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Plan Details

silver hmo

KP GA Silver 3000/30

$733.56/mo Monthly Premium:

Plan Cost

$733.56

Network:Kaiser Permanente HMO

Primary Care Visit:$30

Inpatient Hospital Services:30% after ded.

Medical Deductible:$3,000

EHB & Drug OOP Max:$7,150

Annual Deductible
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkCombined
Medical DeductibleIndividual: $3,000 Family: $6,000--Individual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not Applicable
Drug Benefits DeductibleIndividual: $500 Family: $1,000--Individual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not Applicable
Annual Out-of-Pocket
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkCombined
Out of Pocket Max for Med and Drug EHB Benefits (Total)Individual: $7,150 Family: $14,300--Individual: Not Applicable Family: Not ApplicableIndividual: Not Applicable Family: Not Applicable
Professional Services
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Other Practitioner Office Visit (Nurse, Physician Assistant)$30--Not CoveredSee Brochure
Imaging (CT/PET Scans, MRIs)$300--Not CoveredExplanation: Greater member cost share when performed in an outpatient hospital setting.
X-rays and Diagnostic Imaging30% Coinsurance after deductible--Not CoveredExplanation: Greater member cost share when performed in an outpatient hospital setting.
Specialist Visit$60--Not CoveredSee Brochure
Chiropractic Care$60--Not CoveredLimit: 20 Visit(s) per Year Explanation: Coverage limited to Spinal Manipulation.
Laboratory Outpatient and Professional Services30% Coinsurance after deductible--Not CoveredExplanation: Greater member cost share when performed in an outpatient hospital setting.
Primary Care Visit to Treat an Injury or Illness$30--Not CoveredSee Brochure
Prescription Drug Coverage
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Generic Drugs$15--Not CoveredExplanation: Tier 1 generics available @ lower cost share. Tier 2 generics @ cost share shown. Non-preferred generics @ 50% after deductible. Greater member cost share @ network pharmacies. Network pharmacies can only be used for initial prescription fills.
Preferred Brand Drugs$45 Copay after deductible--Not CoveredExplanation: Greater member cost share @ network pharmacies. Network pharmacies can only be used for initial prescription fills.
Non-Preferred Brand Drugs50% Coinsurance after deductible--Not CoveredExplanation: Network pharmacies can only be used for initial prescription fills.
Specialty Drugs 50% Coinsurance after deductible--Not CoveredExplanation: Network pharmacies can only be used for initial prescription fills.
Preventative Care
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Well Baby Visits and CareNo Charge--Not CoveredExplanation: Care provided for cildren from birth through age 5.
Preventive Care/Screening/ImmunizationNo Charge--Not CoveredSee Brochure
Emergency Health
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Urgent Care Centers or Facilities$100--Not CoveredSee Brochure
Emergency Room Services30% Coinsurance after deductible--30% Coinsurance after deductibleSee Brochure
Emergency Transportation/Ambulance30% Coinsurance after deductible--30% Coinsurance after deductibleSee Brochure
Outpatient Services
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Outpatient Surgery Physician/Surgical Services30% Coinsurance after deductible--Not CoveredSee Brochure
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)30% Coinsurance after deductible--Not CoveredSee Brochure
Outpatient Rehabilitation Services30% Coinsurance after deductible--Not CoveredExplanation: Please refer to Plan Brochure and SBC.
Hospitalization Services
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Inpatient Physician and Surgical Services30% Coinsurance after deductible--Not CoveredSee Brochure
Habilitation Services$30--Not CoveredExplanation: Visit limits may apply. Please refer to Plan Brochure and SBC.
Inpatient Hospital Services (e.g., Hospital Stay)30% Coinsurance after deductible--Not CoveredSee Brochure
Skilled Nursing Facility30% Coinsurance after deductible--Not CoveredLimit: 60 Days per Year
Substance Abuse Disorder Outpatient Services$60--Not CoveredSee Brochure
Substance Abuse Disorder Inpatient Services30% Coinsurance after deductible--Not CoveredSee Brochure
Maternity Care
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Delivery and All Inpatient Services for Maternity Care30% Coinsurance after deductible--Not CoveredSee Brochure
Prenatal and Postnatal Care30% Coinsurance after deductible--Not CoveredSee Brochure
Home Health Care
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Home Health Care Services30% Coinsurance after deductible--Not CoveredLimit: 120 Visit(s) per Year
Other Services
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Mental/Behavioral Health Inpatient Services30% Coinsurance after deductible--Not CoveredSee Brochure
Durable Medical Equipment30% Coinsurance after deductible--Not CoveredSee Brochure
Hospice ServicesNo Charge--Not CoveredSee Brochure
Routine Eye Exam (Adult)$30--Not CoveredLimit: 1 Exam(s) per Year
Mental/Behavioral Health Outpatient Services$60--Not CoveredSee Brochure
Rehabilitative Speech Therapy$30--Not CoveredLimit: 20 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy$30--Not CoveredLimit: 20 Visit(s) per Year Explanation: 20 visit limit per year for PT and OT combined
Abortion for Which Public Funding is Prohibited30%--Not CoveredSee Brochure
Accidental Dental50%--Not CoveredSee Brochure
Allergy Testing$60--Not CoveredExplanation: Services performed in an outpatient hospital setting are usually at a greater member cost share.
Chemotherapy30% Coinsurance after deductible--Not CoveredSee Brochure
Diabetes EducationNo Charge--Not CoveredSee Brochure
Dialysis30% Coinsurance after deductible--Not CoveredSee Brochure
Infusion Therapy30% Coinsurance after deductible--Not CoveredSee Brochure
Nutritional Counseling$60--Not CoveredSee Brochure
Prosthetic Devices30% Coinsurance after deductible--Not CoveredSee Brochure
Radiation30% Coinsurance after deductible--Not CoveredSee Brochure
Reconstructive Surgery30% Coinsurance after deductible--Not CoveredExplanation: With limitations
Transplant30% Coinsurance after deductible--Not CoveredSee Brochure
Treatment for Temporomandibular Joint Disorders50%--Not CoveredSee Brochure
Dental
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Dental Check-Up for ChildrenNo Charge--Not CoveredLimit: 1 Visit(s) per 6 Months
Major Dental Care – Child50% Coinsurance after deductible--Not CoveredSee Brochure
Basic Dental Care – Child50% Coinsurance after deductible--Not CoveredSee Brochure
Orthodontia – Child50% Coinsurance after deductible--Not CoveredSee Brochure
Vision
 Tier 1 - In NetworkTier 2 - In NetworkOut of NetworkLimits and Exclusions
Routine Eye Exam for Children$30--Not CoveredLimit: 1 Exam(s) per Year
Eye Glasses for ChildrenNo Charge--Not CoveredLimit: 1 Item(s) per Year Explanation: Frames from a specified Collection