KP HI Gold 1000 Ded/250 Rx Ded

Health Insurance Plan Details (2024 Plan)

by Kaiser Foundation Health Plan, Inc.

Monthly Premium

HMO
$ubsidy
Gold
Deductible
$1,000 /yr
Max Out-of-Pocket
$8,700 /yr

Details

Deductible (per individual) $1,000 /yr
Deductible (per family) $2,000 /yr
Max Out-of-Pocket (per individual) $8,700 /yr
Max Out-of-Pocket (per family) $17,400 /yr
Drug Deductible (per individual) $250
Drug Deductible (per family) $500
Drug Max Out-of-Pocket (per individual) Included in Medical
Drug Max Out-of-Pocket (per family) Included in Medical
Plan Type HMO
Includes Child Dental? No
Includes Adult Dental? No
Medical Services
Preventive Care No Charge
Primary Care Visit $30 Copay
Specialist Visit $70 Copay
Emergency Room $350 Copay after deductible
Inpatient Facility 30% Coinsurance
Inpatient Physician 30% Coinsurance
Drug Costs
Generic Drugs $10 Copay
Preferred Brand Drugs 30% Coinsurance after deductible
Non-preferred Brand Drugs 30% Coinsurance after deductible
Specialty Drugs 30% Coinsurance after deductible

Plan Documents

Summary of Benefits and Coverage SBC doc
Provider Directory Doctor lookup
Drug Formulary List drug list

* Figures shown are only for in-network medical costs

** Please check with insurance company if Copay and Coinsurance rates are before or after the deductible


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