Platinum Benefits from Kaiser Permanente Individual and Family Health Plans

Oregon Health Insurance
Call 800.884.2343 or
541.434.9613
FAX - 541.284.2994

TRADITIONAL COPAY PLANS	Platinum RX	Platinum
Features
Deductible (individual/family)	None
Out-of-pocket maximum (individual/family)	$2,000/$6,000	$2,500/$7,500
Lifetime maximum	None
Benefits	You Pay
Preventive Care
Immunizations	No charge
Routine physicals	$20 copay	$25 copay
Well-baby visits
Gynecholgical exams/Mammograms
Outpatient services (per visit or procedure)
Primary care office visit	$20 copay	$25 copay
Specialty care office visit	$30 copay	$35 copay
Nurse treatment visit (includes allergy injections)¹	$10 copay
Outpatient surgery²	$50 copay	$100 copay
Lab tests²	$15 copay
X-rays²	$25 copay
Inpatient hospital care
Inpatient care (including maternity)	$300 copay per day	$500 copay per day
Maximum per admittance	$1,500 per admission	$2,500 per admission
Maternity coverage
Prenatal care (applies to prenatal office visits, one postnatal visit, and lactation consultants)	$20 copay	$25 copay
Emergency & urgent care
Emergency Department visit	$100 copay (waived if admitted)
Urgent care visit	$40 copay	$45 copay
Ambulance Service	$50 per trip	$75 per trip
Prescription drugs
(up to a 30-day supply)	$15 or 50% (whichever is greater)	Not Covered
Other services
Vision exams	$20 copay	$25 copay
Vision hardware allowance (applies to lenses, frames, and/or contacts every 24 months)	$150 copay	Not covered