HMO HSA 4500

Source answer: $4,500 Individual / $7,350 Family

Benefit details: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the policy, the overall family deductible must be met before the plan begins to pay.

Benefit details: Summary (Inside Network): Individual deductible: $4,500 per calendar year Family deductible: $7,350 per calendar year Until the total family annual deductible is met, benefits will not be provided for any family member

Source answer: No.

Benefit details: You don’t have to meet deductibles for specific services.

Inside Network: No copay, deductible and coinsurance apply

Inside Network: Insulin, needles, syringes and lancets-see Prescription drugs. External insulin pumps, blood glucose monitors, testing reagents and supplies-see Devices, equipment and supplies. When Devices, equipment and supplies or Prescription drugs are covered and have benefit limits, diabetic supplies are not subject to these limits.

Source answer: $6,750 Individual / $7,900 Family

Benefit details: The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met.

Benefit details: Summary (Inside Network): Individual out-of-pocket limit: $6,750 Family out-of-pocket limit: $7,900 Out-of-pocket expenses for the following covered services are included in the out-of-pocket limit: All cost shares for covered services If enrolled on the family plan you must meet the family out-of-pocket maximum

Source answer: Premiums, balance-billing charges, health care this plan doesn’t cover, and services indicated in chart starting on page 2.

Benefit details: Even though you pay these expenses, they don’t count toward the out-of-pocket limit.

In-network: 30% coinsurance

In-network: 30% coinsurance

In-network: No charge, deductible does not apply.

Benefit details: You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for.

Benefit details: Summary (Inside Network): Covered in full Women's contraception is covered as preventive, and Men's contraception is covered in full after annual deductible has been satisfied

In-network: 30% coinsurance

Benefit details: Summary (Inside Network): Inpatient: Covered under Hospital services Outpatient: Deductible and coinsurance apply High end radiology imaging services such as CT, MRI and PET must be determined Medically Necessary and require prior authorization except when associated with Emergency care or inpatient services.

In-network: 30% coinsurance

Benefit details: Preauthorization required

In-network: 30% coinsurance (retail); 3x retail cost share (mail order) / prescription

Benefit details: Up to a 90-day supply (retail / mail order). No charge for contraceptives. Subject to formulary guidelines.

In-network: 30% coinsurance (retail); 3x retail cost share (mail order) / prescription

Benefit details: Up to a 90-day supply (retail / mail order). Subject to formulary guidelines.

In-network: Applicable Preferred generic or Preferred brand cost shares apply.

Benefit details: Up to a 90-day supply (retail / mail order). Subject to formulary guidelines , when approved through the exception process..

In-network: Applicable Preferred generic or Preferred brand cost shares apply.

Benefit details: Up to a 30-day supply (retail). Subject to formulary guidelines, when approved through the exception process.

Inside Network: Preferred generic and/or brand Deductible and coinsurance applies. Certain preventive medications are covered in full.

Inside Network: 3 x prescription cost share per 90 day supply

In-network: 30% coinsurance

In-network: 30% coinsurance

In-network: 30% coinsurance

Benefit details: Preauthorization required

In-network: 30% coinsurance

Benefit details: Preauthorization required

Inside Network: Inpatient services: Deductible and coinsurance apply Outpatient surgery: No copay, deductible and coinsurance apply

Inside Network: Unlimited, no waiting period Inpatient: Deductible and coinsurance apply Outpatient: No copay, deductible and coinsurance apply

Source statement: Cosmetic Surgery is listed in the source exclusions; review the qualifications.

In-network: 30% coinsurance

Benefit details: You must notify Kaiser Permanente within 24 hours if admitted to a Non-network provider; limited to initial emergency only.

Benefit details: Summary (Inside Network): $0 copay Deductible and coinsurance apply

In-network: 30% coinsurance

Benefit details: Summary (Inside Network): Deductible and coinsurance

In-network: 30% coinsurance

Benefit details: Non-network providers covered when temporarily outside the service area.

In-network: 30% coinsurance

In-network: 30% coinsurance

Benefit details: Preauthorization required

Inside Network: Deductible and coinsurance apply

Inside Network: No copay, deductible and coinsurance apply

Inside Network: Deductible and coinsurance apply

Inside Network: No copay, deductible and coinsurance apply

In-network: 30% coinsurance

Benefit details: Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound).

In-network: 30% coinsurance

Benefit details: You must notify Kaiser Permanente within 24 hours of admission, or as soon thereafter as medically possible. Newborn services cost shares are separate from that of the mother.

In-network: 30% coinsurance

Benefit details: You must notify Kaiser Permanente within 24 hours of admission, or as soon thereafter as medically possible. Newborn services cost shares are separate from that of the mother.

Inside Network: Inpatient: Deductible and coinsurance apply Outpatient: No copay, deductible and coinsurance apply

Inside Network: Initial hospital stay: See Hospital Services; Office visits: See Outpatient Services; Routine well care: See Preventive care. Any applicable cost share for newborn services is separate from that of the mother.

In-network: 30% coinsurance

Benefit details: Preauthorization required

Benefit details: Summary (Inside Network): No visit limit, deductible and coinsurance apply

In-network: Outpatient: 30% coinsurance Inpatient: 30% coinsurance

Benefit details: Combined with Habilitation services: Outpatient: 45 visit limit / year. Inpatient: 30- day limit / year, preauthorization required.

