Kaiser Permanente of Oregon

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Plan Benefits
Platinum | Gold | Silver | Bronze | HDHP
Plan Premiums
Platinum | Gold | Silver | Bronze | HDHP 1500 | HDHP 2600

High Deductible Health Plan	$1,500 deductible with Rx	$1,500 deductible without Rx	$2,600 deductible with Rx	$2,600 deductible without Rx
Annual Deductible
Individual	$1,500	$1,500	$2,600	$2,600
Family	$3,000	$3,000	$5,200	$5,200
Annual Out-of-Pocket Maximum
Individual	$5,000	$5,000	$5,000	$5,000
Family	$10,000	$10,000	$10,000	$10,000
Benefits	You Pay
Preventive Care
Immunizations	No charge
Adult and well-child physicals	20%
Well-babyy visits	20%
Annual gynecholgical exams	20%
Mammograms	20%
Physician/provider services
Primary care office visit	20%
Specialty care office visit	20%
Inpatient & maternity
Prenatal office visits 3	20% NSD
Hospital care	20%
Emergency & urgent care
Emergency care	20%
Urgent care	20%
Ambulance Service	20%
Prescription drugs
After-deductible copayment	$15 generic $30 brand	Not Covered	$15 generic $30 brand	Not Covered
Other services
Lab	20%
X-ray	20%

“NSD”: Not subject to deductible

1. Waved if admitted to the hospital.
2. 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.
3. This benefit also covers one post-natal visit.