Gold Benefits from Kaiser Permanente Individual and Family Health Plans

Oregon Health Insurance
Call 800.884.2343 or
541.434.9613
FAX - 541.284.2994

GOLD DEDUCTIBLE PLANS w/Rx	$500	$1000
Features
Deductible (individual/family)	$500/$1,500	$1,000/$3,000
Out-of-pocket maximum (individual/family)	$3,750/$11,250
Lifetime maximum	$2 million
Benefits	Services not subject to deductible unless otherwise indicated
Preventive Care
Immunizations	No charge
Routine physicals	$25 copay
Well-baby visits
Gynecholgical exams/Mammograms
Outpatient services (per visit or procedure)
Primary care office visit	$25 copay
Specialty care office visit	$35 copay (after deductible)
Nurse treatment visit (includes allergy injections)¹	$10 copay
Outpatient surgery²	$150 copay
Lab tests²	$15 copay (after deductible)
X-rays²	$25 copay (after deductible)
Inpatient hospital care
Inpatient care (including maternity)	$750 copay per day (after deductible)
Maximum per admittance	$3,750 per admission (after deductible)
Maternity coverage
Prenatal care (applies to prenatal office visits, one postnatal visit, and lactation consultants)	$25 copay
Emergency & urgent care
Emergency Department visit	$100 copay (after deductible - waived if admitted)
Urgent care visit	$45 copay
Ambulance Service	$75 per trip
Prescription drugs
(up to a 30-day supply)	$15 or 50% (whichever is greater)
Other services
Vision exams	$25 copay (after deductible)
Vision hardware allowance (applies to lenses, frames, and/or contacts every 24 months)	$100 copay