2024 Kaiser Permanente Hawaii Group #45041
Basics
Full-Time Employee * Contribution Per Pay Period
Employee Only $0.00
Employee & Spouse/Registered Domestic Partner $125.50
Employee & Child(ren) $112.96
Employee & Family $188.26
Employee & Spouse/Registered Domestic Partner $125.50
Employee & Child(ren) $112.96
Employee & Family $188.26
Part-Time Employee * Contribution Per Pay Period
Employee Only $200.40
Employee & Spouse/Registered Domestic Partner $463.55
Employee & Child(ren) $417.20
Employee & Family $695.32
Employee & Spouse/Registered Domestic Partner $463.55
Employee & Child(ren) $417.20
Employee & Family $695.32
Overall Lifetime Maximum Benefit
No maximum
Plan Year
2024
Pre-Authorization Requirement
In general, benefits are available only for the care you receive from or arranged by your PCP, and at a KP
facility. A listing of KP providers and facilities can be found at www.kp.org.
facility. A listing of KP providers and facilities can be found at www.kp.org.
Offered To
Employees
Care Management
Health Education and Disease Management Programs
- Covered, for the education in appropriate use of Health Plan services, and general health education
publications distributed by Health Plan.
- Covered, for general health education services (including diabetes self-management training and
education) and disease management for members diagnosed with specific medical conditions such as
asthma, diabetes, cardiovascular disease, chronic obstructive pulmonary disease (COPD), and behavioral
health conditions (mental health and substance abuse).
These programs offer services to help you learn self-care skills to understand, monitor, manage and/or improve your condition. Covered, for tobacco cessation classes and counseling sessions.
We also provide programs available through our Healthy Living classes and resources. These classes are
not covered benefits but are available upon payment of reasonable class fees. Healthy living classes and
support groups include educational programs directed to members who wish to make changes in their
behavior that reduce health risks and enhance the quality of their lives or maintain their level of health.
Classes and support groups may include, but are not limited to: weight management, bariatric surgery
program, stress management, and Lamaze. For more information, please see Healthy Living in Chapter 5:
Wellness and Other Special Features, or visit www.kp.org/classes for a list of available classes and
registration fees.
- Covered, for the education in appropriate use of Health Plan services, and general health education
publications distributed by Health Plan.
- Covered, for general health education services (including diabetes self-management training and
education) and disease management for members diagnosed with specific medical conditions such as
asthma, diabetes, cardiovascular disease, chronic obstructive pulmonary disease (COPD), and behavioral
health conditions (mental health and substance abuse).
These programs offer services to help you learn self-care skills to understand, monitor, manage and/or improve your condition. Covered, for tobacco cessation classes and counseling sessions.
We also provide programs available through our Healthy Living classes and resources. These classes are
not covered benefits but are available upon payment of reasonable class fees. Healthy living classes and
support groups include educational programs directed to members who wish to make changes in their
behavior that reduce health risks and enhance the quality of their lives or maintain their level of health.
Classes and support groups may include, but are not limited to: weight management, bariatric surgery
program, stress management, and Lamaze. For more information, please see Healthy Living in Chapter 5:
Wellness and Other Special Features, or visit www.kp.org/classes for a list of available classes and
registration fees.
Body/Description
You may use only Kaiser Permanente doctors and facilities except in emergencies.
Coinsurance
100% after applicable copays
Office co-pay
$15 copay primary/$15 copay specialist
Deductible
No deductible
Benefit Type
Medical
Out-of-Pocket Maximum
$2,500 per individual/ $7,500 family
X-rays (Basic Imaging)
Basic $15 per day
Specialty 20% of applicable charges
Specialty 20% of applicable charges
Maternity Hospital Stay
100%
Baby's First Exam
100%
Birthing Centers
100%
Midwives
100%
If midwife is available at Kaiser Permanente
If midwife is available at Kaiser Permanente
Prenatal and Postnatal Physician Office Visits
100%
Doctor Delivery Charge
100%
Reproductive Health
$15 per day
Mental Health
$15 per visit.
