HMOs
What you need to know
Individuals in the New York, Maryland, Virginia, Washington, D.C., or California metropolitan areas can choose an HMO medical plan instead of a Cigna plan. In the HMO plans, you pay low copays and typically don’t need to pay coinsurance or deductibles. The plans also include prescription drug coverage. Learn if you’re eligible for coverage.
HMO Basics
With an HMO, you receive all care (except in emergencies) within the HMO’s network. A primary care physician (PCP) coordinates your care and authorizes referrals if you need to see a specialist.
If you choose HMO coverage, you will receive detailed information from the HMO about what your plan covers, its cost-sharing requirements, limits and exclusions, rules and procedures to follow, a list of its providers, and contact information.
You can review information about all of the HMO options that are available. You are eligible to enroll in an HMO option as long as it is available in the area where you live. Please note that if you are electing an HMO Plan, the Tiers will also apply, depending on the HMO plan you choose. There are no buy-up/elect-down options with HMO plan elections:
- For Kaiser Northern CA., Southern CA., and Mid-Atlantic HMO coverage, you will be eligible to elect any of these HMO Plans regardless of the Tier of coverage you earn, in which only 11 weeks will get used.
- For Emblem Health (HIP NY) HMO Prime Coverage, you will be eligible to elect this HMO Plan ONLY if you qualify for Tier 1, in which 15 weeks will get used.
- For Emblem Health (HIP NY) HMO Point of Service Coverage, you will be eligible to elect this HMO Plan ONLY if you qualify for Tier 2. Please note that this HMO Plan has more out-of-picket costs vs. the HMO Prime HMO Plan, in which 11 weeks will get used.
Extended tour out of town?
HMO coverage is local. If you think you’ll be away from your residence and working in a location where an HMO is not available, consider a Cigna plan instead.
HIP, an EmblemHealth company—New York
Your care is covered when you use EmblemHealth network doctors and facilities. To see a specialist, you must receive a referral from your primary care doctor. Except for preventive care, you’ll pay a small copay for most office visits, and you’ll pay nothing for most inpatient services. This plan includes dental checkups, basic vision care, and eyeglasses for covered participants and their dependents.
Manage your health, set up prescription delivery and refills, and access information by signing in to your member portal.
To see what you pay for coverage, view the premium rates.
Plan at a glance
The Plan design below is for the Tier 1 Plan. See the HMO plan option for Tier 2.
Plan features
What You Pay
Annual Deductible
Out-of-Pocket Maximum
$14,300 family
Preventive Care (includes age-appropriate screenings and vaccines)
Primary Care Visits
Specialist Visits
X-Rays, Labs, and Diagnostic Tests
Urgent Care
Emergency Room
Hospitalization, Inpatient Services
Mental Health and Substance Use (outpatient)
Mental Health and Substance Use (inpatient)1
Chiropractic Therapy
Physical Therapy
$30 per visit copay when services are performed at a primary care provider’s office
Acupuncture
1 Preauthorization is required, except for emergency admissions.
Prescription drug coverage
Prescription drug coverage is managed by Express Scripts, the largest independent manager of pharmacy benefits. This plan offers network coverage only. You can fill your prescriptions via mail order or at your local pharmacy—just show your prescription drug ID card.
Your HMO plan covers generic and preferred brand drugs, and 30- and 90-day fills for generic and preferred drugs. The prescription drug coverage has a $100 annual deductible. Once you meet the $100 deductible, the copays show in the chart below apply.
Retail (30-day fill)
Generic
Brand
Non-Preferred Brand
Specialty (Generic or Preferred)
Preferred: $50 copay
Non-Preferred: $100 copay
Mail Order
(90-day fill)
Generic
Brand
Non-Preferred Brand
Specialty (Generic or Preferred)
Kaiser Permanente—Mid-Atlantic
Most services are only covered by Kaiser plan providers and facilities; however, for emergency care, you will pay the same copay if you see a non-plan provider. This plan includes dental checkups, basic vision care, and eyeglasses for your covered child(ren).
Get resources to manage your care and get the most from your plan by logging in to your Kaiser member portal.
Learn more about Kaiser Permanente—Mid-Atlantic.
To see what you pay for coverage, view the premium rates.
Plan at a glance
Plan features
What You Pay
Annual Deductible
Out-of-Pocket Maximum
$9,400 family
Preventive Care (includes age-appropriate screenings and vaccines)
Primary Care and Specialist Visits
X-Rays, Labs, and Diagnostic Tests
Urgent Care
Emergency Room
Hospitalization, Inpatient Services
Mental Health and Substance Use (outpatient)
Mental Health and Substance Use (inpatient)
Physical Therapy
Acupuncture
Prescription drug coverage1,2
Kaiser prescription drug benefits are covered through Kaiser Pharmacy. This plan offers network coverage only. You can fill prescriptions via mail order, at a Kaiser retail pharmacy, or at other participating pharmacies.
For detailed information about prescription drug coverage, visit Kaiser’s drug formulary page.
Kaiser Pharmacy
Generic
Preferred
Non-preferred
Participating Pharmacy
Generic
Preferred
Non-preferred
Mail Order (90-day fill)
Generic
Preferred
Non-preferred
1 You pay nothing for preventive drugs, contraceptives, or oral chemotherapy drugs.
2 Up to 60-day supply. For a 90-day supply, your copay will be 1.5 times the 60-day copay.
For specialty drugs, the applicable generic, preferred, and non-preferred brand copays apply.
Kaiser Permanente—Northern California
Most services are only covered by Kaiser plan providers and facilities; however, you will pay the same copay if you see a non-plan provider for urgent and emergency services. The plan includes an eye exam for your covered child(ren).
Get resources to manage your care and get the most from your plan by logging in to your Kaiser member portal.
Learn more about Kaiser—Northern California.
To see what you pay for coverage, view the premium rates.
Plan at a glance
Plan features
What You Pay
Annual Deductible
Out-of-Pocket Maximum
$3,000 family
Preventive Care (includes age-appropriate screenings and vaccines)
Primary Care and Specialist Visits
X-Rays, Labs, and Diagnostic Tests
Urgent Care
Emergency Room
Hospitalization, Inpatient Services
Mental Health and Substance Use (outpatient)
Mental Health and Substance Use (inpatient)
Physical Therapy
Acupuncture1
1Kaiser will refer you to an acupuncturist if you need these services.
Prescription drug coverage
Kaiser prescription drug benefits are covered through Kaiser Pharmacy. This plan offers network coverage only. You can fill prescriptions via mail order or at a Kaiser retail pharmacy.
For detailed information about prescription drug coverage, visit Kaiser’s drug formulary page.
Kaiser Pharmacy
Generic1
Preferred1
Non-Preferred2
Specialty3
Mail Order
(90-day fill)
Generic1
Preferred1
Non-Preferred2
Specialty3
1 Up to a 100-day supply pharmacy and mail order; no charge for contraceptives.
2 You pay the same as for a preferred brand drug when approved through exception process.
3 Up to a 30-day supply through Kaiser retail pharmacy. Subject to formulary guidelines.
Kaiser Permanente—Southern California
Most services are only covered by Kaiser plan providers and facilities; however, you will pay the same copay if you see a non-plan provider for urgent and emergency services. The plan includes an eye exam for your covered child(ren).
Get resources to manage your care and get the most from your plan by logging in to your Kaiser member portal.
Learn more about Kaiser—Southern California.
To see what you pay for coverage, view the premium rates.
Plan at a glance
Plan features
What You Pay
Annual Deductible
Out-of-Pocket Maximum
$3,000 family
Preventive Care (includes age-appropriate screenings and vaccines)
Primary Care and Specialist Visits
X-Rays, Labs, and Diagnostic Tests
Urgent Care
Emergency Room
Hospitalization, Inpatient Services
Mental Health and Substance Use (outpatient)
Mental Health and Substance Use (inpatient)
Physical Therapy
Acupuncture1
1Kaiser will refer you to an acupuncturist if you need these services.
Prescription drug coverage
Kaiser prescription drug benefits are covered through Kaiser Pharmacy. This plan offers network coverage only. You can fill prescriptions via mail order or at a Kaiser retail pharmacy.
For detailed information about prescription drug coverage, visit Kaiser’s drug formulary page.
Kaiser Pharmacy
Generic1
Preferred1
Non-Preferred2
Specialty3
Mail Order
(100-day fill)
Generic1
Preferred1
Non-Preferred2
Specialty3
1 Up to a 100-day supply pharmacy and mail order; no charge for contraceptives.
2 You pay the same as for a preferred brand drug when approved through exception process.
3 Up to a 30-day supply through Kaiser retail pharmacy. Subject to formulary guidelines.