Kaiser Permanente

KP DC Gold 1700 Ded/HSA/Vision

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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Plan Overview

Medical Deductible	Individual: $1,700 Family: $3,400 Per Person: $1,700
Medical Out-of-Pocket Maximum	Individual: $5,000 Family: $10,000 Per Person: $5,000
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: $25 Copay after deductible
Specialist	Standard: $50 Copay after deductible

Prescription Drug Information

Preferred Brand Drugs	Standard: $50 Copay after deductible
Non Preferred Brand Drugs	Standard: 25% Coinsurance after deductible
Generic Drugs	Standard: $15 Copay after deductible
Specialty Drugs	Standard: 25% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: 25% Coinsurance after deductible
Inpatient Services	Standard: 25% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: $500 Copay after deductible