KP VA Gold 1250 Ded/200 RxDed/Vision

Health Insurance Plan Details (2025 Plan)

SBC doc

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HMO

Gold

Deductible (per individual)	$1,250 /yr
Deductible (per family)	$2,500 /yr
Max Out-of-Pocket (per individual)	$7,500 /yr
Max Out-of-Pocket (per family)	$15,000 /yr
Drug Deductible (per individual)
Drug Deductible (per family)
Drug Max Out-of-Pocket (per individual)
Drug Max Out-of-Pocket (per family)
Plan Type	HMO
Includes Child Dental?	Yes
Includes Adult Dental?	No

Medical Services
Preventive Care	No Charge
Primary Care Visit	$20 Copay
Specialist Visit	$40 Copay
Emergency Room	35.00% Coinsurance after deductible
Inpatient Facility	35.00% Coinsurance after deductible
Inpatient Physician	35.00% Coinsurance after deductible

Drug Costs
Generic Drugs	$10 Copay
Preferred Brand Drugs	$55 Copay after deductible
Non-preferred Brand Drugs	35.00% Coinsurance after deductible
Specialty Drugs	35.00% Coinsurance after deductible

Summary of Benefits and Coverage	SBC doc
Provider Directory	Doctor lookup
Drug Formulary List	n/a

* 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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