Silver Benefits from Kaiser Permanente Individual and Family Health Plans

Oregon Health Insurance
Call 800.884.2343 or
541.434.9613
FAX - 541.284.2994

	Silver 1500 with Prescription	Silver 2500 with Prescription	Silver 3500 with Prescription
Annual Deductible
Individual	$1,500	$2,500	$3,500
Family	$4,500	$7,500	$10,500
Annual Out-of-Pocket Maximum
Individual	$5,000	$7,000	$9,000
Family	$15,000	$21,000	$27,000
Benefits	You Pay
Preventive Care
Immunizations	$0
Adult and well-child physicals	$25 NSD
Well-babyy visits	$25 NSD
Annual gynecholgical exams	$25 NSD
Mammograms	30% NSD
Physician/provider services
Primary care office visit	$25 NSD
Specialty care office visit	30%
Inpatient & maternity
Prenatal office visits 3	$25 NSD
Hospital care	30%
Emergency & urgent care
Emergency care	30%
Urgent care	$25 NSD
Ambulance Service	30%
Prescription drugs
Annual deductible per individual	$500
After-deductible copayment	50% up to $150 max for 30-day supply
Other services
Lab	30%
X-ray	30%

“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.