Kaiser Permanente HMO Medical Plan
Phone no: 1-800-464-4000 (English)
Phone no: 1-800-788-0616 (Spanish)
Group no: 979
ID no: Medical Record # (on ID card)
Website: www.kaiserpermanente.org
Note: This plan is for non-union members.
| Benefit | Coverage/Copay |
| Deductible | None |
| Inpatient Hospital | 100% coverage |
| Physician Office Visits | $15 copay |
| Routine Physical Exams | $15 copay |
| Routine GYN Exams | $15 copay |
| Maternity Care Office Visits | $5 copay |
| Well-Baby Care | $5 copay |
| Prescription Drugs | $10 copay generic;$20 copay for non-generic formulary |
| Emergency Room (waived if admitted) | $50 copay, waived if hospitalized |
| Chiropractic | $15 copay; 30 visits per year |
Mental Health (Outpatient)*
| $15 copay; 20 visits per year
|
| Mental Health (Intpatient)* | 100% coverage; 45 days per year |
| Vision Benefit (Exam) | $15 copay |
| Vision Benefit (Lenses, Frames, and Contacts) | $175 allowance every 24 months |
* Non-severe only. Severe mental health is covered as any other illness. SCU provides additional mental health benefits through its Employee Assisitance Program (EAP) and Mental Health Benefits Program with United Behavioral Health (UBH).
This is a summary of the benefits provided. Please refer to Kaiser Permanente Traditional Plan Evidence of Coverage - for non-union members only (PDF, 23 pages, 678K) and Chiropractic Care (PDF, 1 page, 44k) for plan details, exclusions and limitations.
