CA Residents San Diego County Residents EPO Copay 5000 PPO 5000 with HSA Kaiser CA HMO 2000 w/ HSA SIMNSA Baja CA Premier Access HMO $5,000 / $10,0001 $5,0005 / $10,0001,5 $2,000 / $4,00010 N/A 20% 20% 20% None $7,000 / $14,000 $6,5506 / $13,1006 $3,425 / $6,850 $6,350 / $12,700 N/A You can contribute pre-tax dollars to an HSA through HealthEquity. IRS limits for 2022 are $3,650 (employee only) and $7,300 (family). You can contribute an additional $1,000 if you are age 55 or older in 2022. You can contribute pre-tax dollars to an HSA through HealthEquity. IRS limits for 2022 are $3,650 (employee only) and $7,300 (family). You can contribute an additional $1,000 if you are age 55 or older in 2022. N/A IN-NETWORK YOU PAY NETWORK ONLY YOU PAY NETWORK ONLY YOU PAY Covered in full3 Covered in full3 Covered in full3 Covered in full Through Teladoc $25 copay $25 copay Through Teladoc 10%2 (Cost is $40 per visit) 10%2 (Cost is $40 per visit) 20%2 N/A N/A N/A Through 98point6 FREE Through 98point6 $5 copay N/A N/A $45 copay 20%2 20%2 $5 copay $75 copay 20%2 20%2 $5 copay $75 copay 20%2 20%2 $25 copay (provider in Mexico) $50 copay (provider outside Mexico) $500 copay2,7 then you pay 30% $500 copay2,7 then you pay 30% 20%2 $250 copay7 20%2 20%2 20%2 Covered in full 20%2 20%2 20%2 Covered in full 20%2 20%2 20%2 20%2 20%2 20%2 Covered in full Covered in full 20%2 20%2 20%2 $10 copay 20%2 $45 copay 20%2 20%2 20%2 20%2 Covered in full $5 copay 30-day supply11 100% covered3 $10 copay3 $25 copay2 $40 copay2 20%2,8 up to $125 30-day supply11 100% covered3 $10 copay2 $25 copay2 $40 copay2 20%2,8 up to $125 30-day supply 100% covered3 $10 copay2 $30 copay2 N//A 20%2 up to $125 30-day supply 100% covered $5 copay $5 copay $5 copay $5 copay 90-day supply 100% covered3 $20 copay3 $50 copay2 $80 copay2 90-day supply 100% covered3 $20 copay2 $50 copay2 $80 copay2 100-day supply 100% covered3 $20 copay2 $60 copay2 N/A 90-day supply N/A N/A N/A N/A 7) Emergency Room copay waived if admitted. 8) May be available at CerpassRx retail pharmacy or Pharmacy Mail Service if authorized. Note that any specialty drug discounts through copay cards or coupons will not apply towards the calendar year deductible or out-of-pocket maximum. 9) Intensive outpatient: $250 copay per visit plus 20% after calendar year deductible. 10) $2,800 for one member in family coverage. 11) A $10 copay will be added to the cost for any prescriptions filled at Walgreens. 11 NETWORK ONLY YOU PAY
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