Kaiser Permanente

KP CO Gold 2000/20

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Links

Summary Of Benefits

Plan Overview

Medical Deductible	Individual: $2,000 Family: $4,000 Per Person: $2,000
Prescription Drug Deductible	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical
Medical Out-of-Pocket Maximum	Individual: $8,500 Family: $17,000 Per Person: $8,500
Drug Out-of-Pocket Maximum	Individual: Included in Medical Family: Included in Medical Per Person: Included in Medical

Office Visit

Primary Doctor	Standard: Copay: $20.00 \| Coinsurance: Not Applicable
Specialist	Standard: Copay: $50.00 \| Coinsurance: Not Applicable

Prescription Drug Information

Preferred Brand Drugs	Standard: Copay: $40.00 Copay after deductible \| Coinsurance: Not Applicable
Non Preferred Brand Drugs	Standard: Copay: Not Applicable \| Coinsurance: 30.00% Coinsurance after deductible
Generic Drugs	Standard: Copay: $5.00 \| Coinsurance: Not Applicable
Specialty Drugs	Standard: Copay: Not Applicable \| Coinsurance: 30.00% Coinsurance after deductible

Inpatient Coverage

Hospital Services	Standard: Copay: Not Applicable \| Coinsurance: 30.00% Coinsurance after deductible
Inpatient Services	Standard: Copay: Not Applicable \| Coinsurance: 30.00% Coinsurance after deductible

Emergency and Urgent Care

Emergency Room

Standard: Copay: Not Applicable | Coinsurance: 30.00% Coinsurance after deductible