KP HI Silver 4000 Ded/600 Rx Ded – HMO

Description

Health Care Plan Details

Network type	HMO
Deductible	$4,000 per person $4,000 per person
Out-of-pocket max	$8,900 per person $17,800 per family
Metal tier	Silver

Visit Copay

Primary care visit	$45 copay
Specialist visit	$75 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$45 copay
Emergency room	30% coinsurance after deductible
Ambulance	20% coinsurance
Hospital stay (facility)	30% coinsurance after deductible
Hospital stay (physician)	30% coinsurance after deductible
Outpatient procedure (facility)	30% coinsurance after deductible
Outpatient procedure (physician)	30% coinsurance after deductible
Physical rehabilitation	$45 copay

Maternitowny and Pregnancy

Well baby care	No charge
Labor, delivery, hospital stay	30% coinsurance after deductible

Pharmacy, Drugs, and Medication

Generic	$20 copay
Brand	50% coinsurance after deductible
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	$45 copay
Imaging (CT/PET/MRI)	$350 copay after deductible
Blood work	$45 copay

Mental and Psychiatric Health Care

Mental Health outpatient services	$45 copay
Psychiatric hospital stay	30% 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/2024/60612HI0110013-01-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