Kaiser Permanente

KP MD Gold Virtual Forward 2000

Plan Overview

Combined Medical and Drug Deductible
  • Individual: $2,000
  • Family: $4,000
  • Per Person: $2,000
Combined Medical and Drug Out of Pocket Maximum
  • Individual: $5,000
  • Family: $10,000
  • Per Person: $5,000

Office Visit

Primary Doctor
  • CoPay: $50.00 Copay after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: $0 copay after deductible for children under age 5. There is no charge for the first Primary Care, Other Practitioner, Routine Eye Exam, Mental/Behavioral Health, Substance Abuse Disorder, Diabetes Education and Nutritional Counseling office visits combined; then the primary care cost share applies for all subsequent office visits or services.
Specialist
  • CoPay: $70.00 Copay after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered

Prescription Drug Information

Preferred Brand Drugs
  • CoPay: $50.00 Copay after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
Non Preferred Brand Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered
Generic Drugs
  • CoPay: $10.00 Copay after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
Specialty Drugs
  • CoPay: Not Applicable
  • CoInsurance: 50.00% Coinsurance after deductible
  • Covered: Covered

Inpatient Coverage

Hospital Services
  • CoPay: $300.00 Copay per Day after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: $300 copay per day up to 3 days per admission.
Inpatient Services
  • CoPay: No Charge after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered

Emergency and Urgent Care

Emergency Room
  • CoPay: $200.00 Copay after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
Urgent Care Facility
  • CoPay: $70.00 Copay after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: Non-plan providers are covered only outside the service area.

Maternity

Labor and Delivery Hospital Stay
  • CoPay: $300.00 Copay after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Benefit Explanation: $300 copay per day up to 3 days per admission.
Pre and Postnatal Office Visit
  • CoPay: No Charge
  • CoInsurance: Not Applicable
  • Covered: Covered

Vision

Routine Eye Exams For Children
  • CoPay: $50.00 Copay after deductible
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 1
  • Limit Unit : Exam(s) per Benefit Period
  • Benefit Explanation: There is no charge for the first Primary Care, Other Practitioner, Routine Eye Exam, Mental/Behavioral Health, Substance Abuse Disorder, Diabetes Education and Nutritional Counseling office visits combined; then the primary care cost share applies for all subsequent office visits or services.

Major Dental Care

Routine Dental Checkups for Children
  • CoPay: No Charge
  • CoInsurance: Not Applicable
  • Covered: Covered
  • Limit Quantity: 2
  • Limit Unit : Exam(s) per Benefit Period
  • Benefit Explanation: $10 office visit charge applies to each visit
Basic Dental Care - Child
  • CoPay: Not Applicable
  • CoInsurance: 33.00%
  • Covered: Covered
  • Benefit Explanation: Benefit limitations may apply to individual services.
Major Dental Care - Child
  • CoPay: Not Applicable
  • CoInsurance: 39.00%
  • Covered: Covered
  • Benefit Explanation: Benefit limitations may apply to individual services.
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