11 Southern CA Residents CHOICE HSA PLAN PREMIER EPO PLAN KAISER HMO WITH HSA (CA, CO, OR, WA) SIMNSA Baja CA Premier Access HMO (San Diego County) IN-NETWORK YOU PAY NETWORK ONLY YOU PAY NETWORK ONLY YOU PAY NETWORK ONLY YOU PAY $$ $$$ $$$ $ Covered in full3 Covered in full3 Covered in full3 Covered in full Through Teladoc 10%2 (Cost is $55 per visit) 10%2 (Cost is $55 per visit) Through Teladoc $5 copay $5 copay 20%2 N/A N/A N/A Through 98point6 $8 copay14 Through 98point6 FREE N/A N/A $2,0005 / $4,0001,5 $4,0005 / $8,0001,5 $1,000 / $2,0001 N/A $3,000 / $6,0001 N/A N/A N/A 20% 20% 20% None $6,0006 / $12,0006 $2,000 / $4,000 $4,425 / $8,850 $6,350 / $12,700 You can contribute pre-tax dollars to an HSA through Fidelity. IRS limits for 2025 are $4,300 (employee only) and $8,550 (family). You can contribute an additional $1,000 if you are age 55 or older in 2025. N/A You can contribute pre-tax dollars to an HSA through Fidelity. IRS limits for 2025 are $4,300 (employee only) and $8,550 (family). You can contribute an additional $1,000 if you are age 55 or older in 2025. N/A 20%2 $30 copay 20%2 $5 copay 20%2 $50 copay 20%2 $5 copay 20%2 $50 copay 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 20% 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 $500 copay2, then you pay 20% 20%2 20%2 20%2 Covered in full Covered in full 20%2 FREE 20%2 FREE 20%2,11 N/A $10 copay N/A 20%2 20%2 $500 copay then 20%2 $30 copay9 20%2,12 20%2 Covered in full $5 copay 30-day supply10 (see footnote) 100% covered3/$5 copay13 $10 copay2 $25 copay2 $40 copay2 20%2,8 up to $125 30-day supply10 (see footnote) 100% covered3/$5 copay13 $10 copay3 $25 copay3 $40 copay3 20%3,8 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/$10 copay13 $20 copay2 $50 copay2 $80 copay2 90-day supply 100% covered3/$10 copay13 $20 copay3 $50 copay3 $80 copay3 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) M ay be available at CerpassRX retail pharmacy or Pharmacy Mail Service if authorized. Note that any specialty drug discount coupons will not apply towards the calendar year deductible our out-of-pocket maximum. 9) O utpatient facility: $250 copay per visit plus 20% after calendar year deductible. 10) A $10 copay will be added to the cost for any prescriptions filled at Walgreens. 11) Max 30 visits per year Kaiser HMO with HSA in OR & SE WA. 12) N o charge after deductible for group therapy visits (Kaiser HMO WA). 13) A pplies to certain brand-name preventive drugs not covered under the Affordable Care Act. 14) F ree after calendar year deductible is met.
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