$40 Copayment Plan

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Benefits Summary
Annual Medical Deductible - Individual None
Annual Medical Deductible - Family None
Annual Out-of-Pocket Maximum - Individual $3,000
Annual Out-of-Pocket Maximum - Family $6,000
Professional Services
Primary and specialty care visits (includes urgent care appointments) $40 per visit
Well-child visits from 0 to 23 months $10 per visit
Family planning visits $40 per visit
Eye exams $40 per visit
Hearing tests $40 per visit
Outpatient Services
Outpatient Surgery $200 per procedure
Most X-rays and lab tests $10 per encounter
Maternity Coverage
Maternity Coverage Covered
Hospitalization Services
Room and board, surgery, anesthesia, X-rays, lab tests, and medications $350 per day
Emergency Services
Emergency room visits $100 per visit (waived if admitted directly to the hospital)
Ambulance services $200 per trip
Prescription Drug Coverage
Generic drugs $10 up to a 30-day supply
Brand-name drugs $35 up to a 30-day supply
Mail-order program $20 generic/$70 brand for a 100-day supply of most maintenance drugs
 
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  Disclosure Form
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Dental rates are based on family rates. When purchased with a KPIC medical plan where family coverage is not available, actual dental rates may vary from the rates quoted on this page.

The system calculates the estimated rates based on the information you have provided. Actual rates may vary based on which family members are approved for coverage and on your selection of optional benefits.

The quote is not a binding contract between you and Kaiser Permanente. Rates are subject to change.

KFHP and KPIC deductible plans offer a copay for preventative care and certain other services from the first day of coverage. You will have to pay all other health care expenses out of pocket until you meet your deductible. For more information, please refer to the Disclosure Form.