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UNDERS TAND I NG
YOUR
MEDICAL
PLAN
5
Medical Questions? Need to Locate a Provider?
Contact Kaiser Permanente
1-888-865-5813 or
www.kp.orgGroup #: 10022
Plan Name: Oglethorpe University
Overview
Calendar Year Deductible
Individual
Family
Individual
Family
Co-insurance
Lifetime Maximum Benefit
Primary Care Physician Office Visits
Specialist Office Visits
Preventive Care Services - as determined by the US Preventive Services
Task Force
Hospital Inpatient Expenses
(Must be Pre-Certified)
Hospital Outpatient Expenses
Diagnostic Lab / X-Ray
(not performed in Doctor's office)
Emergency Room
(Accidental Injury and Medical Emergency Care)
Urgent Care
Durable Medical Equipment
Chiropractic Services
(20 visit maximum per calendar year)
Rehabilitation Benefits
(includes physical, occupational and speech
therapy)
Kaiser Pharmacy (30-day Supply)
Network Pharmacy (30-day Supply)
Mail Order Program (90-day Supply)
Annual Out of Pocket Maximum
(includes Deductible, Co-insurance, and all Co-pays)
HMO
In Network Only
Participants must visit a Kaiser provider or facility to receive benefits. Use a non-Kaiser provider or facility and no
benefits will be paid by Kaiser.
$1,000
$2,000
$40 Co-pay
$3,000
$6,000
90% after Deductible
Unlimited
$20 Co-pay
$30 Co-pay
Covered at 100%, not subject to deductible or Co-pays
Plan pays 90% after Deductible
Plan pays 90% after Deductible
Plan pays 90% after Deductible
$200 Co-pay, waived if admitted
2 Co-pays per 90 day supply
Plan pays 100% after Deductible
$30 Co-pay
Plan pays 90% after Deductible
Limited to 20 visits per calendar year
Prescription Drugs
$5 for Preventive drugs
$15 for Generic drugs
$30 for Preferred Brand drugs
30% to a $300 max for Specialty Drugs
Non Preferred Brand drugs not covered unless medically necessary
$15 for Preventive drugs
$25 for Generic drugs
$40 for Preferred Brand drugs
30% for Specialty Drugs
Non Preferred Brand drugs not covered unless medically necessary