KP Select CO Gold 0/25 RX Copay – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $25 copay
Specialist visit: $60 copay
Urgent care visit: $75 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $7,500 per person $15,000 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $25 copay |
| Specialist visit | $60 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $75 copay |
| Emergency room | $750 copay |
| Ambulance | 40% coinsurance |
| Hospital stay (facility) | 40% coinsurance |
| Hospital stay (physician) | 40% coinsurance |
| Outpatient procedure (facility) | 40% coinsurance |
| Outpatient procedure (physician) | 40% coinsurance |
| Physical rehabilitation | $60 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 40% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $15 copay |
| Brand | $50 copay |
| Non-preferred Brand | $375 copay |
| Specialty | $625 copay |
Lab Tests and Diagnostic Procedures
| X-rays | 40% coinsurance |
| Imaging (CT/PET/MRI) | $500 copay |
| Blood work | 40% coinsurance |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $25 copay |
| Psychiatric hospital stay | 40% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/onK63MiSwo3SqfhBfoMs48AK.pdf |
