Kaiser Permanente - Georgia HSA Option 3500/100 Self Plan Information
Plan Type HMO
Office Visit for Primary Doctor No Charge after deductible
Office Visit for Specialist No Charge after deductible
Coinsurance None
Annual Deductible Individual: $3,500
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Prescription Drugs Generic: No Charge after deductible Brand: No Charge after deductible (Non-Formulary: Not Covered )
Annual Out-of-Pocket Limit Individual: $3,500 (includes deductible )
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible Yes
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 $15 Copay
Periodic OB-GYN Exam $15 Copay
Well Baby Care $15 Copay
Prescription Drug Coverage
Generic Prescription Drugs No Charge after deductible
Brand Prescription Drugs No Charge after deductible
Non-Formulary Prescription Drugs Coverage Not Covered
Mail Order for Prescription Drugs Generic: No Charge Brand: No Charge Non-Formulary: Not Covered Days Supply: 30
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Hospital Services Coverage
Emergency Room No Charge after deductible
Outpatient Lab/X-Ray No Charge after deductible
Outpatient Surgery No Charge after deductible
Hospitalization No Charge after deductible
Maternity Coverage
Pre & Postnatal Office Visit 20% Coinsurance after deductible
Labor & Delivery Hospital Stay 20% Coinsurance after deductible
Additional Coverage
Chiropractic Coverage Discount Program: 25% discount off
Mental Health Coverage No Charge after deductible
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:
