Kaiser Permanente

KP OR Gold 1750

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $1,750.00 Family: $3500 Per Person: $1750
Prescription Drug Deductible	Individual: $0.00 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,500.00 Family: $17000 Per Person: $8500

Office Visit

Primary Doctor	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Telehealth visits (if clinically appropriate) $0 copay, refer to EOC.
Specialist	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Telehealth visits (if clinically appropriate) $0 copay, refer to EOC.

Prescription Drug Information

Preferred Brand Drugs	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Insulin: $35 max out of pocket for 30 day supply prior to deductible
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Benefit Explanation: Insulin: $35 max out of pocket for 30 day supply prior to deductible
Generic Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Insulin: $35 max out of pocket for 30 day supply prior to deductible
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Benefit Explanation: Insulin: $35 max out of pocket for 30 day supply prior to deductible

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $350.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 30.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: $0.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Telehealth visits (if clinically appropriate) $0 copay, refer to EOC.

Vision

Routine Eye Exams for Children

CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered

Major Dental Care

Routine Dental Checkups for Children

Covered: Not Covered