Individuals and Families, $30/$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) $5,250 / $10,500
Lifetime benefit maximum None

Professional services (plan provider office visits)
Primary and specialty care visits (includes routine and urgent care appointments) $30 per visit after deductible
Well-child visits from 0 to 23 months $10 per visit1
Family planning visits $30 per visit after deductible
Scheduled prenatal care $10 per visit1
First postpartum visit $10 after deductible
Eye exams $30 per visit after deductible
Hearing tests $30 per visit after deductible
Chiropractic office visits Not covered
Physical, occupational, and speech therapy visits $30 per visit after deductible

Outpatient services
Outpatient surgery 30% coinsurance per procedure after deductible
Allergy injection visits $5 per visit after deductible
Vaccines (immunizations) No charge1
Most X-rays and lab tests $10 per encounter after deductible

Health education
Individual visits $30 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 30% coinsurance per admission after deductible

Emergency health coverage
Emergency Department visits 30% coinsurance per admission after deductible
(waived if admitted directly to the hospital)

Ambulance services
Emergency ambulance services $100 per trip after deductible

Prescription drug coverage
Covered items in accord with our drug formulary when obtained at Plan pharmacies  
Generic drugs $10 up to a 30-day supply after deductible
Brand-name drugs $30 up to a 30-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 30% coinsurance per admission after deductible (up to 30 days per calendar year)

Outpatient visits
Individual visits $30 per visit (up to 20 visits per calendar year)
Group therapy visits $15 per visit (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 30% coinsurance per admission after deductible
Outpatient individual therapy visits $30 per visit after deductible
Outpatient group therapy visits $5 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) $100 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) 30% coinsurance 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