Imagine this: all the health care services you need under one roof, your care coordinated centrally so that all you need to do is show up at the right time and place for your appointment. That can be your reality if you live in one of the regions where a Kaiser Health Maintenance Organization (HMO) medical plan is available to you. Keep in mind that this plan uses its own network of doctors and facilities and offers no out-of-network coverage. This plan is only available in CA, CO, GA, HI, WA, and mid-Atlantic states.
Note: The Kaiser HMO is the default plan for State Farm employees who live in Hawaii.
Is this plan available to you?
Access to the Kaiser HMO depends on your residential zip code. To determine which plans are available to you based on your home zip code and how much you’ll pay for coverage, use the Pricing Modeler.
How the plan works
You must use Kaiser network providers
When you enroll in the plan, you choose a primary care provider who will manage all your care and provide referrals to specialists within the Kaiser network, as needed. The plan doesn’t cover out-of-network care, except for emergency care.
You pay nothing for preventive care
In-network preventive care is covered at 100%. You do not have to meet the deductible first.
Getting annual physicals and recommended screenings and vaccinations can help you maintain good health and identify potential health issues as soon as possible.
You’ll pay a copay for primary care and specialist doctor’s office visits
The deductible does not apply.
For other services, you must meet your annual deductible before the plan helps cover the cost of your care
These include labs, X-rays, hospital stays, and emergency care. Once you meet your deductible, you and the plan share the cost of these services through coinsurance.
After you reach the out-of-pocket maximum, the plan pays 100% of the cost of services for the rest of the year
The annual deductible and the amount you pay out of pocket for coinsurance all count toward your out-of-pocket maximum.
Prior authorization may be required
Some medical services and prescription drugs require prior authorization before they are covered. This means your health care provider must get approval from your insurance provider in advance. If prior authorization isn’t obtained, you may be responsible for the full cost. This process helps ensure that care is safe, appropriate, and covered under the plan. Review the plan documents on the My State Farm Benefits Resource website (auto sign-on with SSOYou must be on the State Farm network to access this link. | log in) for more information. On the home page, select Plan Documents from the left navigation, then select the Health and Insurance dropdown.
For plan-specific details, visit the My State Farm Benefits Resource website (auto sign-on with SSOYou must be on the State Farm network to access this link. | log in) to review the Summary of Benefits and Coverage (SBC) for your location.
How to find a provider
To find a Kaiser doctor near you, visit the Kaiser website > Find Doctors and Locations.
Plan at a glance
Here’s what you’ll pay for care.
| Feature or service | Your cost |
|---|---|
| Provider network | Kaiser Permanente |
| Annual deductible (medical only) | Individual: $350 Family: $700 |
| Out-of-pocket maximum (medical and prescription drug) | Individual: $3,000 Family: $6,000 |
| Preventive care (screenings and immunizations) | $0, deductible does not apply |
| Primary care visit | $30 copay, deductible does not apply |
| Specialty care visit | $50 copay, deductible does not apply |
| Mental health visit | $30 copay, deductible does not apply |
| Coinsurance (costs that you and the plan share after you meet the deductible) | You pay 20% after deductible |
| Emergency care | You pay 20% after deductible |
| Outpatient surgery | You pay 20% after deductible |
| Hospitalization | You pay 20% after deductible |
Note that medical coverage differs under the Kaiser Hawaii plans. For more details, review your plan’s Summary of Benefits and Coverage (SBC) on the My State Farm Benefits Resource website (auto sign-on with SSOYou must be on the State Farm network to access this link. | log in). On the home page, select Plan Documents from the left navigation, then select the Health and Insurance dropdown.
Prescription drugs
You can fill prescriptions through Kaiser retail pharmacies or through Kaiser mail order. To review your plan’s Summary of Benefits and Coverage (SBC) for mail-order costs, go to the My State Farm Benefits Resource website (auto sign-on with SSOYou must be on the State Farm network to access this link. | log in). On the home page, select Plan Documents from the left navigation, then select the Health and Insurance dropdown.
Here’s what you can expect to pay at Kaiser retail pharmacies:
| Drug tier | 30-day retail supply |
|---|---|
| Tier 1: Generic drugs | $15 copay |
| Tier 2: Preferred brand | $35 copay |
| Tier 3: Non-preferred brand1 | $65 copay |
| Tier 4: Specialty | You pay 20% after deductible, up to $150 |
1Not available in California
Note that prescription drug coverage differs under the Kaiser Hawaii plans. For prescription drug details, review your plan’s Summary of Benefits and Coverage (SBC) on the My State Farm Benefits Resource website (auto sign-on with SSOYou must be on the State Farm network to access this link. | log in).
Virtual care
Kaiser offers convenient virtual care options, including:
- Video visits with your doctor or specialist (at the same cost as an in-person visit)
- 24/7 Nurse Advice Line (you’ll find the phone number on the back of your Kaiser membership card)
- Secure messaging through kp.org or the Kaiser app