Kaiser HMO for retirees

• Monthly premiums will increase. ALEX is the best resource to understand your specific costs.
• Behavioral health office visits at Kaiser and through the Optum network will continue to have a $30 copay. Next year, the copay will apply beginning with the first visit when using an Optum provider for Kaiser CA HMO members.
• Annual out-of-pocket maximums will increase to $3,000 for individual coverage and to $6,000 for two-party and family coverage. An out-of-pocket maximum is the most you pay during a plan year for covered care and services; after you reach the maximum out-of-pocket dollar amount, the plan pays 100% of covered in-network costs for the remainder of the year.
• High-risk human papillomavirus (hrHPV) testing for cervical cancer will be designated as the preferred screening method for average risk women ages 30-65, and additional follow-up testing will be covered at $0 cost share.
• California only:
  • Costs for non-emergency medical transportation via licensed stretcher/gurney van or wheelchair van will be fully covered at no cost when ordered by a network provider for medically necessary one-way trips home, to a skilled nursing facility or another higher level of care, immediately following an inpatient hospitalization or certain emergency, urgent care, or outpatient hospital encounters.
  • Up to five years of cryopreservation, as well as donor and surrogacy services, including donor eggs, sperm, and embryos, medically necessary testing of the surrogate or donor, and embryo transfer procedures on surrogates are covered. Surrogate prenatal, maternity, and delivery care are not covered.  
• Mid-Atlantic only:
  • Eligibility is expanding to employees from any UC location who live and work in the Mid-Atlantic region from any UC location.
  • A $100 copay will apply for all infused, intravenous or injected drugs administered by medical personnel in an outpatient office visit setting, along with the standard office visit copay.
• All members will receive new ID cards.

Kaiser HMO offers coverage within the Kaiser network only, with no deductible. The annual out-of-pocket maximum is $1,500 for individual coverage and $3,000 for coverage of a family of two or more. In 2027, these maximums are increasing to $3,000 for individual coverage and to $6,000 for two-party and family coverage.

• Office visits/Urgent care: $30
• Emergency room visits: $125
• Hospital stay: $250
• Prescription drugs:
  • Generic: $10
  • Brand name: $30
  • Non-formulary: $50
  • Specialty: 30% up to $150 maximum per prescription
  • Sexual dysfunction: 50% up to a maximum of $50 (Tier 1) or $100 (Tier 2 and 4) for a 100-day supply