Kaiser Foundation Health Plan of Georgia

KP GA Signature Standard Silver 5000/40

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $5,000.00 Family: $10000.0 Per Person: $5000.0
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,000.00 Family: $16000.0 Per Person: $8000.0

Office Visit

Primary Doctor	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Virtual visits (if clinically appropriate) at the same cost share as in person visits. Refer to EOC.
Specialist	CoPay: $80.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Virtual visits (if clinically appropriate) at the same cost share as in person visits. Refer to EOC.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Up to a 90 day supply is available through mail order
Non Preferred Brand Drugs	CoPay: $80.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Up to a 90 day supply is available through mail order
Generic Drugs	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: 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
Specialty Drugs	CoPay: $350.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room

CoPay: Not Applicable
CoInsurance: 40.00% Coinsurance after deductible
Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Virtual visits (if clinically appropriate) at the same cost share as in person visits. Refer to EOC.

Vision

Routine Eye Exams for Children

CoPay: $40.00
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