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: $1,500.00 Family: $3000 Per Person: $1500
Prescription Drug Deductible	Individual: $0.00 Family: $0 Per Person: $0
Combined Medical and Drug Out of Pocket Maximum	Individual: $7,000.00 Family: $14000 Per Person: $7000

Office Visit

Primary Doctor	CoPay: $20.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: $5 copay for the first three in-network primary care provider, other practitioner, outpatient mental/behavioral health, or outpatient substance abuse disorder visits combined per year prior to the deductible being met.
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: $35 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: $35 max out of pocket for 30 day supply prior to deductible
Generic Drugs	CoPay: $10.00 CoInsurance: Not Applicable Covered: Covered Benefit Explanation: Insulin: $35 max out of pocket for 30 day supply prior to deductible
Specialty Drugs	CoPay: Not Applicable CoInsurance: 50.00% Covered: Covered Benefit Explanation: Insulin: $35 max out of pocket for 30 day supply prior to deductible. Cost share capped at $500.

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

Major Dental Care

Routine Dental Checkups for Children

Covered: Not Covered