302435 kpif proofs v5 001 - kaiser...
Post on 24-Mar-2020
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Receiving Care in Another Kaiser Foundation Health Plan Service Area
;
;
Receiving Care in Another Kaiser Foundation Health Plan Service Area.
treatment for that condition and then the external review decision will be provided within 24 hours. This notice may be provided orally, but must be followed in writing to you and us within 48 hours of the oral notification.
500/10
Single: $500
Single $2,250
0
Plan Pays 90% after Annual Deductible wh physician's office
60
90 setting and Plan Pays 60% after Annual
0
00
90 setting and Plan Pays 60% after Annual
0
0
0
P 0
0
0
0
00
0
0
P 0
P 0
0
P 0
P 0
0
0
90 setting and Plan Pays 60% after Annual
90 setting and Plan Pays 60% after Annual
90 setting and Plan Pays 60% after Annual
P 0
0
90
0
P 0
0
0
P
0
0
0
0
0
0
0
0
0
0
$5 Copayment at Kaiser Permanente and $15 at participating community pharmacies$10 Copayment after Annual Deductible at Kaiser Permanente and $20 Copayment after Annual Deductible at participating community pharmacies
Permanente Outpatient Prescription Home Deilvery Service, you will pay two times the applicable Copayments you would pay for a 30-day supply. Any applicable deductible and coinsurance will continue to apply to total refill ordered. There is no shipping charge and no additional fees for home delivery prescriptions.
30
P 0
Not Applicable
Plan Pays 90% after Annual Deductible
Not Applicable
Plan Pays 90% after Annual Deductible
Plan Pays 50% after Rx Deductible
Plan Pays 50% after Rx Deductible
$20 Copayment after Annual Deductible at Kaiser Permanente and $30 Copayment after Annual Deductible at participating community pharmacies
0
0
P 0
P 0
P 0
h
90 after Annual Deductible
90 after Annual Deductible
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