Kaiser Permanente

KP Select CO Silver 3700/20%/HSA

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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Summary Of Benefits

Plan Overview

Medical Deductible	Individual: $3,700 Family: $7,400 Per Person: $3,700
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $7,000 Family: $14,000 Per Person: $7,000
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible
Specialist	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible

Prescription Drug Information

Preferred Brand Drugs	Standard: Copay: $85.00 Copay after deductible \| Coinsurance: Not Applicable
Non Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible
Generic Drugs	Standard: Copay: $15.00 Copay after deductible \| Coinsurance: Not Applicable
Specialty Drugs	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible
Inpatient Services	Standard: Copay: Not Applicable \| Coinsurance: 20.00% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: Copay: Not Applicable | Coinsurance: 20.00% Coinsurance after deductible