HSA Compatible Benefits from Kaiser Permanente Individual and Family Health Plans

Oregon Health Insurance
Call 800.884.2343 or
541.434.9613
FAX - 541.284.2994

HSA-COMPATIBLE PLANS	$1,500 w/Rx	$1,500	$2,600 w/Rx	$2,600
Features
Deductible	$1,500/$3,000		$2,600/$5,200
Out-of-pocket maximum	$5,000/$10,000
Lifetime maximum	$2 million
Benefits	Services not subject to deductible unless otherwise indicated
Preventive Care
Immunizations	No charge
Routine physicals	20% coinsurance
Well-baby visits
Gynecholgical exams/Mammograms
Outpatient services (per visit or procedure)
Primary care office visit	20% coinsurance (after deductible)
Specialty care office visit
Nurse treatment visit (includes allergy injections)¹
Outpatient surgery²
Lab tests²
X-rays²
Inpatient hospital care
Inpatient care (including maternity)	20% coinsurance (after deductible)
Maximum per admittance	None
Maternity coverage
Prenatal care (applies to prenatal office visits, one postnatal visit, and lactation consultants)	20% coinsurance
Emergency & urgent care
Emergency Department visit	20% coinsurance (after deductible)
Urgent care visit
Ambulance Service
Prescription drugs
(up to a 30-day supply)	$15 generic / $30 brand after medical deductible	Not covered	$15 generic / $30 brand after medical deductible	Not covered
Other services
Vision exams	20% coinsurance (after deductible)
Vision hardware allowance (applies to lenses, frames, and/or contacts every 24 months)	Not covered