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

	Platinum with Prescription	Platinum without Prescription
Annual Deductible
Individual	None
Family	None
Annual Out-of-Pocket Maximum
Individual	$2,500	$2,500
Family	$7,500	$7,500
Benefits	You Pay
Preventive Care
Immunizations	$0	$0
Adult and well-child physicals	$20	$25
Well-babyy visits	$20	$25
Annual gynecholgical exams	$20	$25
Mammograms	$20	$25
Physician/provider services
Primary care office visit	$20	$25
Specialty care office visit	$30	$35
Inpatient & maternity
Prenatal office visits 3	$20	$25
Hospital care	$300 day up to $1,500 per admission	$500 day up to $2,500 per admission
Emergency & urgent care
Emergency care	$1001	$1001
Urgent care	$20	$25
Ambulance Service	$50	$75
Prescription drugs
Annual deductible per individual	None	Not Covered
After-deductible copayment	The greater of $15 or 50%2	Not Covered
Other services
Lab	$15	$15
X-ray	$25	$25

“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.