$2000 Deductible Plan (70%)

$2,000 Deductible Plan (70%) with Rx

Annual deductible

Features		Member pays
Individual		$2,000¹

Family		$6,000¹
The deductible applies to all services unless otherwise noted.

Out-of-pocket annual maximum

Features		Member pays
Individual		$5,000

Family		$10,000
The out-of-pocket maximum excludes deductible and copayments.

Lifetime maximum

Features		Member pays
Lifetime maximum paid by the Plan for all care		No lifetime maximum

Routine medical office visits

Features		Member pays
Primary care office visit		$30 per visit²

Specialist office visit		$50 per visit²

In-office procedures

Features		Member pays
Procedures received during office visits		30% coinsurance per procedure

Preventive services³

Features		Member pays
Children's services		No charge²

Preventive services²

Features		Member pays
Adults' services		No charge²

Maternity

Features		Member pays
Prenatal care		Not covered

Delivery and inpatient well-baby care		Not covered

Prescription drugs

Features		Member pays
Prescription drugs⁴		After $200 deductible is met, up to 30-day supply. 90-day refill supply is available by mail order. $15 copay – preferred generic $30 copay – preferred brand name 50% copay - nonpreferred

Inpatient hospital

Features		Member pays
Inpatient hospital		30% coinsurance per admission

Inpatient professional visits		30% coinsurance per visit

Outpatient/ambulatory surgery

Features		Member pays
Outpatient/ambulatory surgery		30% coinsurance per admission

Laboratory and X-ray

Features		Member pays
Diagnostic lab		No charge²

X-ray, including therapeutic		30% coinsurance

MRI/CT/PET		30% coinsurance per procedure

Emergency care

Features		Member pays
Emergency care		30% coinsurance per visit at a designated Kaiser Permanente emergency room or a non-Plan emergency room

Ambulance

Features		Member pays
Ambulance		30% coinsurance up to a maximum of $500 per trip²

Urgent, nonroutine, and after-hours care

Features		Member pays
Office hours visit		$30 per visit at a Kaiser Permanente medical office during office hours²

After-hours visit		$75 per after-hours visit at a designated Kaiser Permanente after-hours medical office²

Procedures received during urgent, nonroutine, and after-hours care

Features		Member pays
Procedures received during urgent, nonroutine, and after-hours care		30% coinsurance per procedure

¹Deductible does not apply toward out-of-pocket maximum.

²Not subject to deductible.

³Preventive services include adult preventive care exams, adult preventive care screenings, well-woman care, immunizations, and well-child care.

⁴Kaiser Permanente uses a list of preferred drugs referred to as our formulary. For coverage to apply, a prescription must be written by your Kaiser Permanente doctor or by your dentist (for acute conditions) and be in our formulary. To learn more about preferred drugs in our formulary, contact our Clinical Pharmacy Call Center at 303-338-4503.

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