Kaiser Foundation Health Plan of Georgia

KP GA Signature Bronze Virtual Complete 5500/1500 RxDed

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $5,500.00 Family: $11000.0 Per Person: $5500.0
Prescription Drug Deductible	Individual: $1,500.00 Family: $3000.0 Per Person: $1500.0
Combined Medical and Drug Out of Pocket Maximum	Individual: $9,100.00 Family: $18200.0 Per Person: $9100.0

Office Visit

Primary Doctor	CoPay: $60.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: First 3 visits deductible waived. Virtual visits (if clinically appropriate) $0 copay, refer to EOC
Specialist	CoPay: $80.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Virtual visits (if clinically appropriate) $0 copay, refer to EOC.

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Up to a 90 day supply is available through mail order
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Up to a 90 day supply is available through mail order
Generic Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Tier 1 generics available @ lower cost share. Tier 2 generics @ cost share shown. Non-preferred generics @ 50% after deductible. Up to a 90 day supply is available through mail order
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room

CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Virtual visits (if clinically appropriate) $0 copay, refer to EOC.

Vision

Routine Eye Exams for Children

CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered
Routine Dental Checkups for Adults	Covered: Not Covered