KP VA Silver Virtual Forward 2500 Ded/CSR – HMO

Description

This plan has 73% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	HMO
Deductible	$2,500 per person $2,500 per person
Out-of-pocket max	$7,550 per person $15,100 per family
Metal tier	Silver

Visit Copay

Primary care visit	first 1 visit(s) $0 then $45 copay after deductible
Specialist visit	first 1 visit(s) $0 then $65 copay after deductible
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	first 1 visit(s) $0 then $65 copay after deductible
Emergency room	20% after deductible
Ambulance	No charge after deductible
Hospital stay (facility)	20% after deductible
Hospital stay (physician)	20% after deductible
Outpatient procedure (facility)	20% after deductible
Outpatient procedure (physician)	20% after deductible
Physical rehabilitation	$65 copay after deductible

Maternitowny and Pregnancy

Labor, delivery, hospital stay

20% 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	20% after deductible
Imaging (CT/PET/MRI)	20% after deductible
Blood work	$65 copay after deductible

Mental and Psychiatric Health Care

Mental Health outpatient services	first 1 visit(s) $0 then $45 copay after deductible
Psychiatric hospital stay	20% after deductible

Health Plan Provider Information

Health Plan Benefits

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