KP HI Gold 1000 Ded/250 Rx Ded – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $30 copay
Specialist visit: $70 copay
Urgent care visit: $30 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $1,000 per person $1,000 per person |
| Out-of-pocket max | $8,700 per person $17,400 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $30 copay |
| Specialist visit | $70 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $30 copay |
| Emergency room | $350 copay after deductible |
| Ambulance | 20% coinsurance |
| Hospital stay (facility) | 30% coinsurance |
| Hospital stay (physician) | 30% coinsurance |
| Outpatient procedure (facility) | 30% coinsurance |
| Outpatient procedure (physician) | 30% coinsurance |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Well baby care | No charge |
| Labor, delivery, hospital stay | 30% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | 30% coinsurance after deductible |
| Non-preferred Brand | 30% coinsurance after deductible |
| Specialty | 30% coinsurance after deductible |
Lab Tests and Diagnostic Procedures
| X-rays | $40 copay |
| Imaging (CT/PET/MRI) | $350 copay after deductible |
| Blood work | $40 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $30 copay |
| Psychiatric hospital stay | 30% coinsurance |
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/2024/60612HI0110011-01-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 |
