Kaiser
Permanente for Individuals
and Families Plans
$0/$2,700
Deductible Plan With
HSA
This is a summary
of the most frequently
asked-about benefits
and their copayments
and coinsurance. For
information on benefits,
copayments, and coinsurance,
please refer to the
Disclosure Form.
Detailed information
about your plan in
included in the Membership
Agreement, which
will be provided to
you upon acceptance.
| Medical
calendar-year deductible (Individual/Family) |
$2,700
/ $5,450 |
| Annual
out-of-pocket maximum (Individual/Family) |
$2,700
/ $5,450 |
| Lifetime
benefit maximum |
None |
Primary
and specialty care visits (includes routine
and urgent care appointments) |
No
charge per visit after deductible |
| Well-child
visits from 0 to 23 months |
No
charge1 |
| Family
planning visits |
No
charge per visit after deductible |
| Scheduled
prenatal care |
No
charge1 |
| First
postpartum visit |
No
charge after deductible |
| Eye
exams |
No
charge per visit after deductible |
| Hearing
tests |
No
charge per visit after deductible |
| Chiropractic
office visits |
Not
covered |
| Physical,
occupational, and speech therapy visits |
No
charge per visit after deductible |
| Outpatient
surgery |
No
charge per procedure after deductible |
| Allergy
injection visits |
No
charge after deductible |
| Vaccines
(immunizations) |
No
charge1 |
| Most
X-rays and lab tests |
No
charge after deductible |
| Individual
visits |
No
charge per visit after deductible |
| Group
visits |
No
charge per class after deductible |
| Room
and board, surgery, anesthesia, X-rays, lab tests, and medications |
No
charge per admission after deductible |
| Emergency
Department visits |
No
charge per admission after deductible |
| Emergency
ambulance services |
No
charge per trip after deductible |
| Covered
items in accord with our drug formulary when obtained at Plan pharmacies |
|
| Generic
drugs |
No
charge up to a 100-day supply after deductible |
| Brand-name
drugs |
No
charge up to a 100-day supply after deductible |
| DME
used in the home in accord with our DME formulary |
Not
covered |
|
| Inpatient
psychiatric care |
| Inpatient
psychiatric care |
No
charge per admission after deductible (up to 30 days per
calendar year) |
|
| Outpatient
visits |
| Individual
visits |
No
charge per visit after deductible (up to 20 visits per calendar
year) |
| Group
therapy visits |
No
charge per visit after deductible(up to 20 visits per calendar
year) |
|
| Note:
Visit and day limits do not apply to severe mental illness and serious
emotional disturbances of children as described in the “Benefits,
Deductibles, Copayments, and Coinsurance” section of the Membership
Agreement. |
| Inpatient
detoxification |
No
charge per admission after deductible |
| Outpatient
individual therapy visits |
No
charge per visit after deductible |
| Outpatient
group therapy visits |
No
charge per visit after deductible |
| Transitional
residential recovery services (up to 60 days per calendar year, not to
exceed 120 days in any five-year period) |
No
charge per admission after deductible |
| Home
health care (up to 100 two-hour visits per calendar year) |
No
charge per visit after deductible |
| Skilled
nursing facility care (100 days per benefit period) |
No
charge per admission after deductible |
| Hospice
care |
No
charge per visit after deductible |
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to main benefits page
|
