KP VA Gold 0 Ded/Vision – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: $20 copay
Specialist visit: $40 copay
Urgent care visit: $40 copay
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $0 per person $0 per person |
| Out-of-pocket max | $9,200 per person $18,400 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | $20 copay |
| Specialist visit | $40 copay |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | $40 copay |
| Emergency room | $500 copay |
| Ambulance | No charge |
| Hospital stay (facility) | 35% coinsurance |
| Hospital stay (physician) | 35% coinsurance |
| Outpatient procedure (facility) | 35% coinsurance |
| Outpatient procedure (physician) | 35% coinsurance |
| Physical rehabilitation | $40 copay |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | 35% coinsurance |
Pharmacy, Drugs, and Medication
| Generic | $10 copay |
| Brand | $55 copay |
| Non-preferred Brand | 35% coinsurance |
| Specialty | 35%, up to $250 copay, 35%, up to $250 coinsurance |
Lab Tests and Diagnostic Procedures
| X-rays | $65 copay |
| Imaging (CT/PET/MRI) | $500 copay |
| Blood work | $30 copay |
Mental and Psychiatric Health Care
| Mental Health outpatient services | $20 copay |
| Psychiatric hospital stay | 35% coinsurance |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/QqNn9o6fqFBpj1h6BDXgtUPf.pdf |
