Kaiser Permanente

KP MD Gold Value 0/20/Vision

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $0 Family: $0 Per Person: $0
Prescription Drug Deductible	Individual: $150 Family: not applicable Per Person: $150
Combined Medical and Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $6,950 Family: $13,900 Per Person: $6,950

Office Visit

Primary Doctor	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: $0 copay for children under age 5
Specialist	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $55.00 CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 35.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 35.00% Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 35.00% Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $500.00 CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Non-plan providers are covered only outside the service area.

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 35.00% Covered: Covered
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $20.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Benefit Period

Major Dental Care

Routine Dental Checkups for Children	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered Limit Quantity: 2 Limit Unit : Exam(s) per Benefit Period Benefit Explanation: $10 office visit charge applies to each visit
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 33.00% Covered: Covered Benefit Explanation: Benefit limitations may apply to individual services.
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 39.00% Covered: Covered Benefit Explanation: Benefit limitations may apply to individual services.

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