- News
- Active Health
- Retiree Health
- DB Pension
- Defined Benefit Plan
- Benefit Tabs™
- SPD
- Plan Document
- FAQs
- Forms
- Life Events
- Links
- DC Pension
- Defined Contribution Plan
- SPD
- Plan Document
- Forms
- Life Events
- Links
- SUB Plan
- Supplemental Unemployment Benefit Plan
(IBEW Local 11 and LA NECA only) - Benefit Tabs™
- SPD
- FAQs
- Forms
- Life Events
- Supplemental Unemployment Benefit Plan
- Contact
New Participant Portal
You can enroll for the new Participant Portal experience. Click here for instructions on how to access the new Participant Portal.
Register for New Participant PortalRetiree Health Summary Plan Description
As of January 1, 2026
2.2 Summary of Benefits
2.2.1 Retirees Under Age 65 and not eligible or enrolled in Medicare
2.2.2 Summary of Benefits for Retirees Under Age 65 and not eligible or enrolled in Medicare
| Kaiser Permanente HMO (In Network Only) |
UnitedHealthcare HMO (In Network Only) |
Out-of-Area Plan UnitedHealthcare (In Network Benefits) | |
|---|---|---|---|
| Member Customer Service Number | (800) 464-4000 | (800) 624-8822 | Northern California (800) 624-8822 Out-of-state (866)633-2446 |
| Website | www.kp.org | www.myuhc.com | www.myuhc.com |
| General Features | |||
| Calendar Year Deductible | None | None | $500 per Individual $1,000 per Family |
| Maximum Benefits | Unlimited | Unlimited | Unlimited |
| Annual Co-payment Maximum | $1,500 per Individual, $3,000 per Family |
$2,500 per Individual, $5,000 per Family |
$4,500 per Individual, $9,000 per Family |
| Hospital Benefits | $250 co-payment per admission | $250 co-payment per admission | 80% after deductible has been met |
Emergency Services Co-payment waived if admitted |
$100 co-payment | $250 co-payment | $100 co-payment; deductible does not apply |
Urgently Needed Services Medically Necessary services required outside geographic area service by Primary Medical Group |
$20 co-payment | $20 co-payment | $50 co-payment; deductible does not apply |
| Pre-existing Conditions | All Medically Necessary conditions are covered provided they are a covered benefit | ||
| Benefits Available While Hospitalized as an Inpatient | |||
| Alcohol, Drug or Other Substance Abuse Detoxification | $250 co-payment per admission | $250 co-payment per admission | 80% after deductible |
Mental Health Services As required by law, coverage includes treatment for Severe Mental Illness of adults and the treatment of Serious Emotional Disturbance (SED). |
$250 co-payment per admission | $250 co-payment per admission | 80% after deductible |
| Physician Care | $250 co-payment | No Charge | 80% after deductible |
| Reconstructive Surgery | $250 co-payment | $250 co-payment | 80% after deductible |
Rehabilitative Care Including physical, occupational and speech therapy |
$250 co-payment | $250 co-payment | $20 co-payment |
Skilled Nursing Facility Up to 100 Consecutive Days from the first treatment per disability |
No Charge | $250 co-payment | 80% after deductible |
| Benefits Available on an Outpatient Basis | |||
| Ambulance | $100 per trip | No Charge | 80% after deductible |
| Alcohol, Drug or Other Substance Abuse Detoxification | $20 per visit per individual visit; $5 co-payment per group visit | $20 per visit | $20 co-payment |
| Durable Medical Equipment | No Charge | No Charge | 80% after deductible |
Laboratory Services When available through or authorized by PCP |
No Charge | No Charge | No Charge |
| Maternity Care, Tests Procedures | No Charge | No Charge | The amount you pay is based on where the covered service is provided. |
Mental Health Services (As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and the treatment of Serious Emotional Disturbance (SED). |
$20 per visit | $25 per visit | 80% after deductible |
| Outpatient Medical Rehabilitation Therapy at Participating Free Standing or Outpatient Surgery Facility | $20 co-payment | $20 co-payment | 80% after deductible |
| Outpatient Surgery at Participating Free Standing or Outpatient Surgery Facility | $250 co-payment per procedure | No Charge | 80% after deductible |
Preventive Care Physician Office Visits (Physician, laboratory, radiology and related services as recommended by the American Academy of Pediatrics (AAP). Advisory Committee on Immunization Practices (ACIP) and U.S. Preventive Services Task Force and authorized through PCP for children). |
No Charge | No Charge | No Charge |
| Well-Woman Care (includes PAP smear (By PCP or an OB/GYN in PMG and a referral by the PMG for screening mammography as recommended by the U.S. Preventive Services Task Force). | No Charge | No Charge | No Charge |
| Other Services | |||
| Chiropractic | $5 per visit (up to 30 visits) | $5 per visit (up to 30 visits) | $5 per visit (up to 30 visits) |
| Vision | Routine eye exam — No charge ($150 allowance for eyeglasses or contact lenses every 24 months) |
Vision refraction only - $20 co-payment | N/A |
| Prescription Drugs | |||
|---|---|---|---|
| Kaiser HMO | UnitedHealthcare HMO * | Out-of-Area Plan UnitedHealthcare | |
| Retail Pharmacy; Generic | $10 co-payment Up to a 100-day supply |
$10 co-payment Up to a 31-day supply |
