KP OR Silver 3500/40

71287OR0420011
Silver
EPO

KP OR Silver 3500/40 is a Silver EPO plan by Kaiser Permanente.

IMPORTANT: You are viewing the 2023 version of KP OR Silver 3500/40 71287OR0420011. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

KP OR Silver 3500/40 is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of KP OR Silver 3500/40 71287OR0420011.
Insurer: Kaiser Permanente
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 71287OR0420011

Cost-Sharing Overview

KP OR Silver 3500/40 offers the following cost-sharing.

Notes:

  • Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
  • You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for KP OR Silver 3500/40?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Plan Features

KP OR Silver 3500/40 offers the following features and referral requirements.

Wellness Program: Yes
Disease Program: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
Notice Pregnancy: No
Referral Specialist: Yes
Specialist Requiring Referral: A referral is not required for outpatient Services provided in the following departments: Cancer Counseling, Chemical Dependency Services., Mental Health Services., Obstetrics/Gynecology, Occupational Health., Ophthalmology, and Optometry (routine eye exams), and Social Services.
Plan Exclusions:
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what KP OR Silver 3500/40 covers when you are out of the service area or out of the country.

Out of Country Coverage: Yes
Out of Country Coverage Description: Emergency medical conditions, