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
Basic Option
Plan Features
- 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
2021 plan rates
Self Only
Bi-weekly$226.67
Monthly$491.12
Enrollment
code591
Self Plus One
Bi-weekly$600.32
Monthly$1,300.70
Enrollment
code593
Self and Family
Bi-weekly$555.53
Monthly$1,203.65
Enrollment
code592
Self Only
Bi-weekly$138.12
Monthly$299.26
Enrollment
code594
Self Plus One
Bi-weekly$371.05
Monthly$803.95
Enrollment
code596
Self and Family
Bi-weekly$326.26
Monthly$706.90
Enrollment
code595
Self Only
Bi-weekly$75.24
Monthly$163.02
Enrollment
codeKC1
Self Plus One
Bi-weekly$186.78
Monthly$404.69
Enrollment
codeKC3
Self and Family
Bi-weekly$176.06
Monthly$381.46
Enrollment
codeKC2
High Option | Standard Option | Basic Option | |||||||
Enrollment Code | Bi-Weekly | Monthly | Enrollment Code | Bi-Weekly | Monthly | Enrollment Code | Bi-Weekly | Monthly | |
Self Only | 591 | $226.67 | $491.12 | 594 | $138.12 | $299.26 | KC1 | $75.24 | $163.02 |
Self Plus One | 593 | $600.32 | $1,300.70 | 596 | $371.05 | $803.95 | KC3 | $186.78 | $404.69 |
Self and Family | 592 | $555.53 | $1,203.65 | 595 | $326.26 | $706.90 | KC2 | $176.06 | $381.46 |
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 | Basic Option | |||||||
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.
2021 Summary of Benefits
High Option | Standard Option | Basic Option | |
---|---|---|---|
Deductible | None | $100 | $500 |
2021 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.
- 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 health 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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