KAISER $1,500 Deductible with HSA Option

Kaiser Permanente for Individuals and Families	$1,500 deductible with HSA Option	$1,500 deductible/Rx with HSA Option
Annual individual deductible (per calendar year)	$1,500 member $3,000 per family	$1,500 member $3,000 per family
Annual out-of-pocket maximum (per calendar year) Not all copayments count toward your limit; not all copayments are waived after limit is met.	$5,000 member $10,000 per family	$5,000 member $10,000 per family
Lifetime benefit maximum	$2 million	$2 million
Hospital care (including maternity care)*	Members pay	Members pay
All inpatient care is covered after payment of applicable copayments. There are no limits on prescribed hospital days.	20% coinsurance†	20% coinsurance†
Office visits*	Members pay	Members pay
For diagnosis and treatment by primary care providers, consultation and treatment by specialists, routine physical and hearing exams, well-baby visits through age 2, prenatal care, eye exams, and urgent care.	20% per primary care visit† 20% per specialty care visit†	20% per primary care visit† 20% per specialty care visit†
Outpatient Rx drugs	Members pay	Members pay
When prescribed by a Kaiser Permanente physician or a licensed dentist in accordance with our formulary process.	Not covered	$15 generic Rx $30 brand-name Rx (after deductible) (30-day supply)
Other Benefits	Members pay	Members pay
Laboratory Inpatient and outpatient.	20%‡	20%‡
X-rays and other special procedures Inpatient and outpatient.	20%‡	20%‡
*Emergency care Within and outside Kaiser Permanente Service Area	20% coinsurance (after deductible)**	20% coinsurance (after deductible)**
* Plus any copayments or coinsurance for lab or X-ray ** The emergency care copay will be waived and the hospital copay will apply if admitted directly to hospital from an emergency room. Additional copayments or coinsurance may apply for lab, X-ray, etc. † (After deductible) Deductible waived for well-baby visits, prenatal care, and certain preventive procedures. ‡ (After deductible) No deductible for preventive tests or preventive procedures. The tax references in this brochure relate to federal income tax only. Consult with your financial or tax adviser for more information about your state’s income tax laws. Kaiser Permanente does not provide or administer financial products, including HSAs, and does not offer financial, tax, or investment advice. Members are responsible for their own investment decisions. This benefit summary lists the copayments you pay for services. This summary is not a contract but a general listing of major benefits, exclusions, and limitations.  Your particular benefits are those contained in the Kaiser Permanente Personal Advantage membership agreement, which you will receive if accepted.

Group Product

LifeWise HSA-qualified plans are an affordable way to offer your employees in-network and out-of-network coverage for major illness, as well as the opportunity to grow their health-care dollars. These high-deductible plans keep premiums low and are designed to work in combination with tax-deductible HSAs.