KP WA Gold 0/15 – EPO
Network type: EPO
Coverage tier: Gold
Primary care visit: $15 copay
Specialist visit: $50 copay
Urgent care visit: $40 copay
Description
Health Care Plan Details
Network type | EPO |
Deductible | $0 per person $0 per person |
Out-of-pocket max | $8,200 per person $16,400 per family |
Metal tier | Gold |
Visit Copay
Primary care visit | $15 copay |
Specialist visit | $50 copay |
Preventive care visit | No charge |
Urgent, Emergency Care, and Hospital Care
Urgent care | $40 copay |
Emergency room | $350 copay |
Ambulance | 30% coinsurance |
Hospital stay (facility) | 30% coinsurance |
Hospital stay (physician) | 30% coinsurance |
Outpatient procedure (facility) | $200 copay |
Outpatient procedure (physician) | No charge |
Physical rehabilitation | $50 copay |
Maternitowny and Pregnancy
Labor, delivery, hospital stay | 30% coinsurance |
Pharmacy, Drugs, and Medication
Generic | $10 copay |
Brand | $40 copay |
Non-preferred Brand | 50% coinsurance |
Specialty | 50% coinsurance |
Lab Tests and Diagnostic Procedures
X-rays | $50 copay |
Imaging (CT/PET/MRI) | $350 copay |
Blood work | $50 copay |
Mental and Psychiatric Health Care
Mental Health outpatient services | $15 copay |
Psychiatric hospital stay | 30% coinsurance |