KP GA Gold 500 Ded/500 Rx Ded – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $40 copay
Urgent care visit: $50 copay
Description
Health Care Plan Details
Network type | HMO |
Deductible | $500 per person $500 per person |
Out-of-pocket max | $8,150 per person $16,300 per family |
Metal tier | Gold |
Visit Copay
Primary care visit | $20 copay |
Specialist visit | $40 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $50 copay |
Emergency room | 30% coinsurance after deductible |
Ambulance | $300 copay |
Hospital stay (facility) | 30% coinsurance after deductible |
Hospital stay (physician) | 30% coinsurance after deductible |
Outpatient procedure (facility) | 30% coinsurance after deductible |
Outpatient procedure (physician) | 30% coinsurance after deductible |
Physical rehabilitation | $20 copay |
Maternitowny and Pregnancy
Well baby care | No charge |
Labor, delivery, hospital stay | 30% coinsurance after deductible |
Pharmacy, Drugs, and Medication
Generic | $10 copay |
Brand | $30 copay after deductible |
Non-preferred Brand | 45% coinsurance after deductible |
Specialty | 45% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
X-rays | $50 copay |
Imaging (CT/PET/MRI) | $350 copay |
Blood work | 30% coinsurance |
Mental and Psychiatric Health Care
Mental Health outpatient services | $40 copay |
Psychiatric hospital stay | 30% coinsurance after deductible |
Health Plan Provider Information
Health Plan Benefits | https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/health-plan-documents/summary-of-benefits/ga/individual-family/2024/89942GA0050002-01-en-2024.pdf |
Drug and medication plan formulary | https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/formularies/ga/five-tier-formulary-benefit-ga-en-2024.pdf |
Search doctor list | https://healthy.kaiserpermanente.org/georgia/doctors-locations#/search-form |