Kaiser HMO

Plan Summary

ANNUAL COPAYMENT LIMIT
For each member $1,500
For each Family Unit $3,000
PROFESSIONAL SERVICES (PLAN PROVIDER OFFICE VISITS)
Primary & specialty care visits (includes routine and Urgent Care appointments) $15 per visit
Routine preventive physical exams No per visit
Well-child preventive care visits (0-23 months) No per visit
Family planning visits $10 per visit
Scheduled prenatal care and first postpartum visit $15 per visit
Routine preventive refraction exams $0 charge
Routine preventive hearing tests $0 charge
Physical, occupational, and speech therapy visits $15 per visit
OUTPATIENT SERVICES
Outpatient surgery $15 per procedure
Allergy injection visits $10 per visit
Allergy testing visits $15 per visit
Immunizations No charge
Physical, occupational, and speech therapy visits $15 per visit
X-rays and lab tests No charge
HOSPITAL INPATIENT CARE
Hospital room and board, surgery, anesthesia, X-rays, lab tests, and medications No charge
Skilled Nursing Facility (up to 100 days per benefit period) No charge
PRESCRIPTION DRUGS
Covered items in accord with our formulary when obtained at Plan pharmacies:
Generic $10 up to a 100-day supply (or 3 cycles for oral contraceptives)
Brand name or compounded drugs $25 up to a 100-day supply (or 3 cycles for oral contraceptives)
Drugs related to the treatment of sexual dysfunction disorders (episodic drugs are limited to 27 doses in any 100-day period) 50% Coinsurance up to a 100-day supply
MENTAL HEALTH SERVICES
Inpatient psychiatric care (up to 45 days per calendar year) No charge
Outpatient visits:
Up to a total of 20 individual and/or group therapy visits per calendar year
Individual therapy visits $10 per visit
Group therapy visits $5 per visit
Up to 20 additional group therapy visits that meet Medical Group criteria in the same calendar year $5 per visit
Note: Visit and day limits do not apply to severe mental illnesses and serious emotional disturbances of children.
CHEMICAL DEPENDENCY SERVICES
Inpatient detoxification No charge
Outpatient group therapy visits $5 per visit
Outpatient individual therapy visits $10 per visit
Transitional residential recovery Services (up to 60 days per calendar year, not to exceed 120 days in any five-year period) $100 per admission
OTHER SERVICES
Ambulance Services No charge
Durable medical equipment in accord with our formulary 20% Coinsurance
Health education for specific conditions:
Individual visits $10 per visit
Group visits No charge
Home health care No charge
Hospice care No charge
EMERGENCY CARE
Emergency Department visits $100 per visit (waived if admitted directly to the hospital)

Links & Documents

KAISER Member Service Call Center
800.464.4000 (ENGLISH)
800.788.0616 (SPANISH)

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