KP GA Standard Gold 1500/30

89942GA0130001
Gold
HMO

KP GA Standard Gold 1500/30 is a Gold HMO plan by Kaiser Permanente.

IMPORTANT: You are viewing the 2024 version of KP GA Standard Gold 1500/30 89942GA0130001. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

KP GA Standard Gold 1500/30 is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of KP GA Standard Gold 1500/30 89942GA0130001.
Insurer: Kaiser Permanente
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 89942GA0130001

Cost-Sharing Overview

KP GA Standard Gold 1500/30 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for KP GA Standard Gold 1500/30?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

KP GA Standard Gold 1500/30 offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: All specialists except Dermatology, Behavioral Health, Optometry, Ophthamology, Obestetrical and Gynecology require a referral.
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what KP GA Standard Gold 1500/30 covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Urgent and Emergency Care only
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Urgent and Emergency Care only
National Network: No

Additional Benefits and Cost-Sharing

KP GA Standard Gold 1500/30 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$60.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
No Charge Not ApplicableNot Applicable 100.00%
Routine Dental Services (Adult)
Not Covered
Infertility Treatment
Not Covered
Long-Term/Custodial Nursing Home Care
Not Covered
Private-Duty Nursing
Not Covered
Routine Eye Exam (Adult)
Covered
$30.00 Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Year
Urgent Care Centers or Facilities
Covered
$45.00 Not Applicable$45.00 Not Applicable Non-plan providers are not covered inside the service area
Home Health Care Services
Covered
No Charge Not ApplicableNot Applicable 100.00%120.0 Visit(s) per Year
Emergency Room Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%150.0 Days per Year
Prenatal and Postnatal Care
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$15.00 Not ApplicableNot Applicable 100.00% Tier 1 and Tier 2 generics @ cost share shown. Non-preferred generics @ non-preferred brand cost share. Up to a 90 day supply is available through mail order
Preferred Brand Drugs
Covered
$30.00 Not ApplicableNot Applicable 100.00% Up to a 90 day supply is available through mail order
Non-Preferred Brand Drugs
Covered
$60.00 Not ApplicableNot Applicable 100.00% Up to a 90 day supply is available through mail order
Specialty Drugs
Covered
$250.00 Not ApplicableNot Applicable 100.00%
Outpatient Rehabilitation Services
Covered
$30.00 Not ApplicableNot Applicable 100.00% Please refer to Plan Brochure and SBC.
Habilitation Services
Covered
$30.00 Not ApplicableNot Applicable 100.00%
Chiropractic Care
Covered
$30.00 Not ApplicableNot Applicable 100.00%20.0 Visit(s) per Year Coverage limited to Spinal Manipulation.
Durable Medical Equipment
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
Not Applicable 0.00%Not Applicable 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$30.00 Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Year
Eye Glasses for Children
Covered
No Charge Not ApplicableNot Applicable 100.00%1.0 Item(s) per Year Frames from a specified Collection
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
$30.00 Not ApplicableNot Applicable 100.00%40.0 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$30.00 Not ApplicableNot Applicable 100.00%40.0 Visit(s) per Year 40 visit limit per year for PT and OT combined
Well Baby Visits and Care
Covered
No Charge Not ApplicableNot Applicable 100.00% Care provided for children from birth through age 5.
Laboratory Outpatient and Professional Services
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Not Covered
Orthodontia – Adult
Not Covered
Major Dental Care – Adult
Not Covered
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Accidental Dental
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
$60.00 Not ApplicableNot Applicable 100.00% Services performed in an outpatient hospital setting are usually at a greater member cost share.
Chemotherapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
$60.00 Not ApplicableNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Nutritional Counseling
Covered
$60.00 Not ApplicableNot Applicable 100.00%
Reconstructive Surgery
Covered
Not Applicable 25.00% Coinsurance after deductibleNot Applicable 100.00% With limitations
Gender Affirming Care

Free Preventive Services

There is no copayment or coinsurance for any of the following KP GA Standard Gold 1500/30 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for KP GA Standard Gold 1500/30 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for KP GA Standard Gold 1500/30?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

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