Kaiser Permanente - Ohio Plan 2500/5000 Plan Information
Benefit Summary
Annual Deductible - Individual $2,500
Annual Deductible - Family $5,000
Deductible Life Maximum None
Annual Out-of-Pocket Maximum - Individual $2,500
Annual Out-of-Pocket Maximum - Family $5,000
Outpatient Care
Primary Care Office Visits No charge after deductible
Specialty Care Office Visits No charge after deductible
Allergy Treatment No charge after deductible
Radiation Therapy No charge after deductible
Short-term physical, speech, and OT No charge after deductible
Outpatient Surgery No charge after deductible
Laboratory & Diagnostic Tests, X-rays No charge after deductible
Urgent Care Services at KP facilities No charge after deductible
Preventive Care
Preventive exams $15 per visit, not subject to deductible
Preventive well-child exams $15 per visit, 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 Not covered
Annual Eye Exams for Contacts at United Optical stores only. Not covered
Annual Eye Hardware allowance dispensed at United Optical only. Not covered
Hospital Inpatient Care
Hospital Inpatient Care No charge after deductible
Maternity Care No charge after deductible
Prescription Drugs
Prescription Drugs No charge after deductible
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 No charge after deductible
Biologically based mental illnesses - Outpatient individual therapy No charge after deductible
Biologically based mental illnesses - Outpatient group therapy No charge after deductible
Biologically based mental illnesses - Inpatient alternative services No charge after deductible
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 No charge after deductible
Emergency Services
Ambulance Service No charge after deductible
Chemical Dependency Services
Outpatient detoxification, individual therapy Not covered
Group therapy Not covered
Inpatient care in a specialized facility No charge after deductible
Inpatient care in a general hospital No charge after deductible
Additional Benefits
Infertility services No charge after 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:
