Kaiser Permanente

KP Select CO Silver 4500/30 RX Copay

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

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Summary Of Benefits

Plan Overview

Medical Deductible	Individual: $4,500 Family: $9,000 Per Person: $4,500
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $9,200 Family: $18,400 Per Person: $9,200
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: Copay: $30.00 \| Coinsurance: Not Applicable
Specialist	Standard: Copay: $90.00 \| Coinsurance: Not Applicable

Prescription Drug Information

Preferred Brand Drugs	Standard: Copay: $100.00 \| Coinsurance: Not Applicable
Non Preferred Brand Drugs	Standard: Copay: $400.00 \| Coinsurance: Not Applicable
Generic Drugs	Standard: Copay: $25.00 \| Coinsurance: Not Applicable
Specialty Drugs	Standard: Copay: $700.00 \| Coinsurance: Not Applicable

Inpatient Coverage

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

Emergency and Urgent Care

Emergency Room

Standard: Copay: Not Applicable | Coinsurance: 40.00% Coinsurance after deductible