsurance IVF limited to 1 cycle per lifetime. Includes Infertility drugs
In Vitro Fertilization	20% of applicable charges; Limited to a once per lifetime benefit
In Vitro Fertilization
Additional Benefits
Durable Medical Equipment	Outpatient setting 20% coinsurance; Diabetic DME 50% coinsurance; Included in Total Care settings
Skilled Nursing Facility	10% of applicable charges up to120 days per calendar year
Skilled Nursing Facility	10% of applicable charges up to120 days per calendar year
Home Health	No Charge
Home Health	No Charge
Hospice Care	No charge
Vision Exam	Primary $15 per visit; Specialty $15 per visit
Other Benefits
Hearing aids	60% Coinsurance / 1 device per ear / every 36 months
Chiropractic	$20 per visit / limited to 20 visits per year (Combined with Acupuncture)
Chiropractic
Acupuncture	$20 per visit / limited to 20 visits per year (Combined with Chiropractic)
Acupuncture
Bariatric surgery	10% Coinsurance
Vision Hardware	Not included
Dental	Not included

1. Please refer to EOC documents for a complete explanation of benefits.
2. Kaiser predominately uses Permanente exclusive providers. In certain instances, Kaiser will refer to out of network providers (i.e.: COEs) and benefits are paid as if in network (KP authorization is required). Worldwide emergency and urgent care are covered as if in network.
3. For questions regarding pre-authorization requirements for specific services, please consult your Certificate of Coverage or Evidence of Coverage

Effective Date	8/1/2024
Annual Deductible
Individual / Family	None
Individual / Family	None
Maximum Out-Of-Pocket
Individual / Family	$1,500 / $3,000
Individual / Family	$1,500 / $3,000
Maximum Lifetime Benefit	Unlimited
Grandfathered Status	None
Hospital Inpatient
Services Rendered while Hospitalized	$100 per admission
Maternity Inpatient	$100 per admission
Outpatient
Primary Care	$20 per visit
Urgent Care	$20 per visit
Virtual Care	No charge
Specialist	$20 per visit
Well-child & Preventive Care visits	No charge
Routine Prenatal Care	No charge
Outpatient Surgery	$20 per procedure
Therapies (PT/OT/ST)	$20 per visit (Unlimited Visits)
Therapies (PT/OT/ST)	$20 per visit (Unlimited Visits)
X-rays and Lab Tests	No charge
Advanced Imaging (CT / MRI / PET)	No charge
Ambulance	$50 per trip
Emergency Department Visits	$100 per visit
Outpatient Prescription Drugs
Generic Drugs	$10
Brand Drugs	$20
Non-preferred Drugs	$20
Specialty Drugs	Applicable Generic, Preferred Brand, and Non-Preferred Brand cost shares may apply
Pharmacy Deductible	None
Days Supply	30-day supply

Outpatient Prescription Drugs - Mail Order
Generic Drugs	$20
Brand Drugs	$40
Non-preferred Drugs	$40
Specialty Drugs	$40
Pharmacy Deductible	None
Days Supply	100-day supply

Mental Health Services
Inpatient psychiatric care	$100 per admission
Outpatient individual therapy visits	$20 per visit
Outpatient group therapy visits	$10 per visit
Substance Use Services
Inpatient detoxification	$100 per admission
Outpatient individual therapy visits	$20 per visit
Outpatient group therapy visits	$5 per visit
Infertility Services
Covered Services Related to the Diagnosis and Treatment of Infertility	$20 per visit. Includes IVF, GIFT & ZIFT limited to 1 cycle per lifetime. Includes Infertility drugs at applicable Pharmacy Cost Shares
Infertility Drugs Included	Covered at applicable generic/brand/specialty cost shares.
Infertility Drugs Included	Covered at applicable generic/brand/specialty cost shares.
Additional Benefits
Durable Medical Equipment	20% coinsurance
Skilled Nursing Facility	No charge limited to 100 days maximum per benefit period
Skilled Nursing Facility	No charge limited to 100 days maximum per benefit period
Home Health	No Charge limited to 100 days per benefit period
Home Health	No Charge limited to 100 days per benefit period
Hospice Care	No charge
Vision Exam	No charge
Other Benefits
Hearing aids	$3000 allowance / 1 device per ear / every 36 months
Chiropractic	$15 per visit / 20 visit limit per accumulation period
Chiropractic	$15 per visit / 20 visit limit per accumulation period
Acupuncture	$20 copay per visit; subject to to provider referral
Acupuncture	$20 copay per visit; subject to to provider referral
Bariatric surgery	Applicable inpatient/outpatient cost shares.
Vision Hardware	Not included
Dental	Not included

