Kaiser Permanente
for Individuals and Families |
Silver $1,500 Deductible Plan
|
Annual individual deductible
(per calendar year) |
$1,500
|
|
Annual out-of-pocket maximum
(per calendar year)
Not all copayments count toward your limit; not all copayments
are waived after limit is met.
|
$5,000 member
$15,000 per family
|
| Lifetime benefit maximum |
$2,000,000
|
BENEFITS
All benefits must be provided or authorized by a Kaiser
Permanente physician. |
Members pay
|
*Hospital care (including maternity
care)
All inpatient care is covered after payment of applicable
copayments. There are no limits on prescribed hospital days. |
20% coinsurance
(after deductible)
|
*Office Visits
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 exam and urgent
care. |
$25 per primary care visit1
20% coinsurance per specialty care visit
(Deductible waived for wellbaby visits and prenatal
care.)
|
Optional: Outpatient Rx drugs
This is an optional benefit that must be added to the
plan during enrollment with Rx rider. |
Rx deductible: $500
Retail: 50% (after deductible) up to $150 max per 30-day Rx
|
| Laboratory |
Inpatient
|
Included under hospital care benefit
|
Outpatient
|
20% coinsurance
(after deductible) No deductible for preventive tests
|
| X-rays and other special procedures
|
Inpatient
|
Included under hospital care benefit
|
Outpatient
|
20% coinsurance
(after deductible) No deductible for preventive tests
or preventive procedures.
|
| EMERGENCY CARE |
*Emergency care
†
Within and outside Kaiser Permanente Service Area |
20% coinsurance
(after deductible)
|
Ambulance
For medically necessary transportation |
20% per transport
(after deductible)
|
* Plus any copayments or coinsurance for
lab or X-ray.
† 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 
