| CHILD ONLY DEDUCTIBLE PLANS |
KP 2500/25/Rx |
KP 5000/25/Rx |
| Features |
| Deductible |
$2.500 |
$5.000 |
| Out-of-pocket maximum |
$3,750 |
| Benefits |
Services not subject to deductible unless otherwise indicated |
| Preventive Care |
| Immunizations |
No charge |
| Yearly routine physicals |
| Well-baby visits |
| Mammograms |
| Outpatient services (per visit or procedure) |
| Primary care office visit |
$25 copay |
| Specialty office visit |
$35 copay |
| Nurse treatment visit (includes allergy injections)1 |
$10 copay |
| Outpatient surgery2 |
$150 copay (after deductible) |
| Lab tests and X-rays2 |
$10 copay |
| Inpatient hospital care |
| Inpatient care (including maternity) |
$750 copay per day (after deductible) |
| Maximum per admittance |
$3,750 (after deductible) |
| Maternity coverage |
| Prenatal care (applies to prenatal office visits, one postnatal visit, and lactation consultants) |
No charge |
| Emergency & urgent care |
| Emergency Department visit |
20% coinsurance (after deductible) |
| Urgent care visit |
$45 copay |
| Ambulance Service |
20% coinsurance (after deductible) |
| Prescription drugs |
| (up to a 30-day supply) |
$15 or 50%
(whichever is greater) |
| Other services |
| Vision exams |
$25 copay |
| Vision hardware allowance (applies to lenses, frames, and/or contacts every 24 months) |
$100 allowance |
| Dental plans |
Optional coverage available |
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