KP GA Signature Silver 4500/35 – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$4,500 per person $4,500 per person
Out-of-pocket max	$8,150 per person $16,300 per family
Metal tier	Silver

Visit Copay

Primary care visit	$35 copay
Specialist visit	$65 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$65 copay
Emergency room	35% coinsurance after deductible
Ambulance	35% coinsurance after deductible
Hospital stay (facility)	35% coinsurance after deductible
Hospital stay (physician)	35% coinsurance after deductible
Outpatient procedure (facility)	35% coinsurance after deductible
Outpatient procedure (physician)	35% coinsurance after deductible
Physical rehabilitation	$35 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	35% 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	35% coinsurance after deductible
Imaging (CT/PET/MRI)	35% coinsurance after deductible
Blood work	35% coinsurance after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	$65 copay
Psychiatric hospital stay	35% 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/2024/89942GA0050025-01-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