KP OR Silver 4000/40 CSR 87% – EPO

Description

This plan has 87% cost sharing reduction [Popular Plan]

Health Care Plan Details

Network type	EPO
Deductible	$650 per person $650 per person
Out-of-pocket max	$2,800 per person $5,600 per family
Metal tier	Silver

Visit Copay

Primary care visit	$25 copay
Specialist visit	$35 copay
Preventive care visit	No charge

Urgent, Emergency Care, and Hospital Care

Urgent care	$45 copay
Emergency room	$250 copay after deductible
Ambulance	30% coinsurance after deductible
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	$25 copay

Maternitowny and Pregnancy

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

Pharmacy, Drugs, and Medication

Generic	$10 copay
Brand	$45 copay
Non-preferred Brand	50% coinsurance after deductible
Specialty	50% coinsurance after deductible

Lab Tests and Diagnostic Procedures

X-rays	$25 copay
Imaging (CT/PET/MRI)	$250 copay after deductible
Blood work	$25 copay

Mental and Psychiatric Health Care

Mental Health outpatient services	$25 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/nw/individual-family/2024/71287OR0420012-05-en-2024.pdf
Drug and medication plan formulary	http://www.kp.org/orformulary
Search doctor list	https://healthy.kaiserpermanente.org/oregon-washington/doctors-locations#/simple-form