Kaiser DHMO PLUS 1500 Plan Features
In- and out-of-network benefits available under the Kaiser DHMO Plus 1500 plan only (up to 10 out-of-network provider visits allowed per calendar year)
Members are allotted 10 visits with an out-of-network provider. If they exceed 10 visits, any additional services will be an out-of- pocket expense as long as it isn’t emergency or urgent care.
There is a $40.00 copay per visit for the following: • Family Practice • Outpatient Mental Health & Outpatient Chemical Dependency • Outpatient Therapy Office Visits (PT, OT, ST) • Allergy Injection • Each allergy injection will count as a visit used
There is a $60.00 copay per visit for the following: • Specialist Office Visits • Allergy Office Visits • Gynecology Office Visits
There is a 30% coinsurance for the following: • Lab (any lab tests done by the provider on the same day will count as a visit) • Radiology (multiple views of the same body part will count as one visit) • Select Durable Medical Equipment • Items must be supplied from the office visit
Services excluded from the PLUS benefit include, but are not limited to: • Inpatient or outpatient hospital services and any out of area facility fees • Any services provided while in a hospital, skilled nursing facility or ambulatory surgical center • Acupuncture, chiropractic, and massage therapy • Applied behavior analysis (ABA) therapy • Routine prenatal and maternity
• Dialysis • Oxygen
• Bariatric surgery • Genetic testing • Infertility • Home health care and hospice care • Dental services • Office administered drugs • Breast cancer screenings and/or imaging • Therapeutic x-rays • PET, CT, MRI, and Nuclear Medicine • Screening colonoscopies • Exams for the fitting and dispensing of contact lenses • Any and all services not covered under the members in network plan
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