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Gold 80 HMO
Plan Summary
Plan Type HMO
Office Visit for Primary Doctor
Find Doctors 		$35 Copay
Office Visit for Specialist $65 Copay
Office Visit for Other Practitioner (Nurse, Physician Assistant) $35 Copay
Annual Deductible None
Separate Prescription Drugs Deductible $0 per person | $0 per group
Coinsurance 20%
Retail Prescription Drugs Generic Drugs: $15 Copay;
Preferred Brand Drugs: $60 Copay;
Non-Preferred Brand Drugs: $60 Copay;
Specialty Drugs: 20% Coinsurance up to $250 per prescription;
Annual Out-of-Pocket Limit Individual: $8,700
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage No 
Out-of-Country Coverage No.
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required Yes
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room $330 Copay
Emergency Ambulance Services $250 Copay
Urgent Care Facility $35 Copay
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $15 Copay;
Preferred Brand Drugs: $60 Copay;
Non-Preferred Brand Drugs: $60 Copay;
Specialty Drugs: 20% Coinsurance up to $250 per prescription;
Separate Prescription Drugs Deductible $0 per person | $0 per group
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Outpatient Surgery Physician/Surgical Services:
$0 Copay
Outpatient Facility Fee:
$190 Copay
Outpatient Lab/X-Ray Outpatient Lab:
$40 Copay
X-rays:
$75 Copay
Imaging (CT and PET scans, MRIs) $75 Copay
Outpatient Mental Health $35 Copay
Outpatient Substance Abuse $35 Copay
Outpatient Rehabilitation Services (PT, OT, ST) $35 Copay
Inpatient Coverage
Hospitalization Inpatient Hospital Services:
$350 Copay per Day, A copay is required for up to 5 days
Inpatient Physician and Surgical Services:
No Charge
Skilled Nursing Facility $150 Copay per Day, A copay is required for up to 5 days; limited to 100 Days per Benefit Period
Inpatient Mental Health $350 Copay per Day, A copay is required for up to 5 days
Inpatient Substance Abuse $350 Copay per Day, A copay is required for up to 5 days
Home Healthcare $30 Copay, limited to 100 Visit(s) per Year
Maternity Coverage
Pre & Postnatal Office Visit No Charge
Labor & Delivery Hospital Stay $350 Copay per day, A copay is required for up to 5 days
Pediatric Services
Dental Checkup for Children No Charge
Vision Screening for Children No Charge
Eye Glasses for Children No Charge
Major Dental Coverage (Pediatric) $300 Copay
Additional Coverage
Chiropractic Coverage Not Covered
Durable Medical Equipment 20% Coinsurance
Hospice No Charge
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) Not Covered
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating N/A as of 11/12/2024
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Carrier specific notices, disclaimers and fees

  • - Our standard compensation range is $13-$19 per member per month plus a potential bonus. To learn more, visit kp.org/brokercompensation. This compensation does not change the price of your plan.
  • - Get care when and where it works for you. Check out our virtual care options, such as video visits, e-visits, or phone appointments with your Kaiser Permanente care team. Get most prescriptions sent straight to your door with our mail-order delivery service. Learn more about virtual care.