Pebblogo
Kaiser Permanente Classic

Contact Information

Local Phone: 503-813-2000
Toll-Free Phone: 1-800-813-2000
TTY/TDD Phone: 1-800-735-2900
Find a Provider
Visit the Plan's Website

Benefit Summary

Annual Costs 2010 Coverage

Annual deductible

$0

Annual out-of-pocket maximum

$1,500/person
$3,000/family

Annual prescription drug deductible

Does not apply

Medical Benefits 2010 Coverage

Ambulance services

 

(air)

$100/trip

(ground)

$100/trip

Diagnostic tests, laboratory, and X-rays

$10

Durable medical equipment, supplies, and prostheses

20%

Emergency room (copay waived if admitted)

$75

Hearing

 

(routine annual exam)

$20

(hardware)

Enrollee pays any costs above $800, allowed every 36 months for hearing aid and rental/repair combined

Hospital services

 

(inpatient)

$200/day ($1,000 max/ admission)

(outpatient)

$100

Mental health care

 

(outpatient)

$20

Obstetric care

 

(inpatient)

$200/day ($1000 max/admission)

(outpatient)

Enrollee pays $0

Office visits

$20 primary care; $30 specialty care; $40 urgent care

Physical, occupational, and speech therapy (per-visit cost for 60 visits/year combined)

$30

Prescriptions

 

tier 1 (retail pharmacy, 30-day supply)

$15

tier 2 (retail pharmacy, 30-day supply)

$30

tier 3 (retail pharmacy, 30-day supply)

N/A

tier 1 (mail order, 90-day supply)

$30

tier 2 (mail order, 90-day supply)

$60

tier 3 (mail order, 90-day supply)

N/A

Preventive care

Enrollee pays $0

(See Certificate of Coverage or check with plan for full list of services)

Spinal manipulations (per-visit cost for 10 visits/year)

$30

Vision care

 

(annual exam)

$20

(glasses and contact lenses)

Enrollee pays any costs above $150 every 24 months for frames, lenses, contacts, and fitting fees combined.