Autism
Primary and Specialty $15 per visit
Substance Abuse
$15 per visit
Acupuncture
Not covered
Allergy Tests
Primary and Specialty $15 per visit
Alternative Medicine
Not covered
Ambulance charges
Air Ambulance 20% of applicable charges
Ground Ambulance 20% of applicable charges
Ground Ambulance 20% of applicable charges
CT and PET Scans (Complex Imaging)
Specialty 20% of applicable charges
Chiropractors
Not covered
Up to 40 combined chiropractic and acupuncture visits per year
American Specialty Health (ASH) Plans Participating Chiropractors
Up to 40 combined chiropractic and acupuncture visits per year
American Specialty Health (ASH) Plans Participating Chiropractors
Christian Science Practitioners
Not covered
Cosmetic Surgery
Not covered
Dental Treatment
Not covered
Emergency Room
Emergency Services $100 per visit in area,
$100 per visit out of area.
$100 per visit out of area.
Urgent Care
Within Service Area (Primary Care) $15 per visit
Outside Service Area, 20% of applicable charges
Outside Service Area, 20% of applicable charges
Hearing Care
Hearing Exam (for correction)
Primary Care $15 per visit
Specialty Care $15 per visit
Hearing Test
Primary Care $15 per visit
Specialty Care $15 per visit
Appliances 80% of applicable charges covered for lowest priced model, per ear, every 36 months. Hearing aids must be prescribed by a Kaiser physician or audiologist and obtained from Kaiser designated sources.
Primary Care $15 per visit
Specialty Care $15 per visit
Hearing Test
Primary Care $15 per visit
Specialty Care $15 per visit
Appliances 80% of applicable charges covered for lowest priced model, per ear, every 36 months. Hearing aids must be prescribed by a Kaiser physician or audiologist and obtained from Kaiser designated sources.
Home Health Care
100%
Hospice Care
100%
Hospital Stay
Inpatient Hospital Services 10% of applicable charges
Infertility Treatment
Infertility Consultation
Primary Care $15 per visit
Specialty Care $15 per visit In Vitro Fertilization 20% of applicable charges
*Artificial insemination and ovulation induction are covered regardless of partner status and without a diagnosis of infertility.
Primary Care $15 per visit
Specialty Care $15 per visit In Vitro Fertilization 20% of applicable charges
*Artificial insemination and ovulation induction are covered regardless of partner status and without a diagnosis of infertility.
Laboratory Charges
Basic $15 per day; Specialty 20% of applicable charges
Magnetic Resonance Imaging (MRI) (Complex Imaging)
Specialty 20% of applicable charges
Durable Medical Equipment
Outpatient 20% of applicable charges
Total Care Settings Included in Total Care Services
Total Care Settings Included in Total Care Services
Occupational Therapy
Medical Office $15 per visit
Organ Transplants
Transplant Care for Transplant Recipients
Primary Care $15 per visit
Specialty Care $15 per visit
Total Care Settings Included in Total Care Services
Transplant Care for Transplant Donors (based on
health plan approval)
Primary Care $15 per visit
Specialty Care $15 per visit
Total Care Settings Included in Total Care Services
Primary Care $15 per visit
Specialty Care $15 per visit
Total Care Settings Included in Total Care Services
Transplant Care for Transplant Donors (based on
health plan approval)
Primary Care $15 per visit
Specialty Care $15 per visit
Total Care Settings Included in Total Care Services
Skilled Nursing
Skilled Nursing Facility 10% of applicable charges up to 120 days per calendar year
Physical Therapy
Medical Office $15 per visit
Prosthetic & Orthotic Devices
Covered base formulary only at 20%
Surgery : Physician Services
Inpatient Hospital Services 10% of applicable charges
Outpatient Surgery and Procedures in a Hospital-
