Kaiser Permanente

KP Select CO Bronze 6500/50

Prescription Drug Information

Inpatient Coverage

Emergency and Urgent Care

Major Dental Care

Links

Plan Overview

Combined Medical and Drug Deductible	Individual: $6,500 Family: $13,000 Per Person: $6,500
Combined Medical and Drug Out of Pocket Maximum	Individual: $8,700 Family: $17,400 Per Person: $8,700

Office Visit

Primary Doctor	CoPay: $50.00 Copay with deductible CoInsurance: 0% Coinsurance after deductible Covered: Covered Benefit Explanation: 3 visits $50; then ded/coin, higher for Affiliates
Specialist	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Prescription Drug Information

Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Non Preferred Brand Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Generic Drugs	CoPay: $30.00 CoInsurance: Not Applicable Covered: Covered
Specialty Drugs	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Inpatient Coverage

Hospital Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Inpatient Services	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Emergency and Urgent Care

Emergency Room	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Urgent Care Facility	CoPay: $150.00 Copay with deductible CoInsurance: 40.00% Coinsurance after deductible Covered: Covered Benefit Explanation: 3 visits $150; then ded/coin.

Maternity

Labor and Delivery Hospital Stay	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered
Pre and Postnatal Office Visit	CoPay: Not Applicable CoInsurance: 40.00% Coinsurance after deductible Covered: Covered

Vision

Routine Eye Exams For Children

CoPay: Not Applicable
CoInsurance: 0.00% Coinsurance after deductible
Covered: Covered

Major Dental Care

Routine Dental Checkups for Children	CoPay: Not Applicable CoInsurance: 0.00% Coinsurance after deductible Covered: Covered
Basic Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered
Major Dental Care - Child	CoPay: Not Applicable CoInsurance: 50.00% Coinsurance after deductible Covered: Covered

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