| Annual deductible |
| Features |
|
Member pays |
| Individual |
|
No deductible |
|
| Family |
|
No deductible |
|
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| Out-of-pocket annual maximum |
| Features |
|
Member pays |
| Individual |
|
$3,000 |
|
| Family |
|
$7,500 |
|
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| 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 |
|
$40 per visit |
|
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| Preventive services |
| Features |
|
Member pays |
| Children's services |
|
No charge |
|
| Adults' services |
|
No charge |
|
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| Maternity |
| Features |
|
Member pays |
| Prenatal care |
|
Not covered |
|
| Delivery and inpatient well-baby care |
|
Not covered |
|
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| Prescription drugs |
| Features |
|
Member pays |
| Prescription drugs |
|
Not covered |
|
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| Inpatient hospital |
| Features |
|
Member pays |
| Inpatient hospital |
|
20% coinsurance per admission |
|
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| Outpatient/ambulatory surgery |
| Features |
|
Member pays |
| Outpatient/ambulatory surgery |
|
$150 per visit |
|
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| Laboratory and X-ray |
| Features |
|
Member pays |
| Diagnostic lab and X-ray |
|
No charge |
|
| Therapeutic X-ray |
|
$40 per visit |
|
| MRI/CT/PET |
|
$100 per procedure |
|
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| Emergency care |
| Features |
|
Member pays |
| Emergency care |
|
$150 per visit at a designated Kaiser Permanente emergency room or a non-Plan emergency room.
Copayment is waived if admitted as an inpatient.
|
| Payment of non-Plan emergency claims is limited to usual, reasonable, and customary charges. |
|
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| Ambulance |
| Features |
|
Member pays |
| Ambulance |
|
20% coinsurance up to a maximum of $500 per trip |
|
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| Urgent, nonroutine, and after-hours care |
| Features |
|
Member pays |
| Office hours visit |
|
$30 per visit at a Kaiser Permanente medical office |
|
| After-hours visit |
|
$75 per after-hours visit at a designated Kaiser Permanente after-hours medical office |
|
|