Based Setting or Ambulatory Surgery Center (ASC)
10% of applicable charges
Outpatient Surgery and Procedures in a Hospital-
Based Setting or Ambulatory Surgery Center (ASC)
10% of applicable charges
Surgery : Facility Charges
Inpatient Hospital Services 10% of applicable charges
Outpatient Surgery and Procedures in a Hospital-
Based Setting or Ambulatory Surgery Center (ASC)
10% of applicable charges
Outpatient Surgery and Procedures in a Hospital-
Based Setting or Ambulatory Surgery Center (ASC)
10% of applicable charges
Speech Therapy
Medical Office $15 per visit
Tubal Ligation
Voluntary Sterilization (including tubal ligation)
Medical Office 100%
Total Care Settings Included in Total Care Settings
Medical Office 100%
Total Care Settings Included in Total Care Settings
Vasectomy
Prostate Specific Antigen (screening) $15 per visit;
Primary Care $15 per visit;
Specialty Care $15 per visit;
Total Care Settings Included in Total Care Settings
Primary Care $15 per visit;
Specialty Care $15 per visit;
Total Care Settings Included in Total Care Settings
X-rays (Basic Imaging)
Basic $15 per day
Specialty 20% of applicable charges
Specialty 20% of applicable charges
Pharmacy (Retail)
Generic Maintenance Drugs: $3 per prescription
Other Generic Drugs: $10 per prescription
Brand-Name Drugs: $35 per prescription
Specialty drugs: $200
Other Generic Drugs: $10 per prescription
Brand-Name Drugs: $35 per prescription
Specialty drugs: $200
Mail order drug program
Prescription drug
mail-order incentive
Two drug copayments
for a 90-consecutive-day supply
mail-order incentive
Two drug copayments
for a 90-consecutive-day supply
Physical exams for adults
100%
Physical exams for children
100%
Pap smears
100%
Mammograms
100%
Immunizations
Office visit for Travel Immunization;
Primary Care $15 per visit;
Specialty Care $15 per visit
Primary Care $15 per visit;
Specialty Care $15 per visit
Prostate Specific Antigen test - PSA
Prostate Specific Antigen (screening)
- Primary Care $15 per visit
- Specialty Care $15 per visit
- Primary Care $15 per visit
- Specialty Care $15 per visit
Well-woman visits
Preventive Care
- Annual Gynecological Exam 100%
- Mammography (screening) 100%
- Pap Smears (cervical cancer screening) 100%
- Annual Gynecological Exam 100%
- Mammography (screening) 100%
- Pap Smears (cervical cancer screening) 100%
Vision care
Vision Exam (for glasses)
Primary Care $15 per visit
Specialty Care $15 per visit
Primary Care $15 per visit
Specialty Care $15 per visit
Transgender Services
Call Kaiser Hawaii 808-432-7263 for resources. Kaiser offers a broad range of covered gender-affirming care services:
• Mental health care
• Office visits
• Lab and imaging services
• Hormone therapy visits and administration
• Pharmacy services
• Preoperative and postoperative exams
• Facial hair removal
• Vocal therapy
• Tracheal shave
• Mastectomy with chest reconstruction and
gender-affirming chest surgery
• Gender-affirming facial surgery
• Gender-affirming genital surgeries
• Inpatient hospital care
• Outpatient care
• Treatment for medical complications
• Travel and lodging (when referred by Kaiser Permanente to a facility outside your region)
• Mental health care
• Office visits
• Lab and imaging services
• Hormone therapy visits and administration
• Pharmacy services
• Preoperative and postoperative exams
• Facial hair removal
• Vocal therapy
• Tracheal shave
• Mastectomy with chest reconstruction and
gender-affirming chest surgery
• Gender-affirming facial surgery
• Gender-affirming genital surgeries
• Inpatient hospital care
• Outpatient care
• Treatment for medical complications
• Travel and lodging (when referred by Kaiser Permanente to a facility outside your region)
Travel and Lodging
Contact the plan for details