Kaiser Permanente - Georgia Balance HMO 10,000 Plan Information
Plan Type HMO
Office Visit for Primary Doctor $40 Copay
Office Visit for Specialist $50 Copay
Coinsurance 30% after deductible
Annual Deductible Individual:$10,000
Separate Prescription Drugs Deductible $500 Individual applies to brand
Prescription Drugs Generic: $20 Copay Brand: $40 Copay (Non-Formulary: Not Covered )
Annual Out-of-Pocket Limit Individual:$10,000 (Does not include deductible )
Lifetime Maximum $3 Million per person
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage No
Out of Country Coverage Emergency Care Only
Physicians
Primary Care Physician (PCP) Required Yes
Specialist Referrals Required Yes
Preventive Care Coverage
Periodic Health Exam $40 Copay
Periodic OB-GYN Exam $40 Copay
Well Baby Care $40 Copay
Prescription Drug Coverage
Generic Prescription Drugs $20 Copay
Brand Prescription Drugs $40 Copay
Non-Formulary Prescription Drugs Coverage Not Covered
Mail Order for Prescription Drugs Generic: $30 Copay Brand: $50 Copay Non-Formulary: Not Covered Days Supply: 30
Separate Prescription Drugs Deductible $500 Individual applies to Brand
Hospital Services Coverage
Emergency Room $150 Copay (waived if admitted)
Outpatient Lab/X-Ray 30% Coinsurance after deductible
Outpatient Surgery 30% Coinsurance after deductible
Hospitalization 30% Coinsurance after deductible
Maternity Coverage
Pre & Postnatal Office Visit Maternity Services Not Covered
Labor & Delivery Hospital Stay Maternity Services Not Covered
Additional Coverage
Chiropractic Coverage Discount Program: 25% discount off
Mental Health Coverage $60 Copay, 48 Visits Per Year
Additional Information
Application Fee No
Electronic Signature for Application Available Yes
Will insurance company obtain and pay for medical records? No
Other Kaiser Permanente - Georgia health insurance plans:
