Medical
Pathways offers two different medical HMO plan options through Kaiser.
Health Maintenance Organization (HMO)
- Kaiser Deductible HMO
- Kaiser Traditional HMO
Here’s an overview of how an HMO plan works:
An HMO provides for predictable costs to the member. You pay a copay for most services, but all care must be received within the HMO network. Out-of-network care is not covered except in an emergency. You may need to meet a deductible (Deductible HMO) before the plan starts to pay. You must also choose a primary care provider. Kaiser plans only allow you to use facilities and providers within the Kaiser network, with the exception of emergency care services.
Each plan has different:
- Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
- Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
- Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
- Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.
2024-25 Kaiser Traditional HMO
Plan Information
Plan Name: 2024-25 Kaiser Traditional HMO
Policy Number: 35962-0000
Effective Date: 07/01/2024
Provider Network: Kaiser
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$0
Out-of-Pocket Max (Individual/Family)
$1,500/$3,000
Preventive Care
$0
Primary Care Visit
$15 copay
Specialist Visit
$15 copay
Urgent Care
$15 copay
Emergency Room
$100 copay
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$20 copay
Specialty
20% coinsurance (not to exceed $250)
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$40 copay
Contact Information
2024-25 Kaiser Deductible HMO
Plan Information
Plan Name: 2024-25 Kaiser Deductible HMO
Policy Number: 35962-0000
Effective Date: 07/01/2024
Provider Network: Kaiser
In-Network Benefit Highlights
Deductible (Individual/Family)
$XX/$XX
Out-of-Pocket Max (Individual/Family)
$XX/$XX
Preventive Care
$XX
Primary Care Visit
$XX
Specialist Visit
$XX
Urgent Care
$XX
Emergency Room
$XX
Benefit Highlights
In-Network Only
Deductible (Individual/Family)
$1,000/$2,000
Out-of-Pocket Max (Individual/Family)
$3,000/$6,000
Preventive Care
$0
Primary Care Visit
$20 copay
Specialist Visit
$20 copay
Urgent Care
$20 copay
Emergency Room
20% after deductible
Retail Rx (Up to 30-Day Supply)
Generic
$10 copay
Preferred Brand
$30 copay
Specialty
$30 copay
Mail-Order Rx (Up to 90-Day Supply)
Generic
$20 copay
Preferred Brand
$60 copay
Specialty
Not covered