Individuals and Families, $0/$2,700 Deductible Plan with HSA
Features Member pays

Medical calendar-year deductible (Individual/Family) $2,700 / $5,450
Annual out-of-pocket maximum (Individual/Family) $2,700 / $5,450
Lifetime benefit maximum None

Professional services (plan provider office visits)
Primary and specialty care visits (includes routine
and urgent care appointments)		 No charge per visit after deductible
Well-child visits from 0 to 23 months No charge1
Family planning visits No charge per visit after deductible
Scheduled prenatal care No charge1
First postpartum visit No charge after deductible
Eye exams No charge per visit after deductible
Hearing tests No charge per visit after deductible
Physical, occupational, and speech therapy visits No charge per visit after deductible

Outpatient services
Outpatient surgery No charge per procedure after deductible
Allergy injection visits No charge after deductible
Vaccines (immunizations) No charge1
Most X-rays and lab tests No charge after deductible

Health education
Individual visits No charge per visit after deductible
Group visits No charge per class after deductible

Hospitalization services
Room and board, surgery, anesthesia, X-rays, lab tests, and medications No charge per admission after deductible

Emergency health coverage
Emergency Department visits No charge per admission after deductible

Ambulance services
Emergency ambulance services No charge per trip after deductible

Prescription drug coverage
Covered items in accord with our drug formulary when obtained at Plan pharmacies  
Generic drugs No charge up to a 100-day supply after deductible
Brand-name drugs No charge up to a 100-day supply after deductible

Durable medical equipment (DME)
DME used in the home in accord with our DME formulary Not covered
Prosthetic and orthotic devices No charge

Mental health services

Inpatient psychiatric care
Inpatient psychiatric care No charge per admission after deductible (up to 30 days per calendar year)

Outpatient visits
Individual visits No charge per visit after deductible (up to 20 visits per calendar year)
Group therapy visits No charge per visit after deductible(up to 20 visits per calendar year)

Note: Visit and day limits do not apply to severe mental illness and serious emotional disturbances of children as described in the "Benefits and Cost Sharing" section of the Membership Agreement.

Chemical dependency services
Inpatient detoxification No charge per admission after deductible
Outpatient individual therapy visits No charge per visit after deductible
Outpatient group therapy visits No charge per visit after deductible
Transitional residential recovery services (up to 60 days per calendar year, not to exceed 120 days in any five-year period) No charge per admission after deductible

Home health services
Home health care (up to 100 two-hour visits per calendar year) No charge per visit after deductible

Other
Skilled nursing facility care (100 days per benefit period) No charge per admission after deductible
Hospice care No charge per visit after deductible

(1) These services not subject to the deductible.
Dental  |  Doctors  |  Locations  

KaiserQuotes.com is a trademark of eHealthQuotes.
Copyright © 2007 eHealthQuotes. All rights reserved.

1-877-752-4737
Kaiser Permanente Health Insurance