| Annual deductible |
| Features |
|
Member pays |
| Individual |
|
$2,000 |
|
| Family |
|
$6,000 |
| The deductible applies to all services unless otherwise noted. |
|
| Back to top |
| Out-of-pocket annual maximum |
| Features |
|
Member pays |
| Individual |
|
$5,000 |
|
| Family |
|
$10,000 |
| The out-of-pocket maximum excludes deductible
and copayments.
|
|
| Back to top |
| Lifetime maximum |
| Features |
|
Member pays |
| Lifetime maximum paid by the Plan for all care |
|
No lifetime maximum |
|
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| Routine medical office visits |
| Features |
|
Member pays |
| Primary care office visit |
|
$30 per visit |
|
| Specialist office visit |
|
$50 per visit |
|
| Back to top |
| In-office procedures |
| Features |
|
Member pays |
| Procedures received during office visits |
|
30% coinsurance per procedure |
|
| Back to top |
| Preventive services |
| Features |
|
Member pays |
| Children's services |
|
No charge |
|
| Back to top |
| Preventive services |
| Features |
|
Member pays |
| Adults' services |
|
No charge |
|
| Back to top |
| Maternity |
| Features |
|
Member pays |
| Prenatal care |
|
Not covered |
|
| Delivery and inpatient well-baby care |
|
Not covered |
|
| Back to top |
| Prescription drugs |
| Features |
|
Member pays |
| Prescription drugs |
|
Not covered |
|
| Back to top |
| Inpatient hospital |
| Features |
|
Member pays |
| Inpatient hospital |
|
30% coinsurance per admission |
|
| Inpatient professional visits |
|
30% coinsurance per visit |
|
| Back to top |
| Outpatient/ambulatory surgery |
| Features |
|
Member pays |
| Outpatient/ambulatory surgery |
|
30% coinsurance per admission |
|
| Back to top |
| Laboratory and X-ray |
| Features |
|
Member pays |
| Diagnostic lab |
|
No charge |
|
| X-ray, including therapeutic |
|
30% coinsurance |
|
| MRI/CT/PET |
|
30% coinsurance per procedure |
|
| Back to top |
| Emergency care |
| Features |
|
Member pays |
| Emergency care |
|
30% coinsurance per visit at a designated Kaiser Permanente emergency room or a non-Plan emergency room |
|
| Back to top |
| Ambulance |
| Features |
|
Member pays |
| Ambulance |
|
30% coinsurance up to a maximum of $500 per trip |
|
| Back to top |
| Urgent, nonroutine, and after-hours care |
| Features |
|
Member pays |
| Office hours visit |
|
$30 per visit at a Kaiser Permanente medical office during office hours |
|
| After-hours visit |
|
$75 per after-hours visit at a designated Kaiser Permanente after-hours medical office |
|
| Back to top |
| Procedures received during urgent, nonroutine, and after-hours care |
| Features |
|
Member pays |
| Procedures received during urgent, nonroutine, and after-hours care |
|
30% coinsurance per procedure |
|
|
