California Kaiser Permanente

$500.00 deductible plan

Features:	Member pays out of pocket:
Medical calendar year deductible	$500 individual/$1000 family
Annual out of pocket expense maximum	$2500 individual/$5000 family
Lifetime benefit maximum	none

Plan provider office visits

Primary and specialty care visits	$20.00 per visit (Includes routine and urgent care appointments)
Well child visits-0-23 months	none
Family planning visits	$20.00 per office visit
Eye examinations	$20.00 per office visit
Hearing test	$20.00 per office visit
Physical, speech, occupational	$20.00 per office visit after deductible is met

Outpatient Services

Outpatient surgery	$50.00 per surgical procedure after deductible is met
Injection for allergies	$5.00 per injection per visit after deductible is met
Immunizations	none
X-rays and labs	$10.00 per service after deductible is met

Health education

Individual visits	$20.00
Group visits	none

Hospitalization

Room and board, surgery, anesthesia, X-rays, lab tests, and medications

$100.00 per day for covered facility after deductible is met

Emergency Services

Emergency Room visits	$100.00 per visit-excluded if admitted directly to hospital from ER after deductible is met
Emergency Ambulance	$150.00 per ambulance request and ride after deductible is met

Prescription Drug Coverage

Generic	$10.00 30 day supply per prescription
Brand name drugs	$35.00
Mail order	$20.00/generic-$70.00 maintenance drugs 100 day supply

Durable medical equipment

DME in home	20 percent coinsurance up to a $2,000 calendar year benefit limit
Prosthetic and orthotic devices	none

Mental health services

Inpatient psychiatry	$100.00 per day up to 30 days after deductible is met
Outpatient visits individual	$20.00 per visits up to 20 per calendar year
Group therapy	$10.00 per visit up to 20 per calendar year. Up to 20 additional group therapy visits that meet Medical Group criteria in the same calendar year
Inpatient chemical dependency detoxification	$100.00 per day after deductible is met
Outpatient individual therapy	$20.00 per visit after deductible is met
Outpatient group therapy visits	$5.00 per visit after deductible is met
Transitional residential recovery services	$100.00 per admission after deductible is met (Up to 60 days per calendar year, not to exceed 120 days in any five-year period)

Home health services

Home health	no charge for member (up to 100 two hr visits per calendar year)
Nursing facility	no charge for member (up to 100 days per benefit period)
Hospice care	no charge

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