Kaiser Permanente

KP DC Gold 1600/25%/HSA/Vision

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $1,600 Family: $3,200 Per Person: $3,200
Combined Medical and Drug Out of Pocket Maximum	Individual: $5,000 Family: $10,000 Per Person: $5,000

Office Visit

Primary Doctor	CoPay: $25.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: $ copay after deductible for children under age 5
Specialist	CoPay: $50.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $50.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.
Generic Drugs	CoPay: $15.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.
Specialty Drugs	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Prior authorization is required except for emergency admissions and all maternity admissions.
Inpatient Services	CoPay: Not Applicable CoInsurance: 25.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $500.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $50.00 Copay after deductible 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: 25.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $25.00 Copay after deductible
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 : Procedure(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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