Our plan options
High Option
Plan Features
- No deductible
- Lowest copays for services and prescription drugs
Best option if you
- Anticipate frequent care visits
- Want predictable and low out-of-pocket costs
Standard Option
Plan Features
- Lower premiums than High Option
- Predictable copays
- Low $100 deductible
Best option if you
- Want a lower premium and predictable out-of-pocket costs
Prosper (formerly named Basic Option)
- Lowest premium option
- Lower copays for office visits and urgent care services than our Standard Option
- $500 deductible (does not apply to preventive care, office visits, urgent care, prescription drugs and more)
Best option if you
- Are in good overall health
- Want to pay the lowest premiums
2022 plan rates
Self Only
Bi-weekly$217.74
Monthly$471.77
Enrollment
code591
Self Plus One
Bi-weekly$579.64
Monthly$1,255.89
Enrollment
code593
Self and Family
Bi-weekly$530.14
Monthly$1,148.64
Enrollment
code592
Self Only
Bi-weekly$131.24
Monthly$284.35
Enrollment
code594
Self Plus One
Bi-weekly$355.43
Monthly$770.10
Enrollment
code596
Self and Family
Bi-weekly$305.93
Monthly$662.85
Enrollment
code595
Self Only
Bi-weekly$75.99
Monthly$164.64
Enrollment
codeKC1
Self Plus One
Bi-weekly$186.61
Monthly$404.32
Enrollment
codeKC3
Self and Family
Bi-weekly$177.81
Monthly$385.25
Enrollment
codeKC2
| High Option | Standard Option | Prosper | |||||||
| Enrollment Code | Bi-Weekly | Monthly | Enrollment Code | Bi-Weekly | Monthly | Enrollment Code | Bi-Weekly | Monthly | |
| Self Only | 591 | $217.74 | $471.77 | 594 | $131.24 | $284.35 | KC1 | $75.99 | $164.64 |
| Self Plus One | 593 | $579.64 | $1,255.89 | 596 | $355.43 | $770.10 | KC3 | $186.61 | $404.32 |
| Self and Family | 592 | $530.14 | $1,148.64 | 595 | $305.93 | $662.85 | KC2 | $177.81 | $385.25 |
Enrollees covering themselves and one other eligible family member may choose either the Self Plus One or Self and Family enrollment type, whichever has a lower premium.
These rates do not apply to all enrollees. If you are in a special enrollment category, please refer to the FEHBP Program website or contact the agency or Tribal Employer which maintains your health benefits enrollment.
Self Only
Bi-weekly
category 1$223.31
Bi-weekly
category 2$213.25
Enrollment
code591
Self Plus One
Bi-weekly
category 1$593.13
Bi-weekly
category 2$571.57
Enrollment
code593
Self and Family
Bi-weekly
category 1$547.72
Bi-weekly
category 2$524.30
Enrollment
code592
Self Only
Bi-weekly
category 1$134.76
Bi-weekly
category 2$124.70
Enrollment
code594
Self Plus One
Bi-weekly
category 1$363.86
Bi-weekly
category 2$342.30
Enrollment
code596
Self and Family
Bi-weekly
category 1$318.45
Bi-weekly
category 2$295.03
Enrollment
code595
Self Only
Bi-weekly
category 1$72.23
Bi-weekly
category 2$62.45
Enrollment
codeKC1
Self Plus One
Bi-weekly
category 1$179.59
Bi-weekly
category 2$158.03
Enrollment
codeKC3
Self and Family
Bi-weekly
category 1$169.02
Bi-weekly
category 2$146.13
Enrollment
codeKC2
| High Option | Standard Option | Prosper | |||||||
| Enrollment Code | Bi-Weekly Category 1 | Bi-Weekly Category 2 | Enrollment Code | Bi-Weekly Category 1 | Bi-Weekly Category 2 | Enrollment Code | Bi-Weekly Category 1 | Bi-Weekly Category 2 | |
| Self Only | 591 | $223.31 | $213.25 | 594 | $134.76 | $124.70 | KC1 | $72.23 | $62.45 |
| Self Plus One | 593 | $593.13 | $571.57 | 596 | $363.86 | $342.30 | KC3 | $179.59 | $158.03 |
| Self and Family | 592 | $547.72 | $524.30 | 595 | $318.45 | $295.03 | KC2 | $169.02 | $146.13 |
Enrollees covering themselves and one other eligible family member may choose either the Self Plus One or Self and Family enrollment type, whichever has a lower premium.
These rates do not apply to all enrollees. If you are in a special enrollment category, please refer to the FEHBP Program website or contact the agency or Tribal Employer which maintains your health benefits enrollment.
2022 Summary of Benefits
| High Option | Standard Option | Prosper | |
|---|---|---|---|
| Deductible | None | $100 | $500 |
| 2022 Benefits and Services | |||
| Outpatient services | |||
| Preventive care | $0 | $0 | $0 |
| Telehealth | $0 | $0 | $0 |
| Primary care office visit | $15 | $30 | $25 |
| Specialty care office visit | $25 | $40 | $35 |
| Laboratory tests | $0 | $101 | 20%1 |
| X-rays | $0 | $101 | 20%1 |
| Chiropractic services – 20 visits per year | $15 | $15 | $15 |
| Maternity | |||
| Routine prenatal care and postpartum visit | $0 | $0 | $0 |
| Delivery | $250 | $5001 | 20%1 |
| Hospital services | |||
| Outpatient surgery | $50 | $2001 | 20%1 |
| Inpatient hospital | $250 | $5001 | 20%1 |
| Emergency and urgent care | |||
| Urgent care | $15 | $30 | $25 |
| Emergency care | $100 | $1501 | 20%1 |
| Ambulance | $50 | $1501 | 20%1 |
| Prescription drugs | |||
| Generic | $10 | $15 | $15 |
| Brand | $40 | $50 | $60 |
| Specialty | $100 | $150 | $200 |
| Out-of-pocket maximum | $2,000 | $3,000 | $5,500 |
1Deductible applies.
Notes:
- Deductible and out-of-pocket maximum amounts are per person, but no more than 2 times per family.
- Coinsurance (%) is based on our allowance.
- Telehealth options include video, phone, email and more. See page 7, Convenient ways to get care.
- Prescription drug copayments are for a 30-day supply at Kaiser Permanente pharmacies. You pay only 2 copays for up to a 100-day supply for most drugs through Kaiser Permanente’s mail-order program.
This is a summary of the features of the Kaiser Permanente – Northern California FEHB plan. Before making a final decision, please read the Plan’s Federal brochure (RI 73-003). All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure.
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