Dollar Park & Fly Employees ONLY

Kaiser Permanente
Group Number:  8636-002
​Customer Service #: 800-813-2000
Link to summary of benefits 

Medical Out-Of-Pocket*

1 Member
$2,000 per Calendar Year
For Entire Family
$6,000 per Calendar Year

Medical Co-pays*

Preventive Care Services
Routine preventive physical exam (adult, well baby, and well child)

​Scheduled prenatal care and first postpartum visit
​
Immunizations

Preventive tests
$0


$0

​
​$0
​
$0
Outpatient Services
Primary Care Visit
Specialty care visit
Urgent care visit
ER visit

​
Outpatient surgery visit
$20
$20
$40
$150 (Waived if admitted)
​
$150

Medical Co-pays*

Lab, X-ray, imaging, and special diagnostic procedures

CT, MRI, PET scans


​Outpatient durable medical equipment

Physical, speech, and occupational therapies (2o limit per CY)

Inpatient Hospital Services
​​$100 per department visit

​$20 per department visit

​20% Coinsurance


$20



$300 per day up to $1,500 per admission

Outpatient Prescription Drugs

$15 or 50% Coinsurance, whichever is greater, up to a 30 day supply.  $0 for formulary contraceptives

Dental Benefits*  (Group number 8638)

Benefit Max per Calendar Year:   $1,000
Dental Office Visit Charge (applies to all visits)
Deductible
Preventive
Basic
Oral Surgery
Periodontics
Endodontics
Major Restoration
Emergency Dental Care
Orthodontics
 
You Pay
$10
​$0
No additional charge
20% coinsurance
50% coinsurance
50%coinsurance
50% coinsurance
50%coinsurance
50 coinsurance
​Not a covered benefit
This web site is not a legal document.  This web site is not a guarantee of coverage, eligibility, or provider status and is designed for informational illustration only.  Benefits outlined on this web site are subject to change at any time.  Please consult your benefit plan provider(s) or administrator(s) for legal documents regarding your plan and to check coverage and/or eligibility.