Kaiser Permanente Health Plan Northern California Region

Benefits Summary Sheet
2012 Plan Year
Kaiser Permanente Health Plan
Northern California Region
(Option 55) Group #9791
Deductible
Single
Family
$500
$1,000
Out of pocket maximums Single
$3,000
(includes deductible) Family
$6,000
Co-payments
Primary Care Physician (PCP) $20 per office visit
(applies to out of pocket
maximum)
Specialist
$40 per office visit
Inpatient services Plan pays 90% after deductible
Outpatient services Plan pays 90% after deductible or applicable copayment
Primary Care Physician (PCP) Plan pays 100% Includes routine physicals,
(no co-payment) GYN exams, mammograms,
Preventive health
pediatric and eye exams
services
well-baby care--23 months
or younger; Immunizations,
lab tests and X-rays
Inpatient services
Plan pays 80% after deductible
Mental health services
Substance abuse
services
Outpatient services $20 per office visit individual/$10 per office visit
group
Inpatient services
Plan pays 80% after deductible for detoxification
rehabilitation. $100 copay per admission for
transitional residential recovery services in a non
medical setting.
Outpatient services $20 per office visit individual/$5 per office visit
group
Emergency Room Plan pays 80% after deductible
Emergency services Urgent Care $20 co-payment
Ambulance Plan pays 80% after deductible
Pre-admission
None: Permanente Medical Group physicians are responsible for making all medical
certification
decisions
Pre-existing conditions Not applicable
Infertility services
Covered at 50% for diagnosis and treatment of involuntary infertility when approved
by a Plan physician
Durable Medical Supplies 80% covered per item in accordance w/DME formulary guidelines
Speech Therapy
$20 co-payment per visit
Benefits are limited to medically necessary therapy authorized by a Plan physician
Rehabilitative Services $20 co-payment per visit
Autism Therapies
Covered same as other medical illness in accordance with Mental Health Parity
(AB88)
Chiropractic
$15 co-payment/visit
Maximum of 20 visits/year
Hearing Aids
$1500 max per ear; Limited to one device per ear during a period of 36 consecutive
months
Bariatric Services
Plan pays 80% when deemed medically necessary and authorized by a Plan physician

Choice of doctors and
facilities
Prescription drugs
Customer service
Member selects a Primary Care Physician (PCP)
Generally no referrals are required. Please check with the plan regarding specialists.
For provider listing, type www.kaiserpermanente.org in your web browser
Retail $10 generic co-payment; $25 brand copayment/30
day supply
Mail $20 generic co-payment; $50 brand copayment/100
day supply
20% co-payment for testing supplies
50% co-payment for drugs for the treatment of infertility (as part of and approved
treatment) and sexual dysfunction (maximum dosage limit of 27 doses for 100-day
supply)
Kaiser Member Services:
(800) 464-4000
Life Events are events that affect or alter your life. It is important for you to
understand the benefit choices that you make when you are first eligible and during
subsequent annual enrollment periods, because your benefits are binding and cannot
be changed unless you experience a qualified Life Event. These Qualified Life Events
can be found in the Life Events Section of the Summary Plan Description, on i-
Life Events
Connect. To be eligible to make a Benefit Change, you must contact the Employee
Help Line (EHL) to Request the Change during business hours CT, no later than the
30 th calendar day after the date of the event (or 60 th calendar day after a
Medicaid/CHIP-related Life Event). If you do not satisfy the enrollment
requirements, coverage will not be added and no benefits for expenses incurred will
be payable.
Note: This represents a summary of coverage. Details in the Evidence of Coverage (EOC) govern in all cases.