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2021 COSTS & BENEFITS

Kaiser Permanente, a TRICARE® Prime Option

*Group A = For enlistment or appointment prior to January 1, 2018
**Group B = For enlistment or appointment after January 1, 2018
Kaiser Permanente,
a TRICARE Prime Option
Retired,
Groups A* & B**
Kaiser Permanente,
a TRICARE Prime Option
Active Duty Family Members,
Groups A* & B**
Enrollment Fees Groups A* & B**:
$0 for first year of enrollment, after which annual enrollment fees match TRICARE Prime.
$0
Deductibles $0 $0
Catastrophic Cap Group A*: $3000
Group B**: $3,703
Group A*: $1000
Group B**: $1,058
Health Plan Costs    
Outpatient Visit – Primary $21 $0
Outpatient Visit – Specialty $31 $0
Urgent Care $31 $0
Emergency Services $63 $0
Laboratory and X-Ray $0 $0
Ambulance Services $42 $0
Ambulatory Surgery (Same Day) $63 $0
Mental Health (Inpatient) $158/admission $0
Mental Health
(Outpatient/Partial Hospitalization) – Primary Care
$21 $0
Mental Health
(Outpatient/Partial Hospitalization) –
Specialty Care
$31 $0
Mental Health
(Residential Treatment Facility)
$31/day $0
Clinical Preventive Services $0 $0
Durable Medical Equipment, Prosthetics, and Medical Supplies 20% $0
Home Health Care $0 $0
Hospice (Medical equipment and pharmacy are billed separately) $0 $0
Hospitalization (Inpatient Care) $158/admission $0
Immunizations $0 $0
Maternity (Delivery/Inpatient) $158 $0
Maternity (Delivery/Birthing Center) $63 $0
Maternity (Home) Primary $21 $0
Maternity (Home) Specialty $31 $0
Newborn Care $0 $0
Skilled Nursing $31/day $0
Pharmacy    
Generic (Category 1) –
Military Pharmacy
$0 $0
Generic (Category 1) –
Home Delivery
$10 $10
Generic (Category 1) – Retail $13 $13
Brand-name (Category 2) –
Military Pharmacy
$0 $0
Brand-name (Category 2) –
Home Delivery
$29 $29
Brand-name (Category 2) –
Retail
$33 $33
Non-Formulary (Category 3) –
Military Pharmacy
Generally, not
available without
medical necessity
for non-formulary drugs.
Generally, not
available without
medical necessity
for non-formulary drugs.
Non-Formulary (Category 3) – Home Delivery $60 $60
Non-Formulary (Category 3) – Retail $60 $60

 

  Kaiser Permanente,
a TRICARE Prime Option
Benefit Differences  
Telemedicine Video appointments used on kp.org will not have
a cost share
Pharmacy Uses Kaiser Permanente formulary

Vaccines $13
Medical Supplies Covered by Kaiser Permanente pharmacy benefit
Smoking Cessation
  • No age limit
  • No authorization required
  • Kaiser Permanente mail order or Kaiser Permanente pharmacy

    Note: TRICARE pharmacy programs still available.
Breast Pumps
  • One electric breast pump kit. There is no charge for manual breast pump kits. A prescription is not required.
  • Hospital-grade pumps are only covered during an inpatient stay. A prescription is not required.
  • Breast pump rentals are not covered.
  • Replacement items/supplies are not covered.
  • Breastfeeding lactation counseling sessions are unlimited.
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