Benefit details: Summary (Inside Network): Inpatient: 30 days per calendar year. Services with mental health diagnoses are covered with no limit. Deductible and coinsurance apply Outpatient: 45 visits per calendar year. Services with mental health diagnoses are covered with no limit. No copay, deductible and coinsurance apply

In-network: Outpatient: 30% coinsurance Inpatient: 30% coinsurance

Benefit details: Combined with Rehabilitation services: Outpatient: 45 visit limit / year. Inpatient: 30- day limit / year, preauthorization required.

In-network: 30% coinsurance

Benefit details: 60-day limit / year. Preauthorization required

Benefit details: Summary (Inside Network): Up to 60 days per calendar year, deductible and coinsurance apply

In-network: 50% coinsurance

Benefit details: Subject to formulary guidelines. Preauthorization required

Benefit details: Summary (Inside Network): Covered at 50%, deductible applies

In-network: 30% coinsurance

Benefit details: Preauthorization required

Benefit details: Summary (Inside Network): Deductible and coinsurance apply

Inside Network: See Rehabilitation services

Benefit details: Referenced summary Rehabilitation services: Inpatient: 30 days per calendar year. Services with mental health diagnoses are covered with no limit. Deductible and coinsurance apply Outpatient: 45 visits per calendar year. Services with mental health diagnoses are covered with no limit. No copay, deductible and coinsurance apply

In-network: 30% coinsurance for refractive exam

Benefit details: Limited to 1 exam / 12 months

In-network: Not covered

In-network: Not covered

Inside Network: No copay, deductible and coinsurance apply

Inside Network: Not covered

Source answer: Yes, but you may self-refer to certain specialists.

Benefit details: This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist.

Source answer: Yes. See www.kp.org or call 1-888- 901-4636 (TTY: 711) for a list of network providers.

Benefit details: This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services.

Benefit details: Non-emergency care when traveling outside the U.S. Listed under services the plan generally does not cover; see the EOC for emergency and other travel terms.

Core HMO

Benefit details: Health Plan label from the exact January 2027 summary. EOC booklets are marked tbd; confirm the detailed provider network and current participation.

Inside Network: No PEC

Inside Network: Unlimited

Benefit details: • Bariatric surgery • Children’s glasses • Cosmetic surgery • Dental care (Adult and child) • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Private-duty nursing • Routine foot care • Weight loss programs

Benefit details: Limitations may apply; this is not a complete list. See the plan document. • Acupuncture (12 visit limit / year) • Chiropractic care (10 visit limit / year) • Hearing aids (1 aid / ear / 36 months) • Routine eye care (Adult)

Deductibles: $4,500

Copayments: $0

Coinsurance: $2,100

Limits or exclusions: $20

Benefit details: Standardized self-only illustration, not a cost estimator. Actual care and costs differ.

Deductibles: $4,500

Copayments: $0

Coinsurance: $200

Limits or exclusions: $0

Benefit details: Standardized self-only illustration, not a cost estimator. Actual care and costs differ.

Deductibles: $2,800

Copayments: $0

Coinsurance: $0

Limits or exclusions: $0

Benefit details: Standardized self-only illustration, not a cost estimator. Actual care and costs differ.

Inside Network: Women's sterilization is covered as preventive, and Men's sterilization is covered in full after the annual deductible has been satisfied.

Inside Network: Covered up to 12 visits per calendar year No copay, deductible and coinsurance apply

Inside Network: No copay, deductible and coinsurance apply

Inside Network: 1 aid per ear every 36 months; 50% Coinsurance, Deductible applies

Inside Network: Not covered

Inside Network: Covered up to 10 visits per calendar year without prior authorization No copay, deductible and coinsurance apply

Inside Network: Covered up to 3 visits per medical diagnosis per calendar year without prior authorization; additional visits when approved by the plan No copay, deductible and coinsurance apply

Inside Network: Not covered

Inside Network: Inpatient: Deductible and coinsurance apply Outpatient: No copay, deductible and coinsurance apply

Inside Network: Quit for Life Program - covered in full

Source statement: Routine Foot Care is listed in the source exclusions; review the qualifications.

Inside Network: Deductible applies

Inside Network: Deductible applies

Benefit details: Virtual Care Including Telemedicine, Telephone Services and Online (E-Visits). Exact 2027 summary wording; EOC booklets are marked tbd. Confirm the issued contract and deductible conditions.

Inside Network: Deductible applies

Benefit details: Virtual Care Including Telemedicine, Telephone Services and Online (E-Visits). Exact 2027 summary wording; EOC booklets are marked tbd. Confirm the issued contract and deductible conditions.

iht-2027-kaiser-hhsa-4500

HMO HSA 4500

Kaiser Foundation Health Plan of Washington

HDHP

2027-01-01

2027-12-31

BHT classification: N/A (similar to Silver)

Yes

Yes

Source answer: Yes. Preventive care and services indicated in chart starting on page 2.

Benefit details: This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits.

Inside Network: 4th quarter carryover does not apply

Inside Network: Plan pays 70%, you pay 30%