effective 10/1/13 until 10/1/2014

Co-pays/Percentages represent what the member would pay for the given services. 
PPO - "in-network", Non-PPO - "out of network"

This outline is meant to be a brief summary of the plans.  If there is a discrepancy between this summary and the contract (policy), the contract will prevail.
  Kaiser Permanente Health Net
 Type of Policy Health Maintenance Organization (HMO)

 Preferred Provider Organization (PPO) 

 Maximum Coverage per policy year Unlimited 


 Deductible $150 per insured person, per calendar year 

 $1,000 per insured person, per policy year 

 Out of Pocket Max
 2 Party/ Family


 Hospital 20% after deductible  20% PPO, 40% Non-PPO after $500 ded. 
 Physician $20 copay (deductible waived)  PPO $20 copay (deductible waived), 40% Non-PPO 
 Emergency Room  20% after deductible 

 $100 copay (waived if admitted), then 20% PPO, 40% Non-PPO 

 Outpatient & Day Surgery Facility 20% after deductible  20% PPO, 40% Non-PPO 
 X-Rays, radiology, and laboratory  $10 ($50 for MRI, CT and PET) copay after deductible  20% PPO, 40% Non-PPO 
 Chemotherapy/Radiation Therapy  No copay  20% PPO, 40% Non-PPO  
 Maternity  No charge (deductible waived)  Same as any other condition 
 Outpatient Mental Health  20$ copay per visit  PPO $20 copay (deductible waived), 40% Non-PPO 
 Prescriptions (through participating pharmacies)  Generic $15 copay; Brand formulary $30 copay (30 day supply, deductible waived)  $20 copay 
 24-hour Nurse Call Lin  Included. Call you Medical Center and transfer to the Nurse Call Line (800) 893 5597 
 Pre-Existing Medical Conditions  Covered  Not covered until continuously insured for 6 months 
 Provider Network  www.kp.org  www.healthnet.com 
 Customer Service  (800) 464 4000  (866) 801 1446