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NEW 2012 Kaiser Permanente Plan In-Network Benefit Summaries
Description of Benefits	Classic Plans Best Level of Coverage - Unlimited Office Visits - 80% Co-Ins	Advantage Plans Lower Cost, Has a Limited # of Drs. Ofc Visits with Copays - 70% Co-Ins	Essential Plans 100% coverage after deductible - Includes Limited PCP Dr. Copays	HSA Plans High Deductible - Plan Pays 100% After Deductible is Paid by You
Lifetime Maximum Per Member*	Unlimited	Unlimited	Unlimited	Unlimited
Annual Deductible Per Member (for families, only 2 members must meet deductible each yearin catastrophic family event)	Choose From $1,500, $2,500 $3,500 or $5,000 Deductibles	Choose From $2,500, $3,500 $5,000 or $7,500 Deductibles	Choose from $1,500, $3,000, $5,000 or $7,500 Deductible	$5,000 Individual or $10,000 Family
Annual Out-of-Pocket Maximum (for families, only 2 members must meet maximum each year in catastropic family event)	The out-of-pocket maximum per member is the same amount as your deductible (in addition to paying your deductible)	$5,000 plus deductible per member	Deductible Only then 100% Coverage	Deductible Only then 100% Coverage
Coinsurance (the amount that Kaiser pays after the deductible has been met)	80%	70%	100%	100%
Office Services - Primary Care - Specialty Care - Special Procedures (Cardiac Stress Tests, EMG, others) - Most Preventive Services - Maternity Services***	$35 Copay - Unlimited # of Visits $60 Copay - Unlimited # of Visits Plan Pays 70% After Deductible No Charge Not Covered	$45 Copay - Unlimited # of Visits $75 Copay - 1st 2 Visits/Year 3+ visits - Plan Pays 70% After Deductible (# of visits excludes well check ups) Plan Pays 70% After Deductible No Charge Not Covered	$75 Copay - Unlimited # of Visits Plan Pays 100% After Deductible Plan Pays 100% After Deductible No Charge Not Covered	Plan Pays 100% After Deductible Plan Pays 100% After Deductible Plan Pays 100% After Deductible No Charge Not Covered
Outpatient Services - Most Diagnostic Lab and/or Radiology Services	No Charge	No Charge	No Charge	Plan pays 100% after deductible
- High Tech Radiology Svcs (MRI, CT, PET, others)	Plan pays 80% after deductible	Plan pays 70% after deductible	$250 Copay	Plan pays 100% after deductible
- Rehabilitation Therapies 20 visits (Physical, Occupational, and Speech Therapy)	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 100% after deductible	Plan pays 100% after deductible
-Outpatient Surgery and/or -Outpatient Hospital Facility	Plan pays 80% after deductible	Plan pays 70% after deductible	$500 Copay	Plan pays 100% after deductible
-Physician and Other Outpatient Professional Charges	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 100% after deductible	Plan pays 100% after deductible
Emergency Services - Emergency Room Visit (per visit; copay waived if admitted) - After Hours Urgent Care (per visit) - Ambulance (per trip)	$250 copay $75 copay Plan pays 80% after deductible	$500 copay $100 copay Plan pays 70% after deductible	$500 copay $150 copay Plan pays 100% after deductible	Plan pays 100% after deductible Plan pays 100% after deductible Plan pays 100% after deductible
Inpatient Services - Hospital (facility charge) - Maternity (hospital delivery)*** - Physician and Other Professional Charges	Plan pays 80% after deductible Not Covered Plan pays 80% after deductible	Plan pays 70% after deductible Not Covered Plan pays 70% after deductible	Plan pays 100% after deductible Not Covered Plan pays 100% after deductible	Plan pays 100% after deductible Not Covered Plan pays 100% after deductible
Mental Health Svcs. - Outpatient - Inpatient Mental Health Professional	Plan pays 80% after deductible Plan pays 80% after deductible	Plan pays 70% after deductible Plan pays 70% after deductible	$120 Copay Plan pays 100% after deductible	Plan pays 100% after deductible Plan pays 100% after deductible
Durable Medical Equipment/Prosthetics and Orthotics	Plan pays 80% after deductible	Plan pays 70% after deductible	Plan pays 100% after deductible	Plan pays 100% after deductible
Vision Exam (Routine-well-visit)	$50 Copay Discount for Eyewear	$50 Copay Discount for Eyewear	$50 Copay Discount for Eyewear	$50 Copay Discount for Eyewear
Pharmacy Services - (up to a 30-day supply) Kaiser Permanente Pharmacies Only
- Preventive Generic Prescriptions - (Kaiser Permanente Pharmacies Only)	$5 copay - no deductible	$5 copay - no deductible	Plan pays 100% after deductible	Plan pays 100% after medical deductible
- Generic (Kaiser Permanente Pharmacies Only)	$15 copay - no deductible	$15 copay - no deductible	Plan pays 100% after deductible	Plan pays 100% after medical deductible
- Brand Formulary (after Brand Deductible)	$45 Copay after $500 Deductible	$45 copay after $1,000 Deductible	Plan Pays 50% after $1,000 Deductible	Plan pays 100% after medical deductible
- Brand Non-Formulary (after Brand Deductible)	Not Applicable	Not Applicable	Not Applicable	Not Applicable
- Specialty Prescriptions (after Brand Deductible)	Plan Pays 50% after $500 Deductible	Plan Pays 50% after $1,000 Deductible	Plan Pays 50% after $1,000 Deductible	Plan pays 100% after medical deductible
- Prescription Maximum Out of Pocket for Specialty Drugs	$5,000	$5,000	$5,000	Included in the Medical Deductible
* Some benefits may have limitations Please Note: This is a summary description and is not intended to replace the Individual Agreement or Personal Advantage Evidence of Coverage, which contain the complete provisions of this coverage. Some services require precerification.
Fax your completed application to: 770-396-4318

5 Dunwoody Park, Suite 113 Atlanta, GA 30338	Call Holly, Chris or Bob at (770) 396-9517 Outside of the Atlanta area, call toll-free: 1-877-711-8376. Email: holly@insurance-now.com