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Index | Dental Plan | Exclusions
& Limitations | Locate
Providers | Application
Plan Benefits
Platinum | Gold | Silver | Bronze | HDHP
Plan Premiums
Platinum | Gold | Silver | Bronze | HDHP 1500 | HDHP 2600
Plan Benefits
Platinum | Gold | Silver | Bronze | HDHP
Plan Premiums
Platinum | Gold | Silver | Bronze | HDHP 1500 | HDHP 2600
Oregon Medical Insurance > Kaiser Permanente of Oregon > Gold Benefits
Gold 500 |
Gold 1000 |
|
| Annual Deductible | ||
| Individual | $500 |
$1,000 |
| Family | $1,500 |
$3,000 |
| Annual Out-of-Pocket Maximum | ||
| Individual | $3,750 |
$2,500 |
| Family | $11,250 |
$7,500 |
| Benefits | You Pay |
|
| Preventive Care | ||
| Immunizations | $0 |
|
| Adult and well-child physicals | $25 NSD |
|
| Well-babyy visits | $25 NSD |
|
| Annual gynecholgical exams | $25 NSD |
|
| Mammograms | $25 NSD |
|
| Physician/provider services | ||
| Primary care office visit | $25 NSD |
|
| Specialty care office visit | $35 |
|
| Inpatient & maternity | ||
| Prenatal office visits 3 | $25 NSD |
|
| Hospital care | $750 day up to $3,750 per admission |
|
| Emergency & urgent care | ||
| Emergency care | $100 |
|
| Urgent care | $25 NSD |
|
| Ambulance Service | $75 |
|
| Prescription drugs | ||
| Annual deductible per individual | $500 |
|
| After-deductible copayment | 50% up to $150 max for 30-day supply |
|
| Other services | ||
| Lab | $15 |
|
| X-ray | $25 |
|
“NSD”: Not subject to deductible
- Waved if admitted to the hospital.
- Copayments apply to prescriptions costing more than $15. The full charge applies to prescriptions that cost $15 or less.
Mail-order prescription delivery is limited to a 30-day supply. - This benefit also covers one post-natal visit.
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