Kaiser Permanente - Georgia Plan 500 Plan Information
Plan Type HMO
Office Visit for Primary Doctor $30 Copay
Office Visit for Specialist $50 Copay
Coinsurance 30% after deductible
Annual Deductible Individual: $500
Separate Prescription Drugs Deductible $200 Individual applies to brand
Prescription Drugs Generic: $15 Copay Brand: $30 Copay (Non-Formulary: Not Covered )
Annual Out-of-Pocket Limit Individual:$2,000 (Does not include deductible )
Lifetime Maximum Unlimited
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 $30 Copay
Periodic OB-GYN Exam $30 Copay
Well Baby Care No Charge up to Age 2
Prescription Drug Coverage
Generic Prescription Drugs $15 Copay
Brand Prescription Drugs $30 Copay
Non-Formulary Prescription Drugs Coverage Not Covered
Mail Order for Prescription Drugs Generic: $15 Copay Brand: $21 Copay Non-Formulary: Not Covered Days Supply: 30
Separate Prescription Drugs Deductible $200 Individual
Hospital Services Coverage
Emergency Room $150 Copay (waived if admitted)
Outpatient Lab/X-Ray No Charge
Outpatient Surgery 30% Coinsurance after deductible
Hospitalization 30% Coinsurance after deductible
Maternity Coverage
Pre & Postnatal Office Visit $1,000 Copay
Labor & Delivery Hospital Stay $2,000 Copay
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:
