Off exchange Kaiser Bronze 60 HDHP (HSA) 5500/40% Plan Details
Benefits in blue: Subject to a deductible
Benefits in black: Not subject to a deductible
The following benefits are for in-network services only. Before selecting a plan we recommend reviewing the plan’s Summary of Benefits and Coverage (SBC) and Evidence of Coverage (EOC) documents for specific costs and out-of-network benefits for PPO plans. There may be variations between plans that are not reflected here.
Standard Benefits for Individuals
Key benefits
Bronze 60 5500/40% HSA
(Health Savings Account)
Individual Deductible
$5,500
No separate pharmacy deductible
No separate pharmacy deductible
Family Deductible
$11,000
No separate pharmacy deductible
No separate pharmacy deductible
Preventative Care Copay
No cost
Primary Care Visit Copay
You pay 40% after deductible
Specialty Care Visit Copay
You pay 40% after deductible
Urgent Care Visit Copay
You pay 40% after deductible
Lab Testing Copay
You pay 40% after deductible
X-Ray Copay
You pay 40% after deductible
Emergency Room Copay
You pay 40% after deductible
Hospitalization (and high cost and infrequent services)
You pay 40% after deductible
Tier 1 (most generics) Drug Copay
You pay 40% after deductible
(Maximum cost of $500 per prescription after deductible)
(Maximum cost of $500 per prescription after deductible)
Tier 2 (preferred brand) Drug Copay
You pay 40% after deductible
(Maximum cost of $500 per prescription after deductible)
(Maximum cost of $500 per prescription after deductible)
Tier 3 (non-preferred brand) Drug Copay
You pay 40% after deductible
(Maximum cost of $500 per prescription after deductible)
(Maximum cost of $500 per prescription after deductible)
Tier 4 (specialty drugs)
You pay 40% after deductible
(Maximum cost of $500 per prescription after deductible)
(Maximum cost of $500 per prescription after deductible)
Maximum Out-of-Pocket For One
$6,550
Maximum Out-of-Pocket For Family
$13,300