Kaiser Permanente Personal Advantage $500 Deductible Plan

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.

Features

Member pays

Medical calendar-year deductible (Individual/Family)	$500/$1,000
Annual out-of-pocket maximum (Individual/Family)	$2,500 / $5,000
Lifetime benefit maximum	None

Professional services (plan provider office visits)
Primary and specialty care visits (includes routine and urgent care appointments)	$20 per visit¹
Well-child visits from 0 to 23 months	No charge¹
Family planning visits	$20 per visit¹
Eye exams	$20 per visit¹
Hearing tests	$20 per visit¹
Physical, occupational, and speech therapy visits	$20 per visit after deductible

Outpatient services
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

Health education
Individual visits	$20 per visit¹
Group visits	No charge¹

Hospitalization services
Room and board, surgery, anesthesia, X-rays, lab tests, and medications	$100 per day after deductible

Emergency health coverage
Emergency Department visits	$100 per visit after deductible (waived if admitted directly to the hospital)

Ambulance services
Emergency ambulance services	$150 per trip after deductible

Prescription drug coverage
Covered items in accord with our drug formulary when obtained at Plan pharmacies
Generic drugs	$10 up to a 30-day supply
Brand-name drugs	$35 up to a 30-day supply
Mail-order program	$20 generic/$70 brand for 100-day supply for most maintenance drugs

Durable medical equipment (DME)
DME used in the home in accord with our DME formulary	20% coinsurance up to a $2,000 calendar year benefit limit¹
Prosthetic and orthotic devices	No charge

Mental health services

Inpatient psychiatric care
Inpatient psychiatric care	$100 per day after deductible (up to 30 days per calendar year)

Outpatient visits
Individual visits	$20 per individual visit (deductible does not apply) up to a total of 20 individual and group visits per calendar year
Group therapy visits	$10 per group visit (deductible does not apply) up to a total of 20 individual and 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.

Chemical dependency services
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 services
Home health care (up to 100 two-hour visits per calendar year)	No charge¹

Other
Skilled nursing facility care	No charge after deductible (up to 100 days per benefit period)
Hospice care	No charge¹

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(1) These services not subject to the deductible.


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