Kaiser
Permanente for Individuals
and Families Plans
$25 Copayment Plan
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 is included in the Membership Agreement, which will be
provided to you upon acceptance.
| Medical
calendar-year deductible (Individual/Family) |
None |
| Pharmacy
calendar-year deductible |
$250
for brand-name drugs |
| Annual
out-of-pocket maximum (Individual/Family) |
$2,500
/ $5,000 |
| Lifetime
benefit maximum |
None |
| Primary
and specialty care visits (includes routine and urgent care
appointments) |
$25
per visit |
| Well-child
visits from 0 to 23 months |
No
charge |
| Family
planning visits |
$25
per visit |
| Scheduled
prenatal care and first postpartum visit |
No
charge |
| Eye
exams |
$25
per visit |
| Hearing
tests |
$25
per visit |
| Chiropractic
office visits |
Not
covered |
| Physical,
occupational, and speech therapy visits |
$25
per visit |
| Outpatient
surgery |
$100
per procedure |
| Allergy
injection visits |
$5
per visit |
| Vaccines
(immunizations) |
No
charge |
| Most
X-rays and lab tests |
$10
per encounter |
| Individual
visits |
$25
per visit |
| Group
visits |
No
charge |
| Room
and board, surgery, anesthesia, X-rays, lab tests, and medications |
$200
per day |
| Emergency
Department visits |
$100
per visit
($100 copayment is waived if admitted directly to the hospital) |
| Emergency
ambulance services |
$100
per trip |
| Covered
items in accord with our drug formulary when obtained at Plan pharmacies |
Brand-name
items and compounded products are subject to a $250 drug deductible; see
“Outpatient Prescription Drugs, Supplies and Supplements” section of
the Membership Agreement for details |
| Generic
drugs |
$10
up to a 100-day supply |
| Brand-name
drugs |
$35
up to a 100-day supply after $250 drug deductible |
| DME
used in the home in accord with our DME formulary |
Not
covered |
|
| Inpatient
psychiatric care |
| Inpatient
psychiatric care |
$200
per day (up to 30 days per calendar year) |
|
| Outpatient
visits |
| Individual
visits |
$25
per visit
(up to a total of 20 individual/group visits per calendar year) |
| Group
therapy visits |
$12
per visit
(up to a total of 20 individual/group visits per calendar year)
Up to 20 additional group therapy visits that meet Medical Group
criteria in the same 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,
Copayments, and Coinsurance” section of the Membership Agreement. |
| Inpatient
detoxification |
$200
per day |
| Outpatient
individual therapy visits |
$25
per visit |
| Outpatient
group therapy visits |
$5
per visit |
| Transitional
residential recovery services (up to 60 days per calendar year, not to
exceed 120 days in any five-year period) |
$100
per admission |
| Home
health care (up to 100 two-hour visits per calendar year) |
No
charge |
| Skilled
Nursing Facility care |
No
charge (up to 100 days per benefit) |
| Hospice
care |
No
charge |
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to main benefits page
|
