You have several options to choose from. Each option is available at different costs. When you enroll, you’ll find plenty of resources to help you choose.
Medical Coverage Level Options
HMSA Gold | Kaiser Gold | HMSA Platinum | Kaiser Platinum |
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Option Type | PPO | HMO | PPO | HMO |
In-network (individual / family) | Combined in-network and out-of-network: $200/$600 |
$200/$400 | N/A | N/A |
Out-of-network (individual / family) | Combined in-network and out-of-network: $200/$600 |
Not covered | $100/$300 | Not covered |
In-network (individual / family) | Combined in-network and out-of-network: $2,200/$6,600 |
$2,200/$4,400 | Combined in-network and out-of-network: $2,500/$7,500 |
$2,500/$7,500 |
Out-of-network (individual / family) | Combined in-network and out-of-network: $2,200/$6,600 |
N/A | Combined in-network and out-of-network: $2,500/$7,500 |
N/A |
Preventive care | 100% covered; deductible waived for most services | 100% covered; deductible waived | 100% covered | 100% covered |
Doctor's office visit | You pay $12 | You pay $15 | You pay $12 | You pay $15 |
Emergency room | You pay 20% after deductible | You pay 20%; deductible waived | You pay 20% | You pay $75 |
Urgent care | You pay $12 | You pay $15 | You pay $12 | You pay $15 |
Inpatient care | You pay 20% after deductible | You pay 10% after deductible | You pay 10% | You pay $75 per day |
Outpatient care | Cost share based on place of service | Cost share based on place of service | Cost share based on place of service | Cost share based on place of service |
Prescription Drug Coverage
HMSA Gold | Kaiser Gold | HMSA Platinum | Kaiser Platinum |
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Preventive Drugs |
You pay $0* | You pay $0* | You pay $0* | You pay $0* |
Prescription Drug Annual Out-of-Pocket Maximum (individual/ family) |
$3,000/$7,200 | Included in medical out-of-pocket maximum | $3,000/$5,700 | Included in medical out-of-pocket maximum |
Tier 1 (generally lowest cost options) | You pay $7 | You pay $5 for generic maintenance drugs; $10 for other generic drugs | You pay $5 | You pay $5 for generic maintenance drugs; $10 for other generic drugs |
Tier 2 (generally medium cost options) | You pay $35 | You pay $35 | You pay $30 | You pay $35 |
Tier 3 (generally highest cost options) | You pay $75 | You pay $35 (if authorized) | You pay $70 | You pay $35 (if authorized) |
Tier 1 (generally lowest cost options) | You pay $14 | You pay $10 for generic maintenance drugs; $20 for other generic drugs | You pay $10 | You pay $10 for generic maintenance drugs; $20 for other generic drugs |
Tier 2 (generally medium cost options) | You pay $70 | You pay $70 | You pay $60 | You pay $70 |
Tier 3 (generally highest cost options) | You pay $150 | You pay $70 (if authorized) | You pay $140 | You pay $70 (if authorized) |
Important! If you choose HMSA as your insurance carrier, you’ll have a separate and additional out-of-pocket maximum for prescription drugs. That means your medication costs will not count toward your medical out-of-pocket maximum (and vice versa).
How Does the Deductible and Out-of-Pocket Maximum Work?
- The HMSA Gold and Kaiser Gold options have a traditional deductible. Once a covered family member meets the individual deductible, your insurance will begin paying benefits for that family member. Charges for all covered family members will continue to count toward the family deductible. Once the family deductible is met, your insurance will pay benefits for all covered family members.
- All medical options have a traditional out-of-pocket-maximum. Once a covered family member meets the individual out-of-pocket maximum, your insurance will pay the full cost of covered charges for that family member. Charges for all covered family members will continue to count toward the family out-of-pocket maximum. Once the family out-of-pocket maximum is met, your insurance will pay the full cost of covered charges for all covered family members.
Going Out of Network?
- If you choose HMSA, seeing out-of-network providers will cost you more than seeing in-network providers. For example, you could pay more through a higher deductible, higher coinsurance, and the entire amount that exceeds the maximum allowed amount, which is typically based on the amount Medicare pays.
- If you choose Kaiser Permanente as your insurance carrier, you must designate a primary care physician to coordinate your care and out-of-network care is not covered.