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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© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN90296MD0610015ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN90296MD0610015ACA1

© 2024 HealthMarkets Insurance Agency. All rights reserved.

We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program to get information on all of your options.

Attention: This website is operated by HealthMarkets Insurance Agency, Inc. and is not the Health Insurance Marketplace® website. HealthMarkets Insurance Agency, Inc. is licensed as an insurance agency nationwide except in MA. Not all agents are licensed to sell all products. Service and product availability varies by state. Sales agents may be compensated based on a consumer’s enrollment in an insurance plan. No obligation to enroll. Agent cannot provide tax or legal advice. Contact your tax or legal professional to discuss details regarding your individual business circumstances. Our quoting tool is provided for your information only. All quotes are estimates and are not final until consumer is enrolled. Medicare has neither reviewed nor endorsed this information.

HealthMarkets Insurance Agency offers the opportunity to enroll in either QHPs or off-Marketplace coverage. Please visit HealthCare.gov for information on the benefits of enrolling in a QHP. Off-Marketplace coverage is not eligible for the cost savings offered for coverage through the Marketplaces.

This information is not a complete description of benefits. Call the Plan’s customer service phone number for more information.

HMPLAN90296MD0610015ACA1