| GOLD PLAN w/Rx |
KP 1000/25/Rx |
| Features |
| Deductible (individual/family) |
$1,000/$3,000 |
| Out-of-pocket maximum (individual/family) |
$5,000/$15,000 |
| Benefits |
Services not subject to deductible unless otherwise indicated |
| Preventive Care |
| Immunizations |
No charge |
| Routine physicals |
No charge |
| Well-baby visits |
No charge |
| Mammograms |
No charge |
| Gynecholgical exams |
No charge |
| Lab tests and X-rays (diagnostic) |
No charge |
| Outpatient services (per visit or procedure) |
| Primary care office visit |
$25 copay |
| Specialty care office visit |
$35 copay |
Nurse treatment visit
includes allergy injections 1 |
$10 copay |
Outpatient surgery
waived if admitted |
$150 copay (after deductible) |
| Lab tests & X-rays |
$25 copay |
| Inpatient hospital care |
| Inpatient care |
20% coinsurance (after deductible) |
| Maternity coverage |
| Inpatient care |
20% coinsurance (after deductible) |
| Prenatal |
No charge |
| First postpartum visit |
No charge |
| Emergency & urgent care |
| Emergency Department visit |
$100 copay (after deductible) 2 |
| Urgent care visit |
$45 copay |
| Ambulance Service |
$75 copay (after deductible) |
| Prescription drugs |
| Pharmacy (up to a 30-day supply) |
$15 or 50%
(whichever is greater) |
| Other services |
| Vision exams |
$25 copay |
| Vision hardware allowance (applies to lenses, frames, and/or contacts every 24 months) |
$100 allowance |
| Dental Plans |
Optional coverage available |
| Benefit Highlights |
|
Plan 1 |
Plan 2 |
Plan 3 |
| Benefit maximum |
None |
None |
None |
| Deductible |
$50 |
$50 |
$100 |
| Benefits |
Member pays |
| Preventive and diagnostic services* |
No charge |
20% |
20% |
| Basic restorative services |
50% |
50% |
50% |
| Oral surgery, endodontics, and periodontics |
75% |
75% |
75% |
| Major restorative services |
75% |
75% |
75% |
| Orthodontics* (for children and adults) |
75% |
75% |
75% |
| *Not subject to the deductible. |
|
|
|
| |
|
|
|
|
| Monthly Premiums |
Age range |
0-24 |
25-44 |
45+ |
| Plan 1 |
|
|
|
| Child/Subscriber only |
$39.53 |
$41.90 |
$44.27 |
| Subscriber + spouse/domestic partner |
$79.06 |
$83.80 |
$88.54 |
| Subscriber + child |
$79.06 |
$81.43 |
$83.80 |
| Subscriber + children |
$122.54 |
$140.73 |
$143.10 |
| Subscriber, spouse + child |
$118.59 |
$123.33 |
$128.07 |
| Subscriber, spouse + children |
$162.07 |
$182.53 |
$187.37 |
| Plan 2 |
|
|
|
| Child/Subscriber only |
$35.58 |
$37.71 |
$39.85 |
| Subscriber + spouse/domestic partner |
$71.16 |
$75.42 |
$79.70 |
| Subscriber + child |
$71.16 |
$73.29 |
$75.43 |
| Subscriber + children |
$110.30 |
$126.66 |
$128.80 |
| Subscriber, spouse + child |
$106.74 |
$111.00 |
$115.28 |
| Subscriber, spouse + children |
$145.88 |
$164.37 |
$168.65 |
| Plan 3 |
|
|
|
| Child/Subscriber only |
$32.76 |
$34.73 |
|
| Subscriber + spouse/domestic partner |
$65.52 |
$69.46 |
$73.38 |
| Subscriber + child |
$65.52 |
$67.49 |
$69.45 |
| Subscriber + children |
$101.56 |
$116.63 |
$118.59 |
| Subscriber, spouse + child |
$98.28 |
$102.22 |
$106.14 |
| Subscriber, spouse + children |
$134.32 |
$151.36 |
$155.28 |
With our Individuals and Families Dental Plans, you get the comprehensive benefits you need and high quality of care you've come to expect from Kaiser Permanente. Key features include
the following:
- There is no calendar-year benefit maximum.
- There is no waiting period-you can begin receiving your covered services the moment your coverage takes effect.
- Orthodintia coverage is included.
|
| |
Download Census 
