KP HI Silver 250 Ded/100 Rx Ded CSR87 Plus CAM – HMO
87% cost sharing reduction [Popular Plan]
Network type: HMO
Coverage tier: Silver
Primary care visit: $20 copay
Specialist visit: $50 copay
Urgent care visit: $20 copay
Description
This plan has 87% cost sharing reduction [Popular Plan]
Health Care Plan Details
| Network type | HMO |
| Deductible | $250 per person $250 per person |
| Out-of-pocket max | $2,850 per person $5,700 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $50 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $20 copay |
| Emergency room | 20% coinsurance after deductible |
| Ambulance | 20% coinsurance |
| Hospital stay (facility) | 20% coinsurance after deductible |
| Hospital stay (physician) | 20% coinsurance after deductible |
| Outpatient procedure (facility) | 20% coinsurance after deductible |
| Outpatient procedure (physician) | 20% coinsurance after deductible |
| Physical rehabilitation | $20 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 20% coinsurance after deductible |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | 40% coinsurance after deductible |
| Non-preferred Brand | 40% coinsurance after deductible |
| Specialty | 40% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $20 copay |
| Imaging (CT/PET/MRI) | $200 copay |
| Blood work | $20 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $20 copay |
| Psychiatric hospital stay | 20% coinsurance after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/health-plan-documents/summary-of-benefits/hi/individual-family/2024/60612HI0110009-05-en-2024.pdf |
| Drug and medication plan formulary | https://healthy.kaiserpermanente.org/content/dam/kporg/final/documents/formularies/hi/marketplace-drug-formulary-hi-en.pdf |
| Search doctor list | https://healthy.kaiserpermanente.org/hawaii/doctors-locations#/search-form |
