KP HI Silver 25/5 CSR94 – HMO

Description

This plan has 94% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	HMO
Deductible	$25 per person $25 per person
Out-of-pocket max	$2,000 per person $4,000 per family
Metal tier	Silver

Visit Copay

Primary care visit	$5 copay
Specialist visit	$25 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$5 copay
Emergency room	10% coinsurance after deductible
Ambulance	20% coinsurance
Hospital stay (facility)	10% coinsurance after deductible
Hospital stay (physician)	10% coinsurance after deductible
Outpatient procedure (facility)	10% coinsurance after deductible
Outpatient procedure (physician)	10% coinsurance after deductible
Physical rehabilitation	$10 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	10% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$10 copay
Brand	5% coinsurance
Non-preferred Brand	5% coinsurance
Specialty	5% coinsurance

Lab Tests and Diagnostic Procedures

X-rays	$5 copay
Imaging (CT/PET/MRI)	$25 copay
Blood work	$5 copay

Mental and Psychiatric Health Care

Mental Health outpatient services	$5 copay
Psychiatric hospital stay	10% 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/2024/60612HI0110013-06-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