Gold $500 Deductible Plan

Hospital care
(including maternity care)
Office visits
Optional: outpatient Rx drugs

Laboratory
X-rays and other special procedures
Emergency care

Features		Member pays
Annual deductible (per calendar year)		$500 member $1,500 per family

Annual out-of-pocket maximum (per calendar year)		$3,750 member $11,250 per family

Lifetime benefit maximum		$2 million

Hospital care (including maternity care)*

Features		Member pays
All inpatient care is covered after payment of applicable copayments. There are no limits on prescribed hospital days.		$750 per day, up to $3,750 per admission (after deductible)

Office visits*

Features		Member pays
For diagnosis and treatment by primary care providers, consultation and treatment by specialists, routine physical and hearing exams, well-baby visits through age 2, prenatal care, eye exams, and urgent care.		$25 per primary care visit deductible waived $35 per specialty care visit¹

Optional: outpatient Rx drugs

Features		Member pays
This is an optional benefit that must be added to the plan during enrollment with Rx rider.		Rx deductible: $500³ Retail: 50% (after deductible) up to $150 max per 30-day Rx (deductible is per calendar year and does not count towards medical deductible)⁴

Laboratory

Features		Member pays
Inpatient		Included under hospital care benefit

Outpatient		$15 per visit²

X-rays and other special procedures

Features		Member pays
Inpatient		Included under hospital care benefit

Outpatient		$25 per visit²

Emergency care*

Features		Member pays
Within and outside Kaiser Permanente service area		$100 copay (after deductible)**

* Plus any copayments or coinsurance for lab or X-ray

** The emergency care copay will be waived and the hospital copay will apply if admitted directly to hospital from an emergency room. Additional copayments or coinsurance may apply for lab, X-ray, etc.

1 (After deductible) Deductible waived for well-baby visits, prenatal care, and certain preventive procedures.

2 (After deductible) No deductible for preventive tests or preventive procedures.

3 Rx deductible is per calendar year and does not count toward medical deductible.

⁴ Mail order: up to 90 for maintenance drugs; but will not exceed two times to copay max (i.e., $300). For nonmaintenance drugs, copay max applies to each 30-day supply.

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