KP VA Silver Virtual Forward 4000 Ded – HMO
Network type: HMO
Coverage tier: Silver
Primary care visit: first 1 visit(s) $0 then $55 copay after deductible
Specialist visit: first 1 visit(s) $0 then $75 copay after deductible
Urgent care visit: first 1 visit(s) $0 then $75 copay after deductible
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $4,000 per person $4,000 per person |
| Out-of-pocket max | $8,000 per person $16,000 per family |
| Metal tier | Silver |
Visit Copay
| Primary care visit | first 1 visit(s) $0 then $55 copay after deductible |
| Specialist visit | first 1 visit(s) $0 then $75 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | first 1 visit(s) $0 then $75 copay after deductible |
| Emergency room | 30% after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | 30% after deductible |
| Hospital stay (physician) | 30% after deductible |
| Outpatient procedure (facility) | 30% after deductible |
| Outpatient procedure (physician) | 30% after deductible |
| Physical rehabilitation | $75 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 30% after deductible |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $50 copay after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible, up to $250 copay, 50% after deductible, up to $250 |
Lab Tests and Diagnostic Procedures
| X-rays | 30% after deductible |
| Imaging (CT/PET/MRI) | 30% after deductible |
| Blood work | $75 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 1 visit(s) $0 then $55 copay after deductible |
| Psychiatric hospital stay | 30% after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/pKpGrEJFkFwsFuCyftq5VWEp.pdf |
