Kaiser Permanente

KP DC Catastrophic 8700/0/Vision

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $8,700 Family: $17,400 Per Person: $8,700
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: The deductible applies to all visits except the first 3 primary care and mental health office visits combined.
Specialist	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.
Generic Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.
Specialty Drugs	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: Prior authorization is required except for emergency admissions and all maternity admissions.
Inpatient Services	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered
Urgent Care Facility	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: Non-plan providers are covered only outside the service area.

Maternity

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

Vision

Routine Eye Exams For Children

CoPay: Not Applicable
CoInsurance: No Charge after deductible
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Benefit Period

Major Dental Care

Routine Dental Checkups for Children	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Limit Quantity: 2 Limit Unit : Procedure(s) per Benefit Period
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: Benefit limitations may apply to individual services.
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: No Charge after deductible Covered: Covered Benefit Explanation: Benefit limitations may apply to individual services.

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