Kaiser
Permanente for Individuals
and Families Plans
$500
Deductible 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) |
$500/$1,000 |
| 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) |
$20
per visit after deductible |
| Well-child
visits from 0 to 23 months |
No
charge1 |
| Family
planning visits |
$20
per visit1 |
| Scheduled
prenatal care and first postpartum visit |
No
charge1 |
| Eye
exams |
$20
per visit1 |
| Hearing
tests |
$20
per visit1 |
| Chiropractic
office visits |
Not
covered |
| Physical,
occupational, and speech therapy visits |
$20
per visit after deductible |
| Outpatient
surgery |
$50
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 |
$20
per visit1 |
| Group
visits |
No
charge1 |
| Room
and board, surgery, anesthesia, X-rays, lab tests, and medications |
$100
per day after deductible |
| Emergency
Department visits |
$100
per visit after deductible
($100 copayment is waived if admitted directly to the hospital) |
| Emergency
ambulance services |
$75
per trip after deductible |
| 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 |
20%
coinsurance up to a $2,000 calendar year benefit limit1 |
|
| Inpatient
psychiatric care |
| Inpatient
psychiatric care |
$100
per day after deductible (up to 30 days per calendar year) |
|
| Outpatient
visits |
| Individual
visits |
$20
per visit after deductible
(up to a total of 20 individual/group visits per calendar year) |
| Group
therapy visits |
$10
per visit after deductible
(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,
Deductibles, Copayments, and Coinsurance” section of the Membership
Agreement. |
| Inpatient
detoxification |
$100
per day after deductible |
| Outpatient
individual therapy visits |
$20
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
charge1 |
| Skilled
nursing facility care |
No
charge after deductible (up to 100 days per benefit period) |
| Hospice
care |
No
charge1 |
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|