1. Please refer to EOC documents for a complete explanation of benefits.
2. Kaiser predominately uses Permanente exclusive providers. In certain instances, Kaiser will refer to out of network providers (i.e.: COEs) and benefits are paid as if in network (KP authorization is required). Worldwide emergency and urgent care are covered as if in network.
3. For questions regarding pre-authorization requirements for specific services, please consult your Certificate of Coverage or Evidence of Coverage

Effective Date	8/1/2024
Annual Deductible
Individual / Family	None
Individual / Family	None
Maximum Out-Of-Pocket
Individual / Family	$1,500 / $3,000
Individual / Family	$1,500 / $3,000
Maximum Lifetime Benefit	Unlimited
Grandfathered Status	None
Hospital Inpatient
Services Rendered while Hospitalized	$100 per admission
Maternity Inpatient	$100 per admission
Outpatient
Primary Care	$20 per visit
Urgent Care	$20 per visit
Virtual Care	No charge
Specialist	$20 per visit
Well-child & Preventive Care visits	No charge
Routine Prenatal Care	No charge
Outpatient Surgery	$20 per procedure
Therapies (PT/OT/ST)	$20 per visit (Unlimited Visits)
Therapies (PT/OT/ST)	$20 per visit (Unlimited Visits)
X-rays and Lab Tests	No charge
Advanced Imaging (CT / MRI / PET)	No charge
Ambulance	$50 per trip
Emergency Department Visits	$100 per visit
Outpatient Prescription Drugs
Generic Drugs	$10
Brand Drugs	$20
Non-preferred Drugs	$20
Specialty Drugs	$20
Pharmacy Deductible	None
Days Supply	30-day supply

Outpatient Prescription Drugs - Mail Order
Generic Drugs	$20
Brand Drugs	$40
Non-preferred Drugs	$40
Specialty Drugs	$40
Pharmacy Deductible	None
Days Supply	100-day supply

Mental Health Services
Inpatient psychiatric care	$100 per admission
Outpatient individual therapy visits	$20 per visit
Outpatient group therapy visits	$10 per visit
Substance Use Services
Inpatient detoxification	$100 per admission
Outpatient individual therapy visits	$20 per visit
Outpatient group therapy visits	$5 per visit
Infertility Services
Covered Services Related to the Diagnosis and Treatment of Infertility	$20 per visit. Includes IVF, GIFT & ZIFT limited to 1 cycle per lifetime. Includes Infertility drugs at applicable Pharmacy Cost Shares
Infertility Drugs Included	Covered at applicable generic/brand/specialty cost shares.
Infertility Drugs Included	Covered at applicable generic/brand/specialty cost shares.
Additional Benefits
Durable Medical Equipment	20% coinsurance
Skilled Nursing Facility	No charge limited to 100 days maximum per benefit period
Skilled Nursing Facility	No charge limited to 100 days maximum per benefit period
Home Health	No Charge limited to 100 visits per accumulation period
Home Health	No Charge limited to 100 visits per accumulation period
Hospice Care	No charge
Vision Exam	No charge
Other Benefits
Hearing aids	$3000 allowance / 1 device per ear / every 36 months
Chiropractic	$15 per visit limited to 20 visits per year
Chiropractic	$15 per visit limited to 20 visits per year
Acupuncture	Not Included
Acupuncture	Not Included
Bariatric surgery	$100 per admission
Vision Hardware	Not included
Dental	Not included

1. Please refer to EOC documents for a complete explanation of benefits.
2. Kaiser predominately uses Permanente exclusive providers. In certain instances, Kaiser will refer to out of network providers (i.e.: COEs) and benefits are paid as if in network (KP authorization is required). Worldwide emergency and urgent care are covered as if in network.
3. For questions regarding pre-authorization requirements for specific services, please consult your Certificate of Coverage or Evidence of Coverage

A Welcome Message From Dr. Cadle

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Telehealth is covered at no cost with most plans.²

Connected care

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Get seamless care with the help of your electronic health record

Transitioning your care

Convenient ways to get what you need

Personalized for you

While traveling

Mental health services

Your thoughts and feelings affect your overall well-being.

Maternity care

We’re here to give you the care you need for a happy, healthy pregnancy.

Chronic conditions

Gender-affirming care

Coordinated, compassionate support.

Our goal is your goal: for you to be healthy and thrive as your true self.

Added support - for all that is you¹

Extras for your mind and body

Make the most of your membership¹

Acupuncture, massage
therapy, chiropractic care

Reduced rates on
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Healthy lifestyle
programs

Wellness
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See what it's like being a member

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