$10 co-payment Up to a 30-day supply |
| Retail Pharmacy; Brand — Formulary | $30 co-payment Up to a 30-day supply |
$30 co-payment Up to a 31-day supply |
$25 co-payment Up to a 30-day supply |
| Retail Pharmacy — Brand — Non-Formulary |
N/A | N/A | $45 co-payment up to a 30-day supply |
| Mail Order; Generic | $20 co-payment Up to a 100-day supply |
$20 co-payment Up to a 90-day supply |
$25 co-payment Up to a 90-day supply |
| Mail Order; Brand - Formulary | $60 co-payment Up to a 100-day supply |
$60 co-payment Up to a 90-day supply |
$62.50 co-payment Up to a 90-day supply |
| Mail Order — Brand — Non-Formulary | N/A | N/A | $112.50 co-payment Up to a 90-day supply |
Medicare Eligible Retirees (Enrolled in Medicare Parts A and B)
| Summary of Benefits for Medicare Eligible Retirees (Enrolled in Medicare Parts A & B) | ||
|---|---|---|
| Kaiser Permanente Senior Advantage HMO | Anthem Blue Cross Medicare Preferred PPO (In Network) |
|
| Member Customer Service Number | (800) 464-4000 | (833) 848-8730 |
| Website | www.kp.org | www.anthem.com/ca |
| General Features | ||
| Calendar Year Deductible | None | None |
| Maximum Benefits | Unlimited | Unlimited |
| Annual Co-Payment Maximum | $1,000 per individual | $6,700 |
| Hospital Benefits | No charge | No charge |
Emergency Services Co-payment waived if admitted |
$5 co-payment | $20 co-payment |
Urgently Needed Services Medically Necessary services required outside geographic area service by Primary Medical Group |
$5 co-payment | $10 co-payment |
| Pre-existing Conditions | All Medically Necessary conditions are covered provided they are a covered benefit. | |
| Inpatient Hospital Benefits | ||
| Alcohol, Drug or Other Substance Abuse Detoxification | No Charge | No Charge |
Mental Health Services As required by law, coverage includes treatment for Severe Mental Illness (SMI) of adults and the treatment of Serious Emotional Disturbance (SED) |
No Charge | No Charge |
| Physician Care | No Charge | No Charge |
| Reconstructive Surgery | No Charge | No Charge |
Rehabilitative Care Including physical, occupational and speech therapy |
No Charge | No Charge |
Skilled Nursing Facility Up to 100 Consecutive Days from the first treatment per disability |
No Charge | No Charge |
| Outpatient Benefits | ||
| Alcohol, Drug or Other Substance Abuse Detoxification | $5 per individual visit $2 per group visit |
$10 co-payment |
| Ambulance | No Charge | $50 per trip |
| Durable Medical Equipment | No Charge | 5% co-payment |
Mental Health Services As required by law, coverage includes treatment for Severe Mental Illness of adults and the treatment of Serious Emotional Disturbance |
$5 per individual visit $2 per group visit |
$10 co-payment |
| Outpatient Medical Rehabilitation Therapy at a Participating Free-Standing or Outpatient Surgery Facility | $5 co-payment | $10 co-payment |
| Outpatient Surgery at a Participating Free-Standing or Outpatient Surgery Facility | $5 co-payment | No Charge |
Periodic Health Evaluations Physician, laboratory, radiology, and related services as recommended by the American Academy of Pediatrics, Advisory Committee on Immunization Practices and U.S. Preventive Services Task Force and authorized through the patient's primary care physician |
No Charge | No Charge |
Well-Woman Care Office Visit Includes PAP smear by PCP or an OB/GYN in Primary Medical Group and a referral by the Primary Medical Group for screening mammography as recommended by the U.S. Preventive Services Task Force |
$5 co-payment | No Charge |
| Other Services | ||
| Chiropractic | $5 per visit (30 visits per year) | $10 per visit (15 visits per year) |
| Routine Dental Services | Diagnostic Services: No Charge Preventative: $15 co-payment (2 routine cleanings every calendar year) Please refer to the Evidence of Coverage or Description of Benefits and Copayments related to Fillings, Other Minor Services, Simple Extractions, Oral Surgery, Endodontics, Periodontics, Crowns (See the DeltaCare Evidence of Coverage for additional details and coverages) |
Diagnostic and Preventative Services: No Charge Cleanings, Exam and X-Rays: No Charge: (2 routine cleanings every calendar year) Basic Services (Fillings, Other Minor Services and Simple Extractions): Covered at 80% Major Services (Oral Surgery, Endodontics, Periodontics, Crowns): Covered at 50% $1,500 maximum annual benefit (See the Anthem Medicare Evidence of Coverage for additional details and coverages) |
| Routine Vision Services | $5 per visit ($150 allowance for eyeglasses or contact lenses every 24 months) |
No Charge ($150 allowance for eyeglasses or contact lenses every 12 months) |
| Prescription Drugs | ||
| Retail Pharmacy; Generic Drugs | $5 co-payment Up to a 100-day supply |
$5 co-payment Up to a 30-day supply |
| Retail Pharmacy; Brand Retail Drugs | $15 co-payment Up to a 100-day supply |
$15 co-payment Up to a 30-day supply |
| Mail Order; Generic Drugs | $5 co-payment Up to a 100-day supply |
$10 co-payment Up to a 30-day supply |
| Mail Order; Brand Name Drugs | $15 co-payment Up to a 100-day supply |
$30 co-payment Up to a 30-day supply |