This Kaiser Plan is for Medicare-Eligible Retirees
| ANNUAL COPAYMENT LIMIT | |
|---|---|
| For each member | $1,500 |
| For each Family Unit | $3,000 |
| OUTPATIENT CARE | |
| Allergy injection visits | No charge |
| Eye exams to provide a prescription for eyeglasses | $10 per visit |
| Hearing exams | $10 per visit |
| Immunizations | No charge |
| Manual manipulation of the spine | $10 per visit |
| Outpatient Surgery | $10 per procedure |
| Physical, Occupational, and Speech Therapy Visits | $10 per visit |
| Primary and specialty care visits for internal medicine, family practice, pediatrics, and gynecology (includes routine and urgent care appointments | $10 per visit |
| Scheduled prenatal care and first postpartum visit | $5 per visit |
| Well-child preventative care visits (23 months or younger) | $5 per visit |
| X-rays, annual mammograms, and lab tests | No charge |
| HOSPITAL INPATIENT CARE | |
| Hospital room and board, surgery, anesthesia, X-rays, lab tests, and medications | No charge |
| PRESCRIPTION DRUGS | |
| Generic | $10 up to 100-day supply |
| Brand name or compunded drugs | $20 up to a 100-day supply |
| Drugs related to the treatment of sexual dysfunction disorders (episodic drugs are limited to 27 does in any 100-day period) | 50% coinsurance up to a 100-day supply |
| MENTAL HEALTH SERVICES | |
| Inpatient psychiatric care (up to 45 days per calendar year) | No charge |
| Outpatient visits: | |
| Up to a total of 20 individual and/or group therapy visits per calendar year | |
| Individual therapy visits | $10 per visit |
| Group therapy visits | $5 per visit |
| Note: Visit and day limitations do not apply to severe mental illnesses and serious emotional disturbances of children as described in the Evidence of Coverage. | |
| CHEMICAL DEPENDENCY SERVICES | |
| Inpatient detoxification | No charge |
| Outpatient group therapy visits | $5 per visit |
| Outpatient individual therapy visits | $10 per visit |
| Transitional residential recovery Services (up to 60 days per calendar year, not to exceed 120 days in any five-year period) | $100 per admission |
| OTHER SERVICES | |
| Ambulance Services | $50 per trip |
| Durable Medical Equipment in accord with our formulary | No charge |
| External prosthetic and orthotic devices | No charge |
| Eyewear purchased from Plan optical sales office every 24 months | $150 allowance* |
| Health Education for specific conditions - Individual | $10 per visit |
| Health Education for specific conditions - Group | No charge |
| Home Health Care (part-time, intermittent) | No charge |
| Hospice Care | No charge |
| EMERGENCY CARE | |
| Emergency Department visits | $50 per visit (waived if admittd directly to hospital) |
| * Your price will be reduced by the allowance indicated. If the price of the item(s) you select exceeds the allowance, you will pay the difference. | |
This chart is only a summary. Please see the evidence of coverage or disclosure form for the selected plan for a thorough description of its benefits, limitations, exclusions and conditions of coverage.
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800.788.0616 (SPANISH)
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