KP GA Signature Bronze Virtual Complete 5500/1500 Rx Ded – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$5,500 per person $5,500 per person
Out-of-pocket max	$9,100 per person $18,200 per family
Metal tier	Expanded Bronze

Visit Copay

Primary care visit	$60 copay after deductible
Specialist visit	$80 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$100 copay
Emergency room	30% coinsurance after deductible
Ambulance	30% coinsurance after deductible
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	30% coinsurance after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$30 copay
Brand	30% coinsurance after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	30% coinsurance after deductible
Imaging (CT/PET/MRI)	30% coinsurance after deductible
Blood work	No charge after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$60 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/2024/89942GA0050019-01-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