KP GA Signature Silver 3400 Ded/500 Rx Ded – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: $30 copay
Specialist visit: $60 copay
Urgent care visit: $60 copay
Description
Health Care Plan Details
Network type | HMO |
Deductible | $3,400 per person $3,400 per person |
Out-of-pocket max | $9,100 per person $18,200 per family |
Metal tier | Silver |
Visit Copay
Primary care visit | $30 copay |
Specialist visit | $60 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $60 copay |
Emergency room | 40% coinsurance after deductible |
Ambulance | 40% coinsurance after deductible |
Hospital stay (facility) | 40% coinsurance after deductible |
Hospital stay (physician) | 40% coinsurance after deductible |
Outpatient procedure (facility) | 40% coinsurance after deductible |
Outpatient procedure (physician) | 40% coinsurance after deductible |
Physical rehabilitation | $30 copay |
Maternitowny and Pregnancy
Well baby care | No charge |
Labor, delivery, hospital stay | 40% coinsurance after deductible |
Pharmacy, Drugs, and Medication
Generic | $15 copay |
Brand | $50 copay after deductible |
Non-preferred Brand | 50% coinsurance after deductible |
Specialty | 50% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
X-rays | 40% coinsurance after deductible |
Imaging (CT/PET/MRI) | $500 copay |
Blood work | 40% coinsurance after deductible |
Mental and Psychiatric Health Care
Mental Health outpatient services | $60 copay |
Psychiatric hospital stay | 40% 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/2024/89942GA0050017-01-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 |