|
Kaiser "D" Plan
Plan Benefits Summary |
Costs |
| Annual
Deductible |
None |
| Lifetime
Maximum Benefits |
Unlimited |
| Doctor's
Office Visits |
$5 per visit |
| Periodic Health Evaluations |
$15 per visit |
| Well Baby Care (to age 2) |
Covered in Full |
| Prenatal Care |
Covered in Full |
In-Patient
hospital Charges
|
Covered in Full |
| In-Patient
Surgery Charges |
Covered in Full |
| Outpatient
Surgery Charges |
Covered in Full |
| Lab &
X-Ray |
Covered in Full |
| Emergency
Room |
$35 per visit* |
| Allergy
Testing |
Covered in Full |
| Vision &
Hearing Exams |
$15 per visit** |
Mental Health
/ Severe
Inpatient |
No Charge |
| Outpatient |
$15 per visit |
Mental Health
/ Non-Severe
Inpatient |
30 Days; No Charge |
| Outpatient |
$15 per visit / 20 visits
max |
| Physical
Therapy |
$15 per visit |
Prescription Drugs
|
$10
Up to a 100 Day
Supply*** |
Prescription
by Mail
(90 day supply) |
N/A |
|
Maximum out-of-pocket |
$1,500 Single
$3,000
Family |
PLEASE SEE SUMMARY OF BENEFITS/DISCLOSURE FORM FOR
DETAILED BENEFIT EXPLANATIONS.
*Waived if admitted to
the hospital.
**Exams for fitting of contact lenses are not covered
under this benefit.
***50% co-payment for all prescriptions for
treatment of sexual dysfunction and infertility.
The following
conditions are considered severe mental illnesses: schizophrenia,
schizoaffective disorder, bipolar disorder, major depressive disorders,
panic disorders, obsessive-compulsive disorder, pervasive development
disorder or autism, anorexia nervosa, bulimia nervosa, serious emotional
disturbances of children.
STEP TWO - Locate the appropriate rate
table for your chosen plan and the county you live in
STEP THREE
- Select the rate for the plan of your choice based upon your
coverage
This is only a summary of your health plans
benefits. Please refer to your group's Disclosure Form for more
detailed terms and conditions of coverage's.
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