Plan Details
Plan Name	Kaiser DHMO Basic (Washington)
Effective Dates	Jan 01, 2024 to Jan 01, 2025
Benefits	In-Network
Annual Deductible/Individual	$2,500
Annual Deductible/Family	$5,000
Coinsurance	80%
Office Visit/Exam	$30 $30 copay
Outpatient Specialist Visit	$40 $40 copay
Annual Out-of-Pocket Limit/Individual	$4,000
Annual Out-of-Pocket Limit/Family	$8,000
Preventive Care	0%
Inpatient Hospitalization	80% 80% after deductible per admission
Surgical Services Outpatient Facility Charge	80% after deductible; $500 copay
Emergency Room	80%
Urgent Care Facility	$30
Prescription Drug Deductible	$0 0
Prescription Drugs - Generic	$15
Prescription Drugs - Brand (Formulary/Preferred)	$30
Prescription Drugs - Brand (Non-Formulary/Non-preferred)	$30
Prescription Drugs - Specialty	-
Chiropractic Services	Refer to the Evidence of Coverage for coverage details
Acupuncture	Refer to the Evidence of Coverage for coverage details