Kaiser Permanente

KP DC Gold 1000 Ded/200 RxDed/Vision

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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Plan Overview

Medical Deductible	Individual: $1,000 Family: $2,000 Per Person: $1,000
Prescription Drug Deductible	Individual: $200 Family: $200 Per Person: $200
Medical Out-of-Pocket Maximum	Individual: $6,950 Family: $13,900 Per Person: $6,950
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $20 Copay
Specialist	Standard: $40 Copay

Prescription Drug Information

Preferred Brand Drugs	Standard: $55 Copay
Non Preferred Brand Drugs	Standard: 35% Coinsurance after deductible
Generic Drugs	Standard: $10 Copay
Specialty Drugs	Standard: 35% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: 35% Coinsurance after deductible
Inpatient Services	Standard: 35% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: $500 Copay