Kaiser Permanente - Georgia HSA Option 3500/80 Self Plan Information
Plan Type HMO
Office Visit for Primary Doctor 20% Coinsurance after deductible
Office Visit for Specialist 20% Coinsurance after deductible
Coinsurance 20% after deductible
Annual Deductible Individual: $3,500
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Prescription Drugs Generic: 20% Coinsurance after deductible Brand: 20% Coinsurance after deductible (Non-Formulary: Not Covered )
Annual Out-of-Pocket Limit Individual:$5,000 (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 20% Coinsurance after deductible
Brand Prescription Drugs 20% Coinsurance after deductible
Non-Formulary Prescription Drugs Coverage Not Covered
Mail Order for Prescription Drugs Generic: 20% Coinsurance after deductible Brand: 20% Coinsurance after deductible Non-Formulary: Not Covered Days Supply: 30
Separate Prescription Drugs Deductible Medical Plan Deductible Applies
Hospital Services Coverage
Emergency Room 20% Coinsurance after deductible
Outpatient Lab/X-Ray 20% Coinsurance after deductible
Outpatient Surgery 20% Coinsurance after deductible
Hospitalization 20% Coinsurance 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 20% Coinsurance 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:
