Kaiser Permanente - Ohio Plan 1000/2000 Plan Information
Benefit Summary
Annual Deductible - Individual $1,000
Annual Deductible - Family $2,000
Deductible Life Maximum None
Annual Out-of-Pocket Maximum - Individual $4,000
Annual Out-of-Pocket Maximum - Family $8,000
Outpatient Care
Primary Care Office Visits $25 per visit
Specialty Care Office Visits $35 per visit
Allergy Treatment $5 per visit
Radiation Therapy 20% of eligible charges after deductible
Short-term physical, speech, and OT 20% of eligible charges after deductible (up to 20 visits per therapy per calendar year)
Outpatient Surgery 20% of eligible charges after deductible
Laboratory & Diagnostic Tests, X-rays 20% of eligible charges after deductible
Urgent Care Services at KP facilities $45 per visit
Preventive Care
Preventive exams No charge, not subject to deductible
Preventive well-child exams No charge, not subject to deductible
Preventive lab and X-rays No charge, not subject to deductible
Preventive general immunizations No charge, not subject to deductible
Vision Coverage
Annual Eye Exams for Eyeglasses $35 per visit eyeglass exam
Annual Eye Exams for Contacts at United Optical stores only. $50 per visit contact lens exam
Annual Eye Hardware allowance dispensed at United Optical locations only. $100 hardware allowance once every 24 months
Hospital Inpatient Care
Hospital Inpatient Care 20% of eligible charges after deductible
Maternity Care 20% of eligible charges after deductible
Prescription Drugs
Prescription Drugs $15 generic or $45 brand
Mail order Up to a 62-day supply of maintenance drugs for the cost of one copay through the Kaiser Permanente Direct Mail Pharmacy
Infertility Drugs Not covered
Mental Health Services
Biologically based mental illnesses - Inpatient, unlimited days 20% of eligible charges after deductible
Biologically based mental illnesses - Outpatient individual therapy $35 per visit
Biologically based mental illnesses - Outpatient group therapy $17 per visit ,
Biologically based mental illnesses - Inpatient alternative services $35 per visit
Other Mental Health Services
Other mental health illness - Inpatient (up to 30 days of hospital care per year) Not covered
Other mental health illness - Outpatient individual therapy Not covered
Other mental health illness - Outpatient group therapy Not covered
Other mental health illness - Inpatient alternative services Not covered
Emergency and Nonroutine
Emergency Services at a Plan or non-Plan facility $125 per visit, Copay is waived if admitted.
Emergency Services
Ambulance Service $125 per trip, after deductible
Chemical Dependency Services
Outpatient detoxification, individual therapy Not covered
Group therapy Not covered
Inpatient care in a specialized facility Not covered
Inpatient care in a general hospital 20% of eligible charges after deductible
Additional Benefits
Infertility Services 30% of eligible charges after deductible; 30% of outpatient charges (not subject to deductible)
Dependent Coverage To age 23, end of birth month
Dental
Preventive dental plan services 30% copayment ($250 maximum benefit per member, per calendar year)
Other Kaiser Permanente - Ohio health insurance plans:
