Kaiser
Permanente for Individuals
and Families Plans
$30/$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) |
$5,250
/ $10,500 |
| Lifetime
benefit maximum |
None |
| Primary
and specialty care visits (includes routine and urgent care
appointments) |
$30
per visit after deductible |
| Well-child
visits from 0 to 23 months |
$10
per visit1 |
| Family
planning visits |
$30
per visit after deductible |
| Scheduled
prenatal care |
$10
per visit1 |
| First
postpartum visit |
$10
after deductible |
| Eye
exams |
$30
per visit after deductible |
| Hearing
tests |
$30
per visit after deductible |
| Chiropractic
office visits |
Not
covered |
| Physical,
occupational, and speech therapy visits |
$30
per visit after deductible |
| Outpatient
surgery |
30%
coinsurance per procedure after deductible |
| Allergy
injection visits |
$5
per visit after deductible |
| Vaccines
(immunizations) |
No
charge1 |
| Most
X-rays and lab tests |
$10
per encounter after deductible |
| Individual
visits |
$30
per visit after deductible |
| Group
visits |
No
charge per class after deductible |
| Room
and board, surgery, anesthesia, X-rays, lab tests, and medications |
30%
coinsurance per admission after deductible |
| Emergency
Department visits |
30%
coinsurance per admission after deductible
(waived if admitted directly to the hospital) |
| Emergency
ambulance services |
$100
per trip after deductible |
| Covered
items in accord with our drug formulary when obtained at Plan pharmacies |
|
| Generic
drugs |
$10
up to a 30-day supply after deductible |
| Brand-name
drugs |
$30
up to a 30-day supply after deductible |
| DME
used in the home in accord with our DME formulary |
Not
covered |
|
| Inpatient
psychiatric care |
| Inpatient
psychiatric care |
30%
coinsurance per admission after deductible (up to 30 days per
calendar year) |
|
| Outpatient
visits |
| Individual
visits |
$30
per visit (up to 20 visits per calendar year) |
| Group
therapy visits |
$15
per visit (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 |
30%
coinsurance per admission after deductible |
| Outpatient
individual therapy visits |
$30
per visit after deductible |
| Outpatient
group therapy visits |
$5
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) |
$100
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) |
30%
coinsurance per admission after deductible |
| Hospice
care |
No
charge per visit after deductible |
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to main benefits page
|
