Kaiser Permanente - Ohio Plan 25 Plan Information
Benefit Summary
Annual Deductible - Individual None
Annual Deductible - Family None
Deductible Life Maximum None
Annual Out-of-Pocket Maximum - Individual $3,000
Annual Out-of-Pocket Maximum - Family $9,000
Outpatient Care
Primary Care Office Visits $25 per visit
Specialty Care Office Visits $45 per visit
Allergy Treatment No charge
Radiation Therapy $25 per visit
Short-term physical, speech, and OT $20 per visit (up to 20 visits per therapy per calendar year)
Outpatient Surgery $250 per visit
Laboratory & Diagnostic Tests, X-rays No charge
Urgent Care Services at KP facilities $45 per visit
Preventive Care
Preventive exams Included in Outpatient Care
Preventive well-child exams Included in Outpatient Care
Preventive lab and X-rays Included in Outpatient Care
Preventive general immunizations Included in Outpatient Care
Vision Coverage
Annual Eye Exams for Eyeglasses $45 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 $750 per admission
Maternity Care $750 per admission
Prescription Drugs
Prescription Drugs $200 deductible, then $25 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 illness - Inpatient, unlimited days $750 per admission
Biologically Based mental illness - Outpatient individual therapy $45 per visit
Biologically Based mental illness - Outpatient group Therapy $22 per visit
Biologically Based mental illness - Inpatient alternative services $45 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
Outpatient detoxification, individual therapy Not covered
Group therapy Not covered
Inpatient care in a specialized facility Not covered
Inpatient care in a general hospital $750 per admission
Additional Benefits
Infertility services 30% of eligible charges
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:
