Our plan options
High Option
Plan Features
- $0 copay for telehealth — always
- Lowest copays
- Most out of pocket costs are copays
- $0 deductible
Best option if you
- Anticipate frequent care visits
- Want predictable and low out-of-pocket costs
Standard Option
Plan Features
- $0 copay for telehealth — always
- Lower premium than High Option
- Most out of pocket costs are copays
- $0 copays for children
- $0 for inpatient maternity
- $0 deductible
Best option if you
- Want a lower premium and predictable out-of-pocket costs
- Have young children or plan to start a family
Prosper
Plan Features
- $0 copay for telehealth — always
- Our lowest premium option
- Most out of pocket costs are copays
- $100 deductible
Best option if you:
- Are in good overall health
- Want to pay the lowest premiums
High Option
| Enrollment Code | Bi-weekly | Monthly |
|---|---|---|
| Self only (621) |
$99.93 | $216.51 |
| Self + 1 (623) |
$270.70 | $586.52 |
| Self & Family (622) |
$219.80 | $476.24 |
Standard Option
| Enrollment Code | Bi-weekly | Monthly |
|---|---|---|
| Self only (624) |
$60.92 | $132.00 |
| Self + 1 (626) |
$140.81 | $305.08 |
| Self & Family (625) |
$140.81 | $305.08 |
Prosper
| Enrollment Code | Bi-weekly | Monthly |
|---|---|---|
| Self only (FL1) |
$42.15 | $91.33 |
| Self + 1 (FL3) |
$96.96 | $210.07 |
| Self & Family (FL2) |
$118.03 | $255.74 |
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.
2023 Summary of Benefits
| High Option | Standard Option | Prosper | |
|---|---|---|---|
| Deductible | None | None | $100 |
| 2023 Benefits and Services | |||
| Outpatient services | |||
| Preventive care | $0 | $0 | $0 |
| Telehealth | $0 | $0 | $0 |
| Primary care office visit | $15 | $30 ($0 for children through age 17) | $30 |
| Specialty care office visit | $25 | $40 ($0 for children through age 17) | $40 |
| Laboratory tests | $0 | $10 | $101 |
| X-rays | $0 | $10 | $101 |
| Chiropractic and acupuncture services – 20 combined visits per year | $15 | $15 | Not covered |
| Maternity | |||
| Routine prenatal care and postpartum visit | $0 | $0 | $0 |
| Delivery | $250 | $0 | $7501 |
| Hospital services | |||
| Outpatient surgery | $50 | $200 | $3001 |
| Inpatient hospital | $250 | $500 | $7501 |
| Emergency and urgent care | |||
| Urgent care | $15 | $30 ($0 for children through age 17) | $30 |
| Emergency care | $100 | $150 | $1501 |
| Ambulance | $50 | $150 | $2001 |
| Prescription drugs | |||
| Generic | $10 | $15 | $15 |
| Brand | $40 | $50 | $60 |
| Specialty | $100 | $150 | $200 |
| Out-of-pocket maximum | $2,000 | $3,000 | $5,000 |
1 Deductible applies.
Notes:
- 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.
- Deductible and out-of-pocket maximum amounts are per person, but no more than 2 times per family.
This is a summary of the features of the Kaiser Permanente – Southern California FEHB plan. Before making a final decision, please read the Plan’s Federal brochure (RI 73-822). All benefits are subject to the definitions, limitations, and exclusions set forth in the Federal brochure.
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Care for growing families
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