KP GA Signature Gold 1500 Ded/500 Rx Ded

89942GA0050022
Gold
HMO

KP GA Signature Gold 1500 Ded/500 Rx Ded is a Gold HMO plan by Kaiser Permanente.

IMPORTANT: You are viewing the 2024 version of KP GA Signature Gold 1500 Ded/500 Rx Ded 89942GA0050022. 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 Signature Gold 1500 Ded/500 Rx Ded is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of KP GA Signature Gold 1500 Ded/500 Rx Ded 89942GA0050022.
Insurer: Kaiser Permanente
Network Type: HMO
Metal Type: Gold
HSA Eligible?: No
Plan ID: 89942GA0050022

Cost-Sharing Overview

KP GA Signature Gold 1500 Ded/500 Rx Ded 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 Signature Gold 1500 Ded/500 Rx Ded?

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 Signature Gold 1500 Ded/500 Rx Ded 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 Signature Gold 1500 Ded/500 Rx Ded 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 Signature Gold 1500 Ded/500 Rx Ded 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
$20.00 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 30.00% 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
$20.00 Not ApplicableNot Applicable 100.00%1.0 Exam(s) per Year
Urgent Care Centers or Facilities
Covered
$50.00 Not Applicable$50.00 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 30.00% Coinsurance after deductibleNot Applicable 30.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 30.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%150.0 Days per Year
Prenatal and Postnatal Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$10.00 Not ApplicableNot Applicable 100.00% Tier 1 generics available @ lower cost share. Tier 2 generics @ cost share shown. Non-preferred generics @ 45% after deductible. Up to a 90 day supply is available through mail order
Preferred Brand Drugs
Covered
$40.00 Copay after deductible Not ApplicableNot Applicable 100.00% Up to a 90 day supply is available through mail order
Non-Preferred Brand Drugs
Covered
Not Applicable 45.00% Coinsurance after deductibleNot Applicable 100.00% Up to a 90 day supply is available through mail order
Specialty Drugs
Covered
Not Applicable 45.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Rehabilitation Services
Covered
$20.00 Not ApplicableNot Applicable 100.00% Please refer to Plan Brochure and SBC.
Habilitation Services
Covered
$20.00 Not ApplicableNot Applicable 100.00%
Chiropractic Care
Covered
$20.00 Not ApplicableNot Applicable 100.00%20.0 Visit(s) per Year Coverage limited to Spinal Manipulation.
Durable Medical Equipment
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Hearing Aids
Not Covered
Imaging (CT/PET Scans, MRIs)
Covered
$350.00 Not ApplicableNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge Not ApplicableNot Applicable 100.00%
Routine Foot Care
Not Covered
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
$20.00 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
$20.00 Not ApplicableNot Applicable 100.00%40.0 Visit(s) per Year
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$20.00 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 30.00% Coinsurance after deductibleNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 30.00% 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 30.00% Coinsurance after deductibleNot Applicable 100.00%
Accidental Dental
Covered
Not Applicable 40.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
$40.00 Not ApplicableNot Applicable 100.00% Services performed in an outpatient hospital setting are usually at a greater member cost share.
Chemotherapy
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 30.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
Not Applicable 30.00% 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
$40.00 Not ApplicableNot Applicable 100.00%
Reconstructive Surgery
Covered
Not Applicable 30.00% 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 Signature Gold 1500 Ded/500 Rx Ded 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 Signature Gold 1500 Ded/500 Rx Ded 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 Signature Gold 1500 Ded/500 Rx Ded?

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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