Kaiser Permanente
 
Individual and Family Plans 2004 Benefits Summary
(Current Plan in red)
Services $25 Copayment Plan $50 Copayment Plan $1,500 Deductible Plan
Medical Calendar Year Deductible
  Individual None None $1,500
  Family None None $3,000
Pharmacy Calendar Year Deductible $250 for brand name drugs None $250 for brand name drugs
Annual Out-of Pocket Maximum
  Individual $2,500 $3,000 $3,000
  Family $5,000 $6,000 $6,000
Lifetime Benefit Maximum None None None
Professional Services (Plan Provider office visit)
  Primary and specialty care visits for internal medicine, family practice, pediatrics, and gynecology (includes routine and urgent care appointments) $25 per visit  $50 per visit $30 per visit after Deductible
  Well child visits to age 2 No charge $15 per visit $30 per visit**
  Family planning visits $25 per visit $50 per visit $30 per visit**
  Scheduled prenatal care and first postpartum visit No charge $15 per visit $30 per visit**
  Eye exams to provide a prescription for eyeglasses $25 per visit $50 per visit $30 per visit**
  Hearing exams $25 per visit $50 per visit $30 per visit**
  Physical, occupational, and speech therapy visits $25 per visit $50 per visit $30 per visit after Deductible
Outpatient Services
Outpatient surgery $100 per procedure  $250 per procedure $250 per procedure after Deductible
Allergy injection visits $5 per visit $5 per visit $5 per visit after Deductible
Immunizations No charge No charge No charge
X-rays and lab tests $10 per encounter $10 per encounter $10 per encounter after Deductible
Health education for specific conditions:      
  Individual visits $25 per visit $50 per visit $30 per visit**
  Group visits No charge No charge No charge
Hospitalization Services
Room and board, surgery, anesthesia, X-rays,
lab tests, and medications
$200 per day $500 per day $500 per day after Deductible
Emergency Health Coverage
Emergency Department visits $100 per visit ($100 Copayment is waived if admitted directly to the hospital) $150 per visit ($150 Copayment is
waived if admitted directly to the
hospital)
$100 per visit after Deductible ($100 Copayment is waived if admitted directly to the hospital)
Ambulance Services
Ambulance Services $100 per trip $300 per trip $150 per trip after Deductible
Prescription Drug Coverage
Covered items in accord with our drug formulary when obtained at Plan Pharmacies Compounded products and most brand name items are subject to a $250 drug Deductible, see Agreement for details) Most prescription drugs are not covered Compounded products and most brand name items are subject to a $250 drug Deductible, see Agreement for details)
Mental Health Services
Inpatient psychiatric care (up to 30 days per calendar year) $200 per day $500 per day $500 per day after Deductible (up to 10 days per calendar year only)
Outpatient visits:      
  Up to a total of 20 individual and/or group therapy visits per calendar year $25 per individual therapy visit and $12
per group therapy visit
50 per individual therapy visit and $25
per group therapy visit
$30 per individual therapy visit and $15 per group therapy visit after Deductible (up to a total of 10 individual and/or group therapy visits per calendar year only)
  Up to 20 additional group therapy visits that meet Medical Group criteria in the same calendar year $12 per visit $25 per visit $15 per visit after Deductible (up to 30 additional group therapy visits that meet Medical Group criteria in the same calendar year only)
Note: Visit and day limits do not apply to serious emotional disturbances of children and severe mental illnesses as described in the Agreement.
Chemical Dependency Services
Inpatient detoxification $200 per day $500 per day $500 per day after Deductible
Outpatient individual therapy visits $25 per visit $50 per visit $30 per visit after Deductible
Outpatient group therapy visits $5 per visit $5 per visit $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 $100 per admission $100 per admission after Deductible
Home Health Services
Home health care (100 visits per calendar year) No charge No charge No charge (part time, intermittent)
Other
Skilled nursing facility care (up to 100 days per benefit period) No charge No charge $50 per day after Deductible (up to 60 days per benefit period)
Hospice care No charge No charge No charge
       
       
       
       
This is a summary of the most frequently asked-about benefits and their Copayments and Coinsurance. This chart does not describe benefits or Deductibles. To learn what is covered for each benefit (including exclusions and limitations) and additional benefits that are not included in the summary, please refer to the "Benefits" section and to the "Chiropractic Services Amendment" section for the chiropractic benefit in the Agreement. Also, exclusions, limitations, and reductions that apply to all benefits are described in the "Exclusions, Limitations, and Reductions" section in the Agreement. Please refer to the "Deductibles" section for information about Deductibles in the Agreement.

**These Preventive Care services are not subject to the deductible.

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