Beginning January 1, 2026, your portion of the cost for clinically administered medications, such as an injection in an office visit or infusion at an infusion center, will change from $0 to 20% coinsurance (after the deductible if your plan has one). Here are some examples of the medications that will now have a coinsurance:
- Certain autoimmune/immunodeficiency medications [such as Infliximab (Inflectra), Immune Globulin (Gammagard), Abatacept (Orencia), and Vedolizumab (Entyvio)]
- Certain cancer medications [such as Pembrolizumab (Keytruda), fam-trastuzumab deruxtecan-nxki (Enhertu), and Pertuzumab (Perjeta)]
- Certain tumor medications [such as Lanreotide (Somatuline) and Octreotide (Sandostatin LAR Depot)]
- Certain behavioral health medications [such as Paliperidone Palmitate (Invega Sustenna)]
- Certain neurotoxins [such as Botulinum toxin (Botox) for non-cosmetic purposes]
As drug costs continue to rise, this change will help keep monthly premiums affordable for our members. We understand that members who receive one of the medications affected will have higher out-of-pocket expenses, and we don’t take that lightly. We are here to help in any way we can.
How it works
Starting in 2026, when you have a visit to receive a clinically administered medication, you’ll be billed for the medication after your visit. If your plan has a deductible, you’ll pay the full cost until you reach the deductible, and after that, you’ll pay the 20% coinsurance. The coinsurance you pay will count towards your out-of-pocket maximum. Once your out-of-pocket maximum is reached, you will pay nothing for your medical care for the rest of the calendar year.
To learn more about the costs of specific clinically administered medications or to learn more about our Medical Financial Assistance Program (MFA), you can call patient financial services at 404-949-5112 (TTY: 1-800-255-0056) Monday through Friday, 8:30 a.m. to 4:30 p.m. For other questions, just call Member Services at (404) 261-2590 (TTY: 711), Monday through Friday from 7 a.m. to 7 p.m. We value your membership with Kaiser Permanente and are here to help in any way we can.