Kaiser Permanente

KP Select CO Gold 0/25 RX Copay

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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Summary Of Benefits

Plan Overview

Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $7,500 Family: $15,000 Per Person: $7,500
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: Copay: $25.00 \| Coinsurance: Not Applicable
Specialist	Standard: Copay: $60.00 \| Coinsurance: Not Applicable

Prescription Drug Information

Preferred Brand Drugs	Standard: Copay: $50.00 \| Coinsurance: Not Applicable
Non Preferred Brand Drugs	Standard: Copay: $375.00 \| Coinsurance: Not Applicable
Generic Drugs	Standard: Copay: $15.00 \| Coinsurance: Not Applicable
Specialty Drugs	Standard: Copay: $625.00 \| Coinsurance: Not Applicable

Inpatient Coverage

Hospital Services	Standard: Copay: Not Applicable \| Coinsurance: 40.00%
Inpatient Services	Standard: Copay: Not Applicable \| Coinsurance: 40.00%

Emergency and Urgent Care

Emergency Room

Standard: Copay: $750.00 | Coinsurance: Not Applicable