KP VA Gold Virtual Forward 2500 Ded – HMO
Network type: HMO
Coverage tier: Gold
Primary care visit: first 1 visit(s) $0 then $50 copay after deductible
Specialist visit: first 1 visit(s) $0 then $70 copay after deductible
Urgent care visit: first 1 visit(s) $0 then $70 copay after deductible
Description
Health Care Plan Details
| Network type | HMO |
| Deductible | $2,500 per person $2,500 per person |
| Out-of-pocket max | $4,980 per person $9,960 per family |
| Metal tier | Gold |
Visit Copay
| Primary care visit | first 1 visit(s) $0 then $50 copay after deductible |
| Specialist visit | first 1 visit(s) $0 then $70 copay after deductible |
| Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
| Urgent care | first 1 visit(s) $0 then $70 copay after deductible |
| Emergency room | $200 copay after deductible |
| Ambulance | No charge after deductible |
| Hospital stay (facility) | first 3 day(s) $300 per day then $0 copay after deductible |
| Hospital stay (physician) | No charge after deductible |
| Outpatient procedure (facility) | $200 copay after deductible |
| Outpatient procedure (physician) | $70 copay after deductible |
| Physical rehabilitation | $70 copay after deductible |
Maternitowny and Pregnancy
| Labor, delivery, hospital stay | first 3 day(s) $300 per day then $0 copay after deductible |
Pharmacy, Drugs, and Medication
| Generic | $5 copay |
| Brand | $50 copay after deductible |
| Non-preferred Brand | 50% after deductible |
| Specialty | 50% after deductible, up to $250 copay, 50% after deductible, up to $250 |
Lab Tests and Diagnostic Procedures
| X-rays | $50 copay after deductible |
| Imaging (CT/PET/MRI) | $150 copay after deductible |
| Blood work | $50 copay after deductible |
Mental and Psychiatric Health Care
| Mental Health outpatient services | first 1 visit(s) $0 then $50 copay after deductible |
| Psychiatric hospital stay | first 3 day(s) $300 per day then $0 copay after deductible |
Health Plan Provider Information
| Health Plan Benefits | https://d2ed110nmrd591.cloudfront.net/blobs/WpXYQNuMfYch8VHT6QrCBTcp.pdf |
