HMO 5000

Source answer: $5,000 Individual / $10,000 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 plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible.

Benefit details: Summary (Inside Network): Individual deductible: $5,000 per calendar year Family deductible: $10,000 per calendar year

Source answer: No.

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

Inside Network: $15 copay primary/$30 copay specialty, deductible and coinsurance do not 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: $7,900 Individual / $15,800 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, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met.

Benefit details: Summary (Inside Network): Individual out-of-pocket limit: $7,900 Family out-of-pocket limit: $15,800 Out-of-pocket expenses for the following covered services are included in the out-of-pocket limit: All cost shares for covered services

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: $15 / visit, deductible does not apply.

In-network: $30 / visit, deductible does not apply.

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

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: $15 (retail); $30 (mail order) / prescription, deductible does not apply.

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

In-network: $30 (retail); $60 (mail order) / prescription, deductible does not apply.

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: 50% coinsurance up to $150 (retail) / prescription, deductible does not apply

Benefit details: Up to a 30-day supply (retail). Subject to formulary guidelines.

Inside Network: Preferred generic/preferred brand/preferred specialty $15/$30/50% up to $150 per 30 day supply

Inside Network: 2 x prescription cost share per 90 day supply

In-network: $30 / visit, then 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: $15 copay primary/$30 copay specialty, deductible and coinsurance apply

Inside Network: Unlimited, no waiting period Inpatient: Deductible and coinsurance apply Outpatient: $15 copay, deductible and coinsurance do not apply

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

In-network: $50 / visit, then 30% coinsurance

Benefit details: You must notify Kaiser Permanente within 24 hours if admitted to a Non-network provider; limited to initial emergency only. Copayment waived if admitted directly to the hospital as an inpatient.

Benefit details: Summary (Inside Network): $50 copay at a designated facility $50 copay at a non designated facility Deductible and coinsurance apply

In-network: 20% coinsurance, deductible does not apply.

Benefit details: Summary (Inside Network): Plan pays 80%, you pay 20%

In-network: $15 / visit, deductible does not apply.

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

In-network: $15 / visit, deductible does not apply.

In-network: 30% coinsurance

Benefit details: Preauthorization required

Inside Network: Deductible and coinsurance apply

Inside Network: $15 copay, deductible and coinsurance do not apply

Inside Network: Deductible and coinsurance apply

Inside Network: $15 copay, deductible and coinsurance do not 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: $15 copay, deductible and coinsurance do not apply. Routine care not subject to outpatient services copay.

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: No Charge, deductible does not apply.

Benefit details: 130 visit limit / year. Preauthorization required

Benefit details: Summary (Inside Network): Covered in full up to 130 visits total per calendar year

In-network: Outpatient: $30 / visit, deductible does not apply. 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. $15 copay primary/$30 copay specialty, deductible and coinsurance do not apply

In-network: Outpatient: $30 / visit, deductible does not apply. 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: 20% coinsurance, deductible does not apply.

Benefit details: Subject to formulary guidelines. Preauthorization required

Benefit details: Summary (Inside Network): Covered at 80%

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

Benefit details: Preauthorization required

Benefit details: Summary (Inside Network): Covered in full

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. $15 copay primary/$30 copay specialty, deductible and coinsurance do not apply

In-network: $15 / visit for refractive exam, deductible does not apply.

Benefit details: Limited to 1 exam / 12 months

In-network: Not covered

In-network: Not covered

Inside Network: $15 copay, deductible and coinsurance waived

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: $5,000

Copayments: $10

Coinsurance: $2,000

Limits or exclusions: $20

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

Deductibles: $40

Copayments: $900

Coinsurance: $0

Limits or exclusions: $0

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

Deductibles: $900

Copayments: $200

Coinsurance: $200

Limits or exclusions: $0

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

Inside Network: Covered in full

Inside Network: Covered up to 12 visits per calendar year $15 copay, deductible and coinsurance do not apply

Inside Network: $15 copay, deductible and coinsurance do not apply

Inside Network: 1 aid per ear every 36 months; Covered at 80%

Inside Network: Not covered

Inside Network: Covered up to 10 visits per calendar year without prior authorization $15 copay, deductible and coinsurance do not apply

Inside Network: Covered up to 3 visits per medical diagnosis per calendar year without prior authorization; additional visits when approved by the plan $15 copay, deductible and coinsurance do not apply

Inside Network: Not covered

Inside Network: Inpatient: Deductible and coinsurance apply Outpatient: $15 copay, deductible and coinsurance do not 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: Covered in full

Inside Network: Covered in full

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: Covered in full

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-hmo-5000

HMO 5000

Kaiser Foundation Health Plan of Washington

HMO

2027-01-01

2027-12-31

BHT classification: Not inferred: insufficient or disagreeing comparable plan evidence.

No

No

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%

Inside Network: Deductible and coinsurance do not apply to office visits