Kaiser Permanente

KP CO Silver 5000/25

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $5,000 Family: $10,000 Per Person: $5,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,550 Family: $17,100 Per Person: $8,550

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Higher cost share applies to Affiliate providers
Specialist	CoPay: $80.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $85.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $100.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $25.00
CoInsurance: Not Applicable
Covered: Covered

Major Dental Care

Routine Dental Checkups for Children	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

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