<thead>
<tr class="footable-header">
                                                                        <th scope="col"  class="ninja_column_0 ninja_clmn_nm_ninja_column_1 "></th><th scope="col"  class="ninja_column_1 ninja_clmn_nm_value ">Kaiser HDHP with Optional HSA—CA</th><th scope="col"  class="ninja_column_2 ninja_clmn_nm_premier ">Kaiser HDHP with Optional HSA—CO</th><th scope="col"  class="ninja_column_3 ninja_clmn_nm_choiceplus ">Kaiser HDHP with Optional HSA—GA</th></tr>
</thead>
<tbody>

        <tr data-row_id="75" class="ninja_table_row_0 nt_row_id_75">
            <td></td><td><b>In-Network</td><td><b>In-Network</td><td><b>In-Network</td>        </tr>
            <tr data-row_id="74" class="ninja_table_row_1 nt_row_id_74">
            <td><b>Annual Deductible</b><br> Single<br> Family<br> Embedded or Aggregate</td><td>$3,200<br> $6,400<br> Embedded</td><td>$3,200<br> $6,400<br> Embedded</td><td>$3,200<br> $6,400<br> Embedded</td>        </tr>
            <tr data-row_id="73" class="ninja_table_row_2 nt_row_id_73">
            <td><b>Annual Out-of-Pocket Max</b><br> Single<br> Family<br> Embedded</td><td>$6,000<br> $12,000<br> Yes</td><td>$6,000<br> $12,000<br> Yes</td><td>$6,000<br> $12,000<br> Yes</td>        </tr>
            <tr data-row_id="76" class="ninja_table_row_3 nt_row_id_76">
            <td><strong>Office Visit</td><td>30% after deductible</td><td>30% after deductible</td><td>30% after deductible</td>        </tr>
            <tr data-row_id="77" class="ninja_table_row_4 nt_row_id_77">
            <td><b>Preventive Services</td><td>No Charge</td><td>No Charge</td><td>No Charge</td>        </tr>
            <tr data-row_id="78" class="ninja_table_row_5 nt_row_id_78">
            <td><b>Chiropractic Care (May require medical necessity)</td><td>30% after deductible (up to 20 visits per year)</td><td>30% after deductible (up to 20 visits per year)</td><td>30% after deductible (up to 20 visits per year)</td>        </tr>
            <tr data-row_id="79" class="ninja_table_row_6 nt_row_id_79">
            <td><b>Lab & X-Ray</td><td>30% after deductible</td><td>30% after deductible</td><td>30% after deductible</td>        </tr>
            <tr data-row_id="80" class="ninja_table_row_7 nt_row_id_80">
            <td><b>Inpatient Hospitalization</td><td>30% after deductible</td><td>30% after deductible</td><td>30% after deductible</td>        </tr>
            <tr data-row_id="81" class="ninja_table_row_8 nt_row_id_81">
            <td><b>Outpatient Surgery</td><td>30% after deductible</td><td>30% after deductible</td><td>30% after deductible</td>        </tr>
            <tr data-row_id="82" class="ninja_table_row_9 nt_row_id_82">
            <td><b>Urgent Care</td><td>30% after deductible</td><td>30% after deductible</td><td>30% after deductible</td>        </tr>
            <tr data-row_id="83" class="ninja_table_row_10 nt_row_id_83">
            <td><b>Emergency Room</td><td>30% after deductible</td><td>30% after deductible</td><td>30% after deductible</td>        </tr>
            <tr data-row_id="84" class="ninja_table_row_11 nt_row_id_84">
            <td><b>Prescription Drugs</td><td><b>Generic/Brand</td><td><b>Generic/Brand</td><td><b>Generic/Brand</td>        </tr>
            <tr data-row_id="85" class="ninja_table_row_12 nt_row_id_85">
            <td><b>Deductible (Single/Family)</td><td>Combined w/medical</td><td>Combined w/medical</td><td>Combined w/medical</td>        </tr>
            <tr data-row_id="86" class="ninja_table_row_13 nt_row_id_86">
            <td><b>Retail (30 day supply)</td><td>$15/$35<br>(after deductible)</td><td>$15/$35<br>(after deductible)</td><td>$15/$35<br>(after deductible)</td>        </tr>
            <tr data-row_id="88" class="ninja_table_row_14 nt_row_id_88">
            <td><b>Mail Order (90 day supply)</td><td>$30/$70<br>(after deductible)</td><td>$30/$70<br>(after deductible)</td><td>$30/$70<br>(after deductible)<sup>1</sup></td>        </tr>
    </tbody><!--ninja_tobody_rendering_done-->
