| Features |
|
Member pays |
| Annual deductible (per calendar year) |
|
None |
|
| Annual out-of-pocket maximum (per calendar year) |
|
$2,500 member
$7,500 per family
|
|
| Lifetime benefit maximum |
|
None |
|
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| Hospital care (including maternity care)* |
| Features |
|
Member pays |
| All inpatient care is covered after payment of applicable copayments. There are no limits on prescribed hospital days. |
|
$500 per day, up to $2,500 per admission |
|
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| Office visits* |
| Features |
|
Member pays |
| For diagnosis and treatment by primary care providers, consultation and treatment by specialists, routine physical and hearing
exams, well-baby visits through age 2, prenatal care, eye exams, and urgent care
|
|
$25 per primary care visit
$35 per specialty care visit
|
|
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| Outpatient Rx drugs |
| Features |
|
Member pays |
| When prescribed by a Kaiser Permanente physician or a licensed dentist in accordance with our formulary process |
|
Not covered |
|
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| Laboratory |
| Features |
|
Member pays |
| Inpatient |
|
Included under hospital care benefit |
|
| Outpatient |
|
$15 per visit |
|
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| X-rays and other special procedures |
| Features |
|
Member pays |
| Inpatient |
|
Included under hospital care |
|
| Outpatient |
|
$25 per visit |
|
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| Emergency care* |
| Features |
|
Member pays |
| Within and outside Kaiser Permanente service area |
|
$100 copay** |
|
