March 20, 2010

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Kaiser Permanente Colorado – 35 Copayment Plan w/Rx – COLORADO

A comparison of the 35 Copayment Plan w/Rx offered by Kaiser Permanente Colorado is detailed out below for both Network and Non-Network coverage.

  Network Non-Network
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Network See Provider See Provider
Application 35 Copayment Plan w/Rx Application 35 Copayment Plan w/Rx Application
Brochure 35 Copayment Plan w/Rx Brochure 35 Copayment Plan w/Rx Brochure
Copay
  • Primary care- $35 per visit
  • Specialty care- $50 per visit
    		•
  • Primary care- $35 per visit
  • Specialty care- $50 per visit
    		•
    Office Visit
  • Primary Care- $35 per primary office visit
  • Specialist Care- $50 per office visit
    		•
  • Primary Care- $35 per primary office visit
  • Specialist Care- $50 per office visit
    		•
    Deductible N/A N/A
    Coinsurance N/A N/A
    Coinsurance Limit 35 Copayment Plan w/Rx 35 Copayment Plan w/Rx
    Out-of-Pocket Maximum $3,000 Individual / $7,500 Family $3,000 Individual / $7,500 Family
    Lifetime Maximum Unlimited lifetime coverage Unlimited lifetime coverage
    Prescription Drugs Pharmacy (Up to 30-day supply) -
    • $5 Generic (Not subject to deductible)
    • After $200 drug deductible: $30 Brand-name/$50 Non-preferred/80% coinsurance for Specialty Drugs
    Mail-Order (Up to 90-day supply) -
    • $10 Generic (Not subject to deductible)
    • After $200 drug deductible: $60 Brand-name/$100 Non-preferred/80% coinsurance for Specialty Drugs
    		 Pharmacy (Up to 30-day supply) -
    • $5 Generic (Not subject to deductible)
    • After $200 drug deductible: $30 Brand-name/$50 Non-preferred/80% coinsurance for Specialty Drugs
    Mail-Order (Up to 90-day supply) -
    • $10 Generic (Not subject to deductible)
    • After $200 drug deductible: $60 Brand-name/$100 Non-preferred/80% coinsurance for Specialty Drugs
    Emergency Room Emergency and Urgent Care -
    • Emergency room visits (At a designated Kaiser Permanente emergency room or non-Plan emergency room): $200
    • Ambulance Services: 70% (Up to a maximum of $700 per trip)
    • Nonroutine Care (Per visit at a Kaiser Permanente medical office or non-Plan facility outside the service area during office hours): $35
    • After-hours Care (Per after-hours visit at a designated Kaiser Permanente after-hours medical office): $100
    		 Emergency and Urgent Care -
    • Emergency room visits (At a designated Kaiser Permanente emergency room or non-Plan emergency room): $200
    • Ambulance Services: 70% (Up to a maximum of $700 per trip)
    • Nonroutine Care (Per visit at a Kaiser Permanente medical office or non-Plan facility outside the service area during office hours): $35
    • After-hours Care (Per after-hours visit at a designated Kaiser Permanente after-hours medical office): $100
    Adult Preventative Care No charge No charge
    Child Preventative Care No charge No charge
    Lab / X-Ray Laboratory and X-ray -
    • Diagnostic Lab and X-ray: No charge
    • Therapeutic X-ray: $50
    		 Laboratory and X-ray -
    • Diagnostic Lab and X-ray: No charge
    • Therapeutic X-ray: $50
    Maternity Not covered Not covered
    Physical Therapy 35 Copayment Plan w/Rx 35 Copayment Plan w/Rx
    Skilled Nursing 35 Copayment Plan w/Rx 35 Copayment Plan w/Rx
    Home Health Care 35 Copayment Plan w/Rx 35 Copayment Plan w/Rx
    Mental Health 35 Copayment Plan w/Rx 35 Copayment Plan w/Rx
    Hospital Care Inpatient Hospital -
    • Hospital Care: 70% coinsurance per admission
    • Inpatient Professional Visits: 70% coinsurance
    Outpatient -
    • Ambulatory Surgery: $200
    		 Inpatient Hospital -
    • Hospital Care: 70% coinsurance per admission
    • Inpatient Professional Visits: 70% coinsurance
    Outpatient -
    • Ambulatory Surgery: $200
    Optional Benefits 35 Copayment Plan w/Rx 35 Copayment Plan w/Rx