|
Kaiser
Permanente HMO Plan Benefits |
|
Description
of Benefits |
Premier
Plan |
Plan
500 |
Plan
1,000 |
Plan 2,000 |
Plan
3,000 |
Plan 5,000 |
 |
|
Lifetime Maximum
Per Member* |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
Unlimited |
|
Annual Deductible
Per Member (3
person maximum) |
$
0 |
$500 |
$1,000 |
$2,000 |
$3,000 |
$5,000 |
Annual Out-of-Pocket
Maximum
(3
person family maximum) |
$
0 |
$2,000
plus deductible per member |
$2,000
plus deductible per member |
$2,000
plus deductible per member |
$2,000
plus deductible per member |
$2,000
plus deductible per member |
Coinsurance
(the amount that Kaiser
pays after the deductible
has been met) |
100% |
70% |
70% |
70% |
70% |
70% |
|
Office
Services
- Primary
Care
- Specialty
Care
- Special
Procedures
(Cardiac
Stress Tests, EMG, others)
-Preventive
Services**
- Maternity
Services*** |
$30 Copay
$50 Copay
$50 Copay
Plan pays100%
$1,000 copay |
$30 Copay
$50 Copay
Cov. at 70%
Plan pays100%
$1,000 copay |
$30 Copay
$50 Copay
Cov. at 70%
Plan pays100%
$1,000 copay |
$30 Copay
$50 Copay
Cov. at 70%
Plan pays100%
$1,000 copay |
$30 Copay
$50 Copay
Cov. at 70%
Plan pays100%
$1,000 copay |
$30 Copay
$50 Copay
Cov. at 70%
Plan pays100%
$1,000 copay |
|
Outpatient
Services
- Diagnostic
Lab and/or
Radiology Services |
Plan pays 100% |
Plan pays 100% |
Plan pays 100% |
Plan pays 100% |
Plan pays 100% |
Plan pays 100% |
- High Tech Radiology
Svcs
(MRI,
CT, PET, others) |
$100
copay |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
- Rehabilitation
Therapies
20
visits
(Physical, Occupational, and Speech Therapy) |
$50
copay |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
|
-Outpatient Surgery
and/or -Outpatient
Hospital Facility |
$100 |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
|
-Physician and
Other Outpatient Professional Charges |
Plan
pays 100% |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
|
Emergency
Services
- Emergency
Room Visit
(per
visit; copay waived if admitted)
- After Hours Urgent Care (per
visit)
- Ambulance
(per
trip) |
$150
copay
$60 copay
$150 copay
|
$150
copay
$60 copay
$150
copay
|
$150
copay
$60 copay
$150
copay
|
$150
copay
$60 copay
$150
copay
|
$150
copay
$60 copay
$150
copay
|
$150
copay
$60 copay
$150
copay
|
|
Inpatient
Services
- Hospital (facility charge)
- Maternity (hospital delivery)***
- Physician
and Other Professional Charges |
$500 per admission
$2,000
copay
Plan
pays 100% |
Plan pays 70% after deductible
$2,000
copay
Plan
pays 70% after deductible |
Plan pays 70% after deductible
$2,000
copay
Plan
pays 70% after deductible |
Plan pays 70% after deductible
$2,000
copay
Plan
pays 70% after deductible |
Plan pays 70% after deductible
$2,000
copay
Plan
pays 70% after deductible |
Plan pays 70% after deductible
$2,000
copay
Plan
pays 70% after deductible |
|
Mental
Health Svcs.
-
Outpatient (48
visits)
-
Outpatient Group Therapy
-
Inpatient Mental Health Facility - 30 days
-
Inpatient Mental Health Professional |
$60
copay
$30
copay
$500
per admission
Plan
pays 100% |
$60
copay
$30
copay
Plan
pays 70% after deductible
Plan
pays 70% after deductible |
$60
copay
$30
copay
Plan
pays 70% after deductible
Plan
pays 70% after deductible |
$60
copay
$30
copay
Plan
pays 70% after deductible
Plan
pays 70% after deductible |
$60
copay
$30
copay
Plan
pays 70% after deductible
Plan
pays 70% after deductible |
$60
copay
$30
copay
Plan
pays 70% after deductible
Plan
pays 70% after deductible |
|
Durable
Medical Equipment/Prosthetics and Orthotics |
Plan
pays 50% |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
Plan
pays 70% after deductible |
|
Vision
Exam |
$50
copay |
$50
copay |
$50
copay |
$50
copay |
$50
copay |
$50
copay |
|
Pharmacy
Services -
(up
to a 30-day supply) |
|
|
|
|
|
|
|
- Generic
(Kaiser
Permanente Medical Center/Eckerd Drugs) |
$15
/ $21 copay |
$15
/ $21 copay |
$15
/ $21 copay |
$15
/ $21 copay |
$15
/ $21 copay |
$15
/ $21 copay |
|
- Brand
Formulary |
$30
/ $36 copay |
$30
/ $36 copay |
$30
/ $36 copay |
$30
/ $36 copay |
$30
/ $36 copay |
$30
/ $36 copay |
|
- Non-Brand
Formulary |
Not
Applicable |
Not
Applicable |
Not
Applicable |
Not
Applicable |
Not
Applicable |
Not
Applicable |
|
- Prescription Deductible |
$200 Rx Deductible |
$200 Rx Deductible |
$200 Rx Deductible |
$200 Rx Deductible |
$200 Rx Deductible |
$500 Rx Deductible |
|
*
Some benefits may have limitations
**Office visit copay may apply. Well-Child Visit: No charge up
to age 2
***Maternity charges for members are $1,000 for ob/gyn services
(pre/post natal and delivery) and $2,000 for hospital delivery
services.
Please Note: This is
a summary description and is not intended to replace the Individual
Agreement or Personal Advantage Evidence of Coverage, which contain
the complete provisions of this coverage. Some services require
precerification. |
|
Click here
for monthly rates
Click here to apply on-line
Click
here to have an enrollment kit mailed or e-mailed to you (be
sure to specify which plan you're interested in)
Click here to
download a Kaiser Permanente Application and check list
(Adobe Acrobat reader is necessary to download
this file.) |
Click here
to view the HSA plan benefits
Click here
to view the HSA plan rates
Click
here to download the free Adobe Acrobat reader |
|
Fax your completed application to our fax: 770-396-4318
(original must be received prior to underwriting
approval) |
