Kaiser – Traditional

Principal Benefits for Kaiser Permanente Deductible HMO Plan

The Services described below are covered only if all the following conditions are satisfied:

  • The Services are Medically Necessary; and
  • The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive the Services from Plan Providers inside our Northern California Region Service Area (your Home Region), except where specifically noted to the contrary in the Evidence of Coverage (EOC) for authorized referrals, hospice care, emergency care, post-stabilization care, out-of-area urgent care, and emergency ambulance services.
Annual Out-of-Pocket Maximum for Certain Services
For Services subject to the maximum, you will not pay any more Cost Sharing during a calendar year if the Copayments and Coinsurance you pay for those Services, plus all your Deductible payments, add up to one of the following amounts:
For self-only enrollment (a Family of one Member) $3,000 per calendar year
For anyone Member in a Family of two or more Members $3,000 per calendar year
For an entire Family of two or more Members $6,000 per calendar year
Deductible for Certain Services
For Services subject to the Deductible, you must pay Charges for Services you receive in a calendar year until you reach one of the following Deductible amounts:
For self-only enrollment (a Family of one Member) $1,000 per calendar year
For anyone Member in a Family of two or more Members $1,000 per calendar year
For an entire Family of two or more Members $2,000 per calendar year
Lifetime Maximum: None
PROFESSIONAL SERVICES
(Plan Provider office visits)
YOU PAY
Most primary and specialty care consultations, exams, and treatment $30 per visit (Deductible doesn’t apply)
Routine physical maintenance exams No charge (Deductible doesn’t apply)
Well-child preventive exams (through age 23 months) No charge (Deductible doesn’t apply)
Family planning counseling No charge (Deductible doesn’t apply)
Scheduled prenatal care exams and first postpartum follow-up consultation and exam No charge (Deductible doesn’t apply)
Eye exams for refraction No charge (Deductible doesn’t apply)
Hearing exams No charge (Deductible doesn’t apply)
Urgent care consultations, exams, and treatment $30 per Visit (Deductible doesn’t apply)
Physical, occupational, and speech therapy $30 per Visit (Deductible doesn’t apply)
OUTPATIENT SERVICES YOU PAY
Outpatient surgery and certain other outpatient procedures 20% Coinsurance after Deductible
Allergy injections (including allergy serum) No charge (Deductible doesn’t apply)
Most immunizations (including the vaccine) No charge (Deductible doesn’t apply)
Most X-rays and laboratory tests $10 per encounter (Deductible doesn’t apply)
Preventive X-rays, screenings, and laboratory tests as described in the EOC No charge (Deductible doesn’t apply)
MRI, most CT, and PET scans $50 per procedure (Deductible doesn’t apply)
Health education: Covered individual health education counseling No charge (Deductible doesn’t apply)
Health education: Covered health education programs No charge (Deductible doesn’t apply)
HOSPITALIZATION SERVICES YOU PAY
Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs 20% Coinsurance after Deductible
EMERGENCY HEALTH COVERAGE YOU PAY
Emergency Department visits 20% Coinsurance after Deductible
AMBULANCE SERVICES YOU PAY
Ambulance Services $150 per trip (Deductible doesn’t apply)
PRESCRIPTION DRUG COVERAGE YOU PAY
Covered outpatient items in accord with our drug formulary guidelines:
Most generic items at a Plan Pharmacy $10 for up to a 30-day supply, $20 for a 31- to 60-day supply, or $30 for a 61- to 100-day supply (Deductible doesn’t apply)
Most generic refills through our mail-order service $10 for up to a 30-day supply or $20 for a 31- to 100-day supply (Deductible doesn’t apply)
Most brand-name items at a Plan Pharmacy $30 for up to a 30-day supply, $60 for a 31- to 60-day supply, or $90 for a 61- to 100-day supply (Deductible doesn’t apply)
Most brand-name refills through our mail-order service $30 for up to a 30-day supply or $60 for a 31- to 100-day supply (Deductible doesn’t apply)
DURABLE MEDICAL EQUIPMENT YOU PAY
Most covered durable medical equipment for home use in accord with our durable medical equipment formulary guidelines 20% Coinsurance (Deductible doesn’t apply)
MENTAL HEALTH SERVICES YOU PAY
Inpatient psychiatric hospitalization 20% Coinsurance after Deductible
Individual outpatient mental health evaluation and treatment $30 per visit (Deductible doesn’t apply)
Group outpatient mental health treatment $15 per visit (Deductible doesn’t apply)
CHEMICAL DEPENDENCY SERVICES YOU PAY
Inpatient detoxification 20% Coinsurance after Deductible
Individual outpatient chemical dependency evaluation and treatment $30 per visit (Deductible doesn’t apply)
Group outpatient chemical dependency treatment $5 per visit (Deductible doesn’t apply)
HOME HEALTH SERVICES YOU PAY
Home health care (up to 100 visits per calendar year) No charge (Deductible doesn’t apply)
OTHER YOU PAY
Skilled nursing facility care (up to 100 days per benefit period) 20% Coinsurance (Deductible doesn’t apply)
Covered external prosthetic devices, orthotic devices, and ostomy and urological
supplies
No charge (Deductible doesn’t apply)
All Services related to covered infertility treatment 50% Coinsurance (Deductible doesn’t apply)
Hospice care No charge (Deductible doesn’t apply)
This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Sharing, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Sharing. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies).
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