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Home   >  Understanding Your Plan   >   Types of Plans   >   Prescriptions & Exclusions   >   Limitations & Exclusions

Kaiser Permanente California

$40/$4,000 HSA Deductible Health Insurance Plan

A plan summary of the Kaiser Permanente California $40/$4,000 HSA Deductible Plan is detailed out below for both In Network and Out of Network coverage.

                                                In Network Out of Network


 $4,000 Deductible

Not Applicable

  Office Visits

$40 after Deductible Not Applicable

  Annual Deductible

Individual: $4,000

Not Applicable

  Annual Out-Of-Pocket  Limit

Individual: $5,600

Not Applicable

  Lifetime Maximum

Unlimited Not Applicable

  Prescription Drugs

(After Deductible)

Generic: $10

Brand Formulary: $35

Not Applicable

  Laboratory & X-Ray

$10 after Deductible Not Applicable

  Annual Physical Exam

No Charge Not Applicable

  Annual OB-GYN Exam

No Charge Not Applicable

  Well Baby Care

No Charge Not Applicable

  Outpatient Surgery

30% Not Applicable

  Emergency Room

$150 after Deductible (Waived if admitted) $150 after Deductible (Waived if admitted)

  Inpatient Hospital

30% Not Applicable


$150 after Deductible $150 after Deductible

  Home Health Care

See Brochure Not Applicable

  Mental Health - Outpatient

See Brochure Not Applicable

  Chiropractic Care

See Brochure Not Applicable


See Brochure Not Applicable

  Mental Health - Inpatient

See Brochure Not Applicable

  Chemical Dependency

See Brochure Not Applicable

  Maternity Care

Not Covered Not Applicable


To learn more about your individual and family California health insurance options, the price of each plan and/or a detailed benefit summary of the plans, visit us here.

NOTICE! Final rates and benefits are based on actual plan selection (including plan riders you may request) and the assignment of any rate adjustment factors due to the health plan's underwriting guidelines.

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