| PLATINUM COPAYMENT PLAN |
KP 0/20/Rx |
| Features |
|
| Deductible |
None |
| Out-of-pocket maximum |
$2,000 |
| Lifetime maximum |
None |
| Benefits |
You Pay |
| Preventive Care |
| Immunizations |
No charge |
| Yearly routine physicals |
| Well-baby visits |
| Mammograms |
| Outpatient services (per visit or procedure) |
| Primary care office visit |
$20 copay |
| Specialty office visit |
$30 copay |
| Nurse treatment visit (includes allergy injections)1 |
$10 copay |
| Outpatient surgery2 |
$50 copay |
| Lab tests and X-ray2 |
$20 copay |
| Inpatient hospital care |
| Inpatient care (including maternity) |
$300 copay per day |
| Maximum per admittance |
$1,500 |
| Maternity coverage (outpatient) |
| Prenatal care (applies to prenatal office visits, one postnatal visit, and lactation consultants) |
No charge |
| Emergency & urgent care |
| Emergency department visit |
$100 copay 3 |
| Urgent care visit |
$40 copay |
| Ambulance Service |
$50 per trip |
| Prescription drugs |
| (up to a 30-day supply) |
$15
or 50%
(whichever is greater) |
| Other services |
| Vision exams |
$20 copay |
| Vision hardware allowance (applies to lenses, frames, and/or contacts every 24 months) |
$150 allowance |
| Dental plans |
Optional coverage available |
Download Request 
