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Kaiser Silver 70 HMO

In-Network

Cost Share Information

Individual Deductible

$2,500

Family Deductible

$5,000

Out of Pocket Limit-Individual

$6,800 (including deductible)

Out of Pocket Limit-Family

$13,600 (including deductible)

Co-Insurance

20%

Lifetime Maximum

None

Office Visits

Primary Care

$35 deductible waived

Specialist

$70 deductible waived

Adult Preventive Care

No Charge

Child Preventive Care

No Charge

Maternity Prenatal/Postnatal Care

No Charge

Rehabilitation Services

$35 deductible waived

Chiropractic Care

Not Covered

Inpatient Services

Inpatient Hospital

20% after deductible

Maternity Delivery/Inpatient

20% after deductible

Outpatient Services

Outpatient Facility

20% after deductible

Mental Health Outpatient

$35 deductible waived

Lab/X-Ray

$35/$75 deductible waived

Emergency Care

Emergency Room

$350 (waived if admitted)

deductible waived

Urgent Care

$35 deductible waived

Ambulance

$250 after deductible

Prescription Drugs

Rx Deductible

$250 individual/ $500 family

Rx Generic

$15 deductible waived

Rx Preferred

$55 after deductible

Rx Non-Preferred

$80 after deductible

Recovery/ Special Needs

Home Health Care

$45 deductible waived;

100 visits per year

Durable Medical Equipment

20% deductible waived

Optional Benefits

None

Complete Benefit Summary

If you you have questions about the Kaiser Silver 70 HMO plan or any other plans from Kaiser Permanente of California please call The Lynn Company at (800)-326-5966 for more information on California Health Insurance Plans.

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