|
Kaiser "E" Plan
Plan Benefits Summary |
Costs |
| Annual
Deductible |
None |
| Lifetime
Maximum Benefits |
Unlimited |
| Doctor's
Office Visits |
$20 per visit |
| Periodic Health Evaluations |
$20 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 |
$20 per visit** |
Mental Health
/ Severe
Inpatient |
No Charge |
| Outpatient |
$20 per visit |
Mental Health
/ Non-Severe
Inpatient |
30 Days; No Charge |
| Outpatient |
$20 per visit / 20 visits
max |
| Physical
Therapy |
$20 per visit |
Prescription Drugs
|
$15
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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