KP OR Bronze HSA 7100
Kaiser Permanente
Plan overview
Medical deductible
Individual: $7100
Family: $14200
Per Person: $7100
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $7100
Family: $14200
Per Person: $7100
Office visit
Primary Doctor
CoPay: $0.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Telehealth visits (if clinically appropriate) $0 copay after deductible, refer to EOC.
Specialist
CoPay: $0.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Telehealth visits (if clinically appropriate) $0 copay after deductible, refer to EOC.
Prescription drug information
Preferred brand drugs
CoPay: $0.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Insulin: $35 max out of pocket for 30 day supply prior to deductible
Non preferred brand drugs
CoPay: $0.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Insulin: $35 max out of pocket for 30 day supply prior to deductible
Generic drugs
CoPay: $0.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Insulin: $35 max out of pocket for 30 day supply prior to deductible
Specialty drugs
CoPay: $0.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Benefit Explanation: Insulin: $35 max out of pocket for 30 day supply prior to deductible
Inpatient coverage
Hospital services
CoPay: $0.00 Copay per Stay after deductible
CoInsurance: Not Applicable
Covered: Covered
Inpatient services
CoPay: $0.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: $0.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Urgent care facility
CoPay: $0.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: $0.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Pre and Postnatal office visit
CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Telehealth visits (if clinically appropriate) $0 copay after deductible, refer to EOC.
Vision
Routine Eye Exams for Children
CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity:
Limit Unit:
Major dental care
Routine dental checkups for children
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Routine dental checkups for adults
CoPay:
CoInsurance:
Covered: Not Covered
Limit Quantity:
Limit Unit:
Benefit Explanation:
These policies have exclusions, limitations, reduction of benefits, terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, call or write your insurance agent or the company (whichever is applicable).