Kaiser Permanente
for Individuals and Families |
Platinum Rx
|
| Annual Individual deductible |
None
|
| Lifetime benefit maximum |
None
|
|
Annual out-of-pocket maximum
Not all copayments count toward your limit; not all copayments
are waived after limit is met.
|
$2,000 member
$6,000 per family
|
BENEFITS
All benefits must be provided or authorized by a Kaiser
Permanente physician. |
Members pay
|
Office Visits 1
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 |
$20 per primary care visit
$30 per specialty visit
|
Hospital care (including maternity
care)
All inpatient care is covered after payment of
applicable copayments. There are no limits
on prescribed hospital days.. |
$300 per day,
up to $1,500 per admission
|
| Outpatient surgery |
$50 per visit
|
Outpatient Rx drugs
When prescribed by a Kaiser Permanente physician or
a licensed dentist in accordance with our formulary process. |
Full charge for prescriptions costing $15 or less; the
greater of $15 or 50% of charges for prescriptions costing $15 or more
Mail order: 30-day supply per cost
share above
|
| Laboratory |
Inpatient
|
Included under hospital care benefit
|
Outpatient
|
$15 per visit
|
| X-rays and other special procedures |
Inpatient
|
Included under hospital care benefit
|
Outpatient
|
$25 per visit
|
*Emergency care
†
Within and outside Kaiser Permanente Service Area |
$100 copay 6
|
| Immunizations |
No charge
|
| Allergy shots and other injections |
$5 per visit
|
Infertility services
Diagnosis and treatment of infertility, subject to exclusions |
50% copayment
|
| *MATERNITY CARE |
Inpatient
All necessary physician and hospital services, including
care for the newborn. |
$300 per day,
up to $1,500 per admission 1
|
Outpatient
Prenatal and postnatal maternity care.
Note: Applicants who are pregnant are not eligible to enroll in Kaiser
Permanente for Individuals and Families. |
$20 per office visit 1
|
| EMERGENCY CARE 1 |
Within and Outside Kaiser Permanente service
area
|
$100 per incident 3
|
Ambulance
For medically necessary transportation |
$50 per transport
|
| MENTAL HEALTH SERVICES |
| Inpatient psychiatric care. |
The following applies each calendar year:
50% copayment; Kaiser Permanente pays 50% up to a maximum of $2,000; you
pay 100% thereafter |
Outpatient therapy
with mental health professionals. The number of visits
depends on treatment protocols appropriate to the condition. |
Up to 20 visits at $30 per visit; you pay 100% thereafter
|
Chemical dependency services
(care for alcoholism and drug abuse)—Kaiser Permanente pays a maximum
of $4,500 per member for all services (inpatient and outpatient combined)
during a two-year period. 1 |
| Inpatient medical treatment. |
20% coinsurance; Kaiser Permanente pays 80% up to
the maximum; you pay 100% thereafter |
| Residential/day treatment. |
20% coinsurance; Kaiser Permanente pays 80% up to
the maximum; you pay 100% thereafter |
| Outpatient medical treatment. |
Up to 40 visits at $20 per visit; you pay 100% thereafter
|
| Detox |
$300 per day, up to $1,500 per admission*
|
1
Plus any copayments or coinsurance for lab or X-ray.
3 The Emergency care copay will be waived and the hospital copay will
apply if admitted directly to hospital from an emergency room. Additional
copayments or coinsurance may apply for lab, X-ray, etc.
6 The emergency care copayment will be waived and the hospital copayment will apply if you are admitted directly to the hospital from an Emergency
Department. Additional copayments or coinsurance may apply for lab, X-ray, etc.
† Emergency
Services for an Emergency Medical Condition at a Non-Network Facility inside
the Service Area are covered; however, care after your condition is stabilized
must be preauthorized by Health Plan to be covered. Health Plan may require
you to be transferred to a Hospital or Medical Office following stabilization.
Outside Kaiser Permanente service area—Reimbursement of usual and customary
charges for unforeseen illness or injuries. Continuing or follow-up care
must be received at Kaiser Permanente facilities in order to be covered.
This benefit summary lists the copayments you pay for services. This summary
is not a contract but a general listing of major benefits, exclusions, and
limitations. Your particular benefits are those contained in
the Kaiser Permanente Personal Advantage membership agreement, which
you will receive if accepted. |
Plan Updates 
