KP Oregon Standard Gold Plan
Kaiser Permanente
Plan overview
Medical deductible
Individual: $0
Family: $0
Per Person: $0
Prescription drug deductible
Individual: $0
Family: $0
Per Person: $0
Combined medical and drug out of pocket maximum
Individual: $8150
Family: $16300
Per Person: $8150
Office visit
Primary Doctor
CoPay: $20.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: $5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.
Specialist
CoPay: $40.00
CoInsurance: Not Applicable
Covered: Covered
Prescription drug information
Preferred brand drugs
CoPay: $30.00
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: Not Applicable
CoInsurance: 50.00%
Covered: Covered
Limit Quantity:
Limit Unit:
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
Limit Quantity:
Limit Unit:
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
Limit Quantity:
Limit Unit:
Benefit Explanation: Insulin: $35 max out of pocket for 30 day supply prior to deductible. Cost share capped at $500.
Inpatient coverage
Hospital services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Inpatient services
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Emergency and urgent care
Emergency room
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Urgent care facility
CoPay: $60.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation:
Maternity
Labor and delivery hospital stay
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal office visit
CoPay: Not Applicable
CoInsurance: 20.00% Coinsurance after deductible
Covered: Covered
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).