Kaiser Permanente

KP DC Standard Gold 500/25/Vision

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $500 Family: $1,000 Per Person: $500
Prescription Drug Deductible	Individual: $0 Family: not applicable Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $4,950 Family: $9,900 Per Person: $4,950

Office Visit

Primary Doctor	CoPay: $25.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $50.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.
Non Preferred Brand Drugs	CoPay: $70.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.
Generic Drugs	CoPay: $15.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.
Specialty Drugs	CoPay: $150.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Limited to a 30-day supply of Prescription Drugs.

Inpatient Coverage

Hospital Services	CoPay: $600.00 Copay per Day after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: $600 copay per day up to 5 days per admission. 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: $300.00 CoInsurance: Not Applicable Covered: Covered
Urgent Care Facility	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Non-plan providers are covered only outside the service area.

Maternity

Labor and Delivery Hospital Stay	CoPay: $600.00 Copay after deductible CoInsurance: Not Applicable Covered: Covered Benefit Explanation: $600 copay per day up to 5 days per admission. Prior authorization is required except for emergency admissions and all maternity admissions.
Pre and Postnatal Office Visit	CoPay: No Charge CoInsurance: Not Applicable Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: No Charge
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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