Kaiser Permanente

KP DC Gold Virtual Forward 2000

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $2,000 Family: $4,000 Per Person: $2,000
Combined Medical and Drug Out of Pocket Maximum	Individual: $5,000 Family: $10,000 Per Person: $5,000

Office Visit

Primary Doctor

CoPay: $50.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: $ copay after deductible for children under age 5. There is no charge for the first Primary Care, Other Practitioner, Routine Eye Exam, Mental/Behavioral Health, Substance Abuse Disorder, Diabetes Education and Nutritional Counseling office visits combined; then the primary care cost share applies for all subsequent office visits or services.

Specialist

CoPay: $70.00 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: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.
Generic Drugs	CoPay: $10.00 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: 50.00% Coinsurance after deductible Covered: Covered Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.

Inpatient Coverage

Hospital Services	CoPay: $300.00 Copay per Day after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: $300 copay per day up to 3 days per admission after deductible. Prior authorization is required except for emergency admissions and all maternity admissions.
Inpatient Services	CoPay: No Charge after deductible CoInsurance: Not Applicable Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: $200.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $70.00 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: $300.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: $300 copay per day up to 3 days per admission after deductible.
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $50.00 Copay after deductible
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Benefit Period
Benefit Explanation: There is no charge for the first Primary Care, Other Practitioner, Routine Eye Exam, Mental/Behavioral Health, Substance Abuse Disorder, Diabetes Education and Nutritional Counseling office visits combined; then the primary care cost share applies for all subsequent office visits or services.

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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