Benefit Comparison Charts for Kaiser Permanente HMO, Hospital Services DHMO, and Deductible First DHMO

Service Kaiser Permanente HMO
Group #: 602484-0003
Kaiser Permanente Hospital Services DHMO
Group #: 602484-0006
Kaiser Permanente Deductible First DHMO
Group #: 602484-0009
Calendar Year DeductibleNoneMaximum per Member: $1,500
Maximum per Family of 2 or more: $3,000
Self-Only Enrollment: $1,300
Any One Member in a Family of Two or More: $2,600
Family of Two or More: $2,600
Coinsurance NoneVaries - See Kaiser’s Evidence of CoverageVaries - See Kaiser’s Evidence of Coverage
Calendar Year Out of Pocket Maximum (Including Deductibles, Co-pays, and Coinsurance)Self-Only Enrollment: $1,500
Any One Member in a Family of Two or More: $1,500
Family of Two or More: $3,000
Self-Only Enrollment: $4,000
Any One Member in a Family of Two or More: $4,000
Family of Two or More: $8,000
Self-Only Enrollment: $3,000
Any One Member in a Family of Two or More: $6,000
Family of Two or More: $6,000
Lifetime MaximumNone None None

Dependent Children Eligibility

Any Dependent Child under age 26. No age limit if disabled.

Any Dependent Child under age 26. No age limit if disabled.

Any Dependent Child under age 26. No age limit if disabled.
 Out of Network ProvidersNot CoveredNot Covered Not Covered

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Service Kaiser Permanente HMO
Group #: 602484-0003
Kaiser Permanente Hospital Services DHMO
Group #: 602484-0006
Kaiser Permanente Deductible First DHMO
Group #: 602484-0009
Physician & Specialist $10 co-pay$20 co-pay, no deductible $20 co-pay after deductible
Preventive Care Birth to Age 18No ChargeNo Charge, no deductibleNo Charge, no deductible
Preventive Care Adult Routine CareNo ChargeNo Charge, no deductibleNo Charge, no deductible
Preventive Care Adult Routine OB/GYNNo ChargeNo Charge, no deductibleNo Charge, no deductible
Diagnostic Lab and X-RayNo Charge$10 per encounter, no deductible$10 per encounter, no deductible
Physical Therapy (medically necessary treatment only)$10 co-pay medically necessary treatment only$20 co-pay, no deductible$20 co-pay after deductible
ChiropracticDiscounted rates through Kaiser Choose HealthyDiscounted rates through Kaiser Choose HealthyDiscounted rates through Kaiser Choose Healthy
Mental Health & Substance Abuse (Out-patient)Individual Therapy: $10 co-pay
Group Therapy: $5 co-pay
Individual Therapy: $20 co-pay, no deductible
Group Therapy: $10 co-pay, no deductible
$20 co-pay after deductible

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Service Kaiser Permanente HMO
Group #: 602484-0003
Kaiser Permanente Hospital Services DHMO
Group #: 602484-0006
Kaiser Permanente Deductible First DHMO
Group #: 602484-0009
Inpatient Hospital and Physician ServicesNo Charge20% Coinsurance after deductible $250 co-pay per admission after deductible
Outpatient Surgery$10 co-pay 20% Coinsurance after deductible $150 co-pay per procedure after deductible
MaternityNo Charge20% Coinsurance after deductible$250 co-pay per admission after deductible
Emergency Room$50 co-pay20% Coinsurance after deductible$100 co-pay after deductible
Ambulance$50 per trip$150 per trip, no deductible$100 co-pay per admission after deductible
Mental Health & Substance Abuse (Inpatient)No Charge20% Coinsurance after deductible$250 co-pay per admission after deductible
Skilled Nursing Facility

No Charge.
Up to 100 days per benefit period

20% Coinsurance, no deductible.
Up to 100 days per benefit
$250 co-pay per admission after deductible
Home HealthNo Charge.
100 days per year
No Charge (deductible doesn't apply)
100 days per year
No charge after deductible
100 days per year

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ServiceKaiser Permanente HMO
Group #: 602484-0003
Kaiser Permanente Hospital Services DHMO
Group #: 602484-0006
Kaiser Permanente Deductible First DHMO
Group #: 602484-0009
Generic or Tier 1$5 co-pay 100 day supply$10 co-pay 30day supply, no deductible $10 co-pay 30 day supply after deductible
Formulary Brand or Tier 2$10 co-pay 100 day supply$30 co-pay 30day supply, no deductible $30 co-pay 30 day supply after deductible
Mail Order Benefit Generic or Tier 1Same as retail $20 co-pay 100 day supply, no deductible $20 co-pay 100 day supply after deductible
Mail Order Benefit Formulary Brand or Tier 2Same as retail $60 co-pay 100 day supply, no deductible $60 co-pay 100 day supply after deductible
Mandatory Mail OrderNoNoNo
Mandatory Generic Program Not availableNot available Not available

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