The 2 Tier Point-of-Service (POS) plan empowers you to make decisions about how you receive care – and who you receive it from. You can receive care from providers in the In-Network Provider Tier, or from any licensed physician or facility you choose in the Out-of-Network Provider Tier.
You’re free to choose whatever provider you prefer, whenever you receive care.
What does each Tier offer?
In-Network Provider Tier
Fully coordinated, high-quality care, lowest cost of the two Tiers.
- In this tier, choose physicians, specialists and some affiliated providers.
- Kaiser Permanente Providers are connected to your electronic health record, so they’re up-to-date on your care.
- Lowest out-of-pocket costs compared to the Out-of-Network Provider Tier.
- Our medical offices across the region offer many services conveniently under one roof, including pharmacy, imaging, lab, primary care physicians and specialists, and urgent care services.
- Your primary care physician coordinates your care. When you need specialty care, you and your doctor will find the specialist right for you and coordinate the referral. Specialists can often be seen within a few days, or even sooner.
- No claims paperwork is required.
Out-of-Network Provider Tier
Care from any licensed provider in the U.S., highest out-of-pocket costs.
- You can receive care from any licensed care provider in the U.S., including physicians, specialists, hospital, or laboratory (outside of the In-Network Provider Tier).
- Your out-of-pocket costs will usually be the highest with this Tier.
- You may have to pay the provider directly at the point of service.
- A claim form will have to be completed, just as with most traditional health plans. If you are required to pay out of pocket at the point of service, you can complete a medical claim form and submit it for reimbursement from your insurance carrier.
- You can see any specialist you choose without a referral.
- Certain services require prior authorization.
View Kaiser Permanente’s Sample Coverage Documents:
FOR future members – To view our SAMPLE plan documents, click here and choose the line of business and state from the dropdown menu and review items to assist in your plan choice.
FOR current members – The sample documents may vary from your actual benefits. To view a copy of your specific plan documents, please log into kp.org or contact Customer Service at 1-855-364-3185 (TTY 711), Monday through Friday, 7 a.m. to 7 p.m., Eastern time.
- Get the care you need. Choice Products empower you to choose how and where you get covered care.
- Manage your care and costs. You choose your provider.
- Preventive care. It’s covered at no cost to you, when you see an In-Network Provider.
- Pharmacy services. Most Kaiser Permanente medical offices have on-site pharmacies. You can also have prescriptions filled at retail pharmacies across the country.
Check here for more about pharmacy services, finding doctors and facilities, and the benefits of Choice Products.
Are Choice Products right for you?
Here are some examples of how people use Choice Products to get the care they want:
For employers, Choice Products is a great all-in-one solution:
- Give your valuable employees full choice in their providers and allow them to determine and manage their health care costs.
- Having two Tiers of providers to choose from gives your valued employees what they need to be healthier and more productive every day.
- The versatility and benefits of Choice Products can help attract and retain employees.
- Your company has the convenience of one health care provider for all your employee benefits administration.
- Offer it side-by-side with HMO, DHMO, or HDHP plans to decrease your company’s overall health care costs, and still offer your employees plan choice.
How the Choice Products plan works for your company and employees.
With Choice Products, you can offer your participating employees two Tiers of providers when they receive care:
- HMO In-Network Provider Tier: Members can receive in-network care from Kaiser Permanente’s highly rated integrated health care delivery system through our Kaiser Permanente Providers practicing exclusively at our medical offices. This Tier provides the most coordinated care with the lowest out-of-pocket costs, with no or lower deductible. Preventive care is at no cost. Members can also use kp.org and our mobile app to schedule certain appointments, email their doctors, view lab results, and refill prescriptions online.
- Out-of-Network Provider Tier: Members can receive services from any licensed provider or facility they choose outside the In-Network Provider Tier. Members pay deductibles, coinsurance, and any difference between the cost of the service and payment provided. Out-of-pocket costs are generally the highest with this Tier.
- Learn more about what’s included in the In-Network Provider Tier and Out-of-Network Provider Tier, and how they work.
- Choice Products also includes: preventive care, pharmacy services, worldwide coverage, and customized case management services for serious or complicated illnesses.
Employers’ frequently asked questions
What are the pharmacy choices under Choice Products?
Members have several choices for having their prescriptions filled.
- Most Kaiser Permanente medical offices have on-site pharmacies. Members can fill prescriptions written by providers in the In-Network Provider Tier and Out-of-Network Provider Tier at pharmacies located in Kaiser Permanente medical offices, at the lowest out-of-pocket costs among the two Tiers.
- KPIC has contracted with MedImpact to fill outpatient prescriptions at participating retail pharmacies—including Rite Aid, Walgreens, Kroger and many supermarket chains. (Not all pharmacies in a chain may participate).
- Members can also choose to receive prescriptions by mail at Kaiser Permanente medical offices.*
- Members also can fill prescriptions at any pharmacy outside the Kaiser Permanente medical office and MedImpact network.
- Learn more about pharmacy services.
What are guidelines regarding prior approval?
- For care with Kaiser Permanente Providers, the provider will arrange for prior authorization, if required, for certain services.
- For care with Out-of-Network Providers, members must obtain prior authorization for inpatient services, and certain outpatient surgeries, services, and procedures.
- Learn more about prior authorization.
How are new members on-boarded?
- Onboarding includes: Comprehensive New Member Welcome handbooks, an onboarding call from Customer Service agents, and a help line for any questions, from accessing care to transferring prescriptions.
Who do we contact for product pricing or to purchase Choice Products?
Contact Kaiser Permanente at any time through our Business Plans contact page.
Who processes claims?
The plans that underwrite the In-Network Provider Tier and Out-of-Network Provider Tier process the claims:
- Kaiser Permanente Foundation Health Plan of Georgia, Inc. (KFHP GA), underwrites the In-Network Provider Tier.
- Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc. underwrites the Out-of-Network Provider Tier.
*A program operated or arranged by health plan that distributes prescription drugs to members via mail. Some medications are not eligible for the Mail Service Delivery Program. These may include, but are not limited to, drugs that are time or temperature sensitive, drugs that cannot legally be sent by U.S. mail, and drugs that require professional administration or observation.