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

Health Plan Provider Information