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

	Platinum with Prescription	Platinum without Prescription
Annual Deductible
Individual	None
Family	None
Annual Out-of-Pocket Maximum
Individual	$2,500	$2,500
Family	$7,500	$7,500
Benefits	You Pay
Preventive Care
Immunizations	$0	$0
Adult and well-child physicals	$20	$25
Well-babyy visits	$20	$25
Annual gynecholgical exams	$20	$25
Mammograms	$20	$25
Physician/provider services
Primary care office visit	$20	$25
Specialty care office visit	$30	$35
Inpatient & maternity
Prenatal office visits 3	$20	$25
Hospital care	$300 day up to $1,500 per admission	$500 day up to $2,500 per admission
Emergency & urgent care
Emergency care	$100¹	$100¹
Urgent care	$20	$25
Ambulance Service	$50	$75
Prescription drugs
Annual deductible per individual	None	Not Covered
After-deductible copayment	The greater of $15 or 50%²	Not Covered
Other services
Lab	$15	$15
X-ray	$25	$25

“NSD”: Not subject to deductible

Waved if admitted to the hospital.
Copayments apply to prescriptions costing more than $15. The full charge applies to prescriptions that cost $15 or less.
Mail-order prescription delivery is limited to a 30-day supply.
This benefit also covers one post-natal visit.