Benefits of Kaiser Permanente Services DHMO

Medical Plan Comparison

Kaiser Permanente Hospital Services DHMO
Group #: 602484-0006
Calendar Year Deductible

$1,500 Self-Only Enrollment
$1,500 Any one member in a family of two or more
$3,000 Family of two or more

Coinsurance

Varies - See Kaiser’s Evidence of Coverage

Calendar Year Out of Pocket Maximum
(Including Deductibles, Co-pays, and Coinsurance)

$4,000 Self-Only Enrollment
$4,000 Any one member in a family of two or more
$8,000 Family of two or more

Lifetime MaximumNone
Dependent Children Eligibility

Any Dependent child under age 26

Disabled: No age limit

Office Visits and Professional Services

Kaiser Permanente Hospital DHMO
Group #:602484-0006
Physician & Specialist$20 co-pay, no deductible
Preventive Care Adult Routine CareNo Charge, no deductible
Preventive Care Adult Routine Care OB/GYNNo Charge, no deductible
Diagnostic Lab and X-Ray$10 per encounter, no deductible
Physical Therapy (Medically necessary treatment only)$20 co-pay, no deductible
ChiropracticDiscounted rates through Kaiser Choose Healthy
Mental Health & Substance Abuse
(Out-patient)
Individual Therapy: $20 co-pay, no deductible
Group Therapy: $10 co-pay, no deductible

Surgical and Hospital Services

Kaiser Permanente Hospital Services DHMO
Group #: 602484-0006
Inpatient Hospital and Physician Services20% Coinsurance after deductible
Outpatient Surgery20% Coinsurance after deductible
Maternity20% Coinsurance after deductible
Emergency Room20% Coinsurance after deductible
Ambulance$150 per trip, no deductible
Mental Health & Substance Abuse (Inpatient)20% Coinsurance after deductible
Skilled Nursing Facility20% Coinsurance, no deductible
Up to 100 days per benefit
Home HealthNo Charge (deductible doesn't apply)  
100 days per year 

Prescription Drugs

Kaiser Permanente Hospital Services DHMO
Group #: 602484-0006
Generic or Tier 1$10 co-pay 30day supply, no deductible
Formulary Brand or Tier 2$30 co-pay 30day supply, no deductible
Mail Order Benefit Generic or Tier 1$20 co-pay 100 day supply, no deductible
Mail Order Benefit Formulary Brand or Tier 2$60 co-pay 100 day supply, no deductible
Mandatory Mail OrderNo
Mandatory Generic ProgramNot available