KP GA Signature Silver Virtual Complete 200/94% CSR – HMO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	HMO
Deductible	$200 per person $200 per person
Out-of-pocket max	$1,000 per person $2,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	$20 copay after deductible
Specialist visit	$40 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$40 copay after deductible
Emergency room	5% coinsurance after deductible
Ambulance	5% coinsurance after deductible
Hospital stay (facility)	5% coinsurance after deductible
Hospital stay (physician)	5% coinsurance after deductible
Outpatient procedure (facility)	5% coinsurance after deductible
Outpatient procedure (physician)	5% coinsurance after deductible
Physical rehabilitation	$20 copay after deductible

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	5% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$5 copay
Brand	5% coinsurance after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	5% coinsurance after deductible
Imaging (CT/PET/MRI)	5% coinsurance after deductible
Blood work	No charge

Mental and Psychiatric Health Care

Mental Health outpatient services	$20 copay
Psychiatric hospital stay	5% 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/2024/89942GA0050031-06-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