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Plan Highlights

Kaiser Deductible HMO Plan C

Annual Calendar Year DeductibleIn-Network

Maximum Calendar Year Out-of-PocketIn-Network

Lifetime MaximumIn-Network

Professional ServicesIn-Network
Primary Care Physician (PCP)$15 Copay (1)
Specialist$15 Copay (1)
Preventive Care ExamNo Charge (1)
Well-baby Care (First 23 months)No Charge (1)
Diagnostic X-Ray and Lab$10 Copay
Complex Diagnostics (MRI/CT Scan)5% up to $50 Copay per procedure
Therapy (Physical, Occupational and Speech)$15 Copay

Hospital ServicesIn-Network
InpatientNo Charge
Outpatient SurgeryNo Charge
Emergency RoomNo Charge
Urgent Care$15 Copay (1)

Maternity CareIn-Network
Physician Services (prenatal or postnatal)No Charge (1)
Hospital ServicesNo Charge

Mental Health & Substance AbuseIn-Network
InpatientNo Charge
OutpatientIndividual visit: $15 Copay (1)
Group visit: $7 Copay (Mental Health) (1) / $5 Copay (Substance Abuse) (1)

Vision CareIn-Network
Routine Eye Exams with a Plan OptometristNo Charge
Eyeglasses or contact lenses every 24 monthsAllowance up to $175 (1)

Retail Prescription Drugs (up to a 30-day supply)In-Network
Generic Drugs$10 Copay
Preferred Brand Name Drugs$35 Copay

Mail Order Prescription Drugs (Up to a 100-day supply)In-Network
Generic Drugs$20 Copay
Preferred Brand Name Drugs$70 Copay

(1) Deductible Waived

Double Coverage: The member will not be required to pay the deductible, copay, or coinsurance. If the member is asked to pay at the POS, they should inform Reception that they are “Double Covered.” KP’s front-line staff is trained to take the member’s word and inform them that if the service does not qualify for Double Coverage, they will be billed.

Even though the member will not be required to pay for the service, applicable charges will accumulate towards the medical deductible and out-of-pocket maximum under the primary plan.

Coordination of Benefits (COB) will occur when a member receives covered services by a non-KP provider (ex. referrals to a non-KP provider, SNF, DME, Home Health, Hospice, Emergency, Urgent Care, etc.). There may be deductible, copay and/or coinsurance due after claim for service has been processed.

“Double Coverage” does not apply: when the service is not a covered benefit under both plans (a common example is fertility, which is not covered on many plans), to members with one KP commercial plan in a California market and one KP plan from a market outside of California, When one plan is self-funded/KPIC (these are not commercial plans) or a KPIF plan (i.e. individual plan), When both plans are HSA-Qualified HDHP HMOs

Ancillary coverages, such as: Optical allowance, Hearing Aid allowance, Chiropractic and Acupuncture are excluded from the dual coverage guidelines.

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