KAISER PERMANENTE (Medical)
Southern California
Rates and Benefits

Plan 20-S

The monthly rates for the Kaiser Permanente Plan are:
AGE Single Husband  & Wife Parent & Child Family
<30 $163 $455 $447 $633
30-39 $180 $489 $460 $700
40-49 $232 $534 $441 $705
50-54 $302 $628 $498 $803
55-59 $382 $802 $571 $922
60-64 $471 $894 $630 $1,044
65+ $534 $1,154 $803 $1,269

Rates effective 1/1/2007 to 1/1/2008
Rates for areas not listed are available through
The OSSA Group at 1–800–582–8203 or email.
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Kaiser Permanente HMO Benefit Summary

Services

 Members Pay
Deductibles None
Lifetime Maximums None
Professional Services
(Plan Provider Office Visits)		  
  Primary care visits for internal medicine, family practice, pediatrics, and gynecology (includes routine and urgent care appointments)
$20 per visit
  Well-Child preventive care visits (23 months or younger)
No Charge
  Scheduled prenatal care and first postpartum visit
No Charge
  Eye exams to provide a prescription for eyeglasses
$20 per visit
x  Hearing exams
$20 per visit
x  Physical, occupational and speech therapy
$20 per visit
Outpatient Services  
x  Outpatient surgery
$50 per procedure
x  Allergy Testing visits
$20 per visit
x  Allergy injection visits
$5 per visit
x  Immunizations
No Charge
x  X-rays and lab tests
$10 per visit
x  Health education for specific conditions:
 
  Individual visits
$20 per visit
  Group visits
No Charge
Hospitalization Services  
  Room and board
$100 per day
  Physician, surgeon and surgical services
No Charge
Emergency Health Coverage  
  Emergency Department visits
$100 per visit,
(waived if admitted directly to the hospital)
Ambulance Services  
  Ambulance services
$75 per trip
Prescription Drug Coverage  
  Covered prescription drugs in accord with our formulary when obtained at PLAN PHARMACIES
 
  Generic Drugs
 

Refills Obtained through Mail Order
$10 up to a 30 day supply

$20 up to a 100 day supply
  Brand-name drugs
 

Refills Obtained through Mail Order
$30 up to a 30 day supply

$60 up to a 100 day supply
  Drugs for the treatment of infertility
50% of charges up to a 100 day supply
  Drugs related to the treatment of sexual dysfunction disorders (Episodic drugs are limited to 27 doses in any 100 day period.)
50% of charges up to a 100 day supply
Durable Medical Equipment  
  Durable medical equipment in accord with our formulary
20% of charges
  External sexual dysfunction devices in accord with our formulary
50% of charges
  External prosthetic and orthotic devices
20% of charges
Mental Health Services  
  Inpatient psychiatric care
(up to 30 days per calendar year)
$100 per day
  Outpatient visits:
 
  Up to a total of 20 individual and/or group therapy visits per calendar year
$20 per visit
  Up to 20 additional group therapy visits that meet Medical Group criteria in the same calendar year
$20 per visit
NOTE: Visit of day limits do not apply to severe mental illnesses and serious emotional disturbances of children as described in the Evidence of Coverage.
Chemical Dependency Services  
  Inpatient detoxification
$100 per day
  Outpatient individual therapy visits
$20 per visit
  Outpatient group therapy visits
$5 per visit
  Transitional rresidential recovery services (up to 60 days per calendar year, not to exceed 120 days in any 5 year period)
$100 admission
Home Health Services  
  Home health care
No Charge
Other  
  Covered services related to the diagnosis and treatment of infertlity
50% of charges
  Skilled nursing facility care (up to 100 days per benefit period)
No Charge
  Hospice care
No Charge
  Coordination of benefits
Included

Additional information and member support are available through the following Insurance Company websites:

Rate and Comparison charts on this website are provided for informational purposes ONLY and are not to be considered as binding. Not all areas or plans are listed. While every effort is made to maintain the accuracy of this information, you should contact The OSSA Group to confirm rates and coverages available in your area.

If you are a current ROTATOR employee and would like to receive an information pack outlining the specific plans and rates available to you, contact Joe Marini at The OSSA Group, or call 1–800–582–8203 and he will get one in the mail to you.

 
 

Let us put you to work.

ROTATOR Staffing Services, Inc. 
P.O. Box 366  -  557 Cranbury Road  -  East Brunswick, NJ  08816
Phone: (732) 238-6050  -  FAX: (732) 238-2152

ROTATOR Staffing Services, Inc. (New York) 
Suite 2805  -  122 East 42nd Street  -  New York, NY  10117
Phone: (212) 601-9500

ROTATOR Staffing Services, Inc. (California) 
2076 Westwood Boulevard  -  Los Angeles CA  90025
Phone: (310) 234-0345  -  FAX: (310) 441-3011

Medical Staffing Services, Inc. 
P.O. Box 862  -  557 Cranbury Road  -  East Brunswick, NJ  08816
Phone: (732) 238-6050  -  FAX: (732) 238-2152

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