Kaiser Permanente

KP Oregon Standard Gold Plan

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Medical Deductible	Individual: $1,500 Family: $3,000 Per Person: $1,500
Prescription Drug Deductible	Individual: $0 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,300 Family: $14,600 Per Person: $7,300

Office Visit

Primary Doctor	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered
Specialist	CoPay: $40.00 CoInsurance: Not Applicable Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Insulin: $75 max out of pocket for 30 day supply prior to deductible
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Benefit Explanation: Insulin: $75 max out of pocket for 30 day supply prior to deductible
Generic Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Insulin: $75 max out of pocket for 30 day supply prior to deductible
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Benefit Explanation: Insulin: $75 max out of pocket for 30 day supply prior to deductible $500 cap per script

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $60.00 CoInsurance: Not Applicable Covered: Covered

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 20.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Supplemented with FEP BlueVision - High Option.

Major Dental Care

Routine Dental Checkups for Children	Covered: Not Covered Benefit Explanation: Supplemented with OHP Plus.
Basic Dental Care - Child	Covered: Not Covered Benefit Explanation: Supplemented with OHP Plus.
Major Dental Care - Child	Covered: Not Covered Benefit Explanation: Supplemented with OHP Plus.

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