Common Medical What You Will Pay Limitations, Exceptions, & Other Important Event Services You May Need Network Provider Non-Network Provider Information (You will pay the least) (You will pay the most) Physician/surgeon fees No charge Not covered Physician/surgeon fees are included in the Facility fee. You must notify Kaiser Permanente within 24 hours if admitted to a Non-network provider; Emergency room care $250 / visit $250 / visit limited to initial emergency only. Copayment If you need waived if admitted directly to the hospital as immediate medical an inpatient. attention Emergency medical 20% coinsurance, 20% coinsurance , None transportation deductible does not apply. deductible does not apply. Urgent care $15 / visit $250 / visit Non-network providers covered when temporarily outside the service area. Facility fee (e.g., hospital $150 / day up to $750 / Not covered Preauthorization required or will not be If you have a room) admission covered. hospital stay Physician/surgeon fees are included in the Physician/surgeon fees No charge Not covered Facility fee. Preauthorization required or will not be covered. If you need mental Outpatient services $15 / visit Not covered None health, behavioral health, or substance Inpatient services $150 / day up to $750 / Not covered Preauthorization required or will not be abuse services admission covered. Depending on the type of services, a copayment, coinsurance, or deductible may Office visits No charge Not covered apply. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). If you are pregnant Professional services are included in the Childbirth/delivery No charge Not covered Facility services. You must notify Kaiser professional services Permanente within 24 hours of admission, or as soon thereafter as medically possible. Childbirth/delivery facility $150 / day up to $750 / You must notify Kaiser Permanente within 24 services admission Not covered hours of admission, or as soon thereafter as medically possible. If you need help Home health care No charge, deductible does Not covered Preauthorization required or will not be recovering or have not apply. covered. Page 3 of 6