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KAISER PERMANENTE HMO

Members in this plan must use Kaiser Permanente network providers. This is an in-network benefit level plan; there is no coverage for out-of-network in the Kaiser Permanente HMO Plan. Participants must declare a primary care physician from the Kaiser Permanente HMO network at the time of enrollment. On-line provider directory information can be obtained at www.kp.org/ga , or by calling their customer service line at 1-800-255-0056.

PLAN DESIGN FEATURES
Max. Lifetime Benefit	$2 million
Annual Medical Deductible	None
Annual Pharmacy Deductible	None
Maximum Annual Out-of-Pocket (Stop Loss)	Individual-No annual maximum Family-No annual maximum
Pre-Existing Conditions	None
PHYSICIAN SERVICES IN OFFICE SETTING	COPAYS
Physician Office Visit	$15 Copayment
Wellness Care/Preventive Health Care:
Physical Exam	$15 Copayment
Mammogram	$15 Copayment
Pap Smear	$15 Copayment
Prostate Exam/PSA	$15 Copayment
Adult Immunization	$15 Copayment
Routine Eye Exam	$15 Copayment
Routine Hearing Exam; for screenings only	$15 Copayment
Laboratory Services	100% covered for x-ray services 100% covered for diagnostic tests 100% covered for injectable medications with Office visit copayment Precertification may be required for specific svcs
Outpatient Surgery	100% covered after $50 copayment at a physician’s office or designated facility. Facility must be in Kaiser Permanente network. Precertification is required.
Second Surgical Opinion	$15 Copayment per visit
Maternity Services (prenatal, delivery and post- partum	All OB/GYN charges related to prenatal, delivery, and through first postpartum visit are covered at 100% after initial copayment of $15
Allergy Testing	$15 Copayment per visit
Allergy Shots and Serum	$10 Copayment per visit for injections. $50 for 6 months of maintenance serum. If a physician is seen, the visit is subject to $15 copayment
Medical Eye Services	$15 Copayment for routine eye exam. Discounts apply for nonsale merchandise (25% for glasses, 15% for regular contacts, and 5% for disposable contacts. Contact Kaiser Permanente Customer Service for further information.
INPATIENT HOSPITAL SERVICES
Physician Services (surgery, anesthesia, radiology, pathology, etc.)	100% covered for inpatient services. Precertification is required.
TREATMENT OF ILLNESS OR INJURY
Hospital Services Other Than Those for Emergency Room Care (includes inpatient short-term rehabilitation services)	100% covered; limited to semi-private room after a $200 hospital copayment per confinement. Precertification is required.
Maternity Care (Delivery)	100% covered after $200 copayment. Precertification is required.
Laboratory Services	100% covered for inpatient services. Precertification if required.
Hospice Care	100% covered. No lifetime limit. Precertification is required.
Surgical Management for Weight Loss	Not Covered.
OUTPATIENT HOSPITAL FACILITY SVCS	)
Physician Services (surgery, anesthesia, radiology, Pathology, etc)	100% for physician and other professional services
Facility Selected By a Treating Physician (May required precertificatiaon).)	Inpatient services: 100% covered after applicable $200 copayment of $200; Outpatient services: 100% covered after applicable copayment of $100
Care in a Hospital Emergency Room	$75 copayment per visit; waived if admitted within 24 hours
Laboratory Services	100% covered. Precertification may be required.
Urgent Care Services	Provided within or outside service area. Urgent Care services are covered either through a visit to a physician’s ofc or emergency room. The location of treatment determines copayment. $15 copayment at physician’s ofc during regular hrs $30 copayment at a Kaiser Permanent urgent care facility, other than an emergency room, for after hours care or $75 copayment at an emergency room
Home Nursing Care	See Home Hyperalimentation
Extended Care Facility	100% covered up to 60 days per calendar year. Precertification is required.
Home Hyperalimentation	100% covered for medically necessary intravenous medicine. $15 copayment for physician house calls. Limited to 120 visits per plan year. Precertification is required.
Hospice Care	100% covered when attending physician determines that patient is terminally ill and life expectancy is six months or less. Precertification is required.
Cochlear Implants	100% covered for physician and professional svcs.
Ambulance Services (Land or air ambulance for medically necessary emergency transportation only	$75 copayment per transport
Durable Medical Equipment (Rental or purchase)	50% of charges. Precertification is required.
Outpatient Short-Term Rehabilitation Services	Cardiac Therapy: $15 copayment limited to 12 weeks or 36 visits. Radiation/Chemotherapy: $15 copayment Speech Therapy: $15 copayment limited to 20 visits;. Respiratory Therapy: $15 copayment. Physical/Occupational Therapy: $15 copayment limited to 20 visits. Precertification is required.
Chiropractic Care	$15 copayment per visit to Kaiser Permanente chiropractor, limited to 20 visits per year
Dental/Oral Care	Not covered other than accidental injury to natural teeth.
Treatment of TMJ	50% of the cost for the nonsurgical dental treatment, using a Kaiser Permanente dentist
BEHAVIORAL HEALTH SERVICES
Providers of Behavioral Health Services	Referral by a primary care physician for mental health/substance abuse services NOT required. Contact Kaiser Permanent at 404-261-2590 for further information.
Mental Health	Inpatient: 100% covered after $200 copayment, limited to 30 days per year. Outpatient: 100% covered after $25 copayment per visit; after a $12 copayment group therapy session; limited to 20 visits per year.
Substance Abuse	100% covered for inpatient services after $200 copayment, limited to 30 days per year. Outpatient: 100% covered for outpatient services after $25 copayment per visit, limited to 40 visits per year.
PRESCRIPTION DRUGS	Member copayments for the use of Kaiser Permanente Pharmacy: Generic Drug: $10 copay Brand Name Drug: $25 copay Member copayments for the use of a network pharmacy: Generic Drug: $16 copay Brand Name: $31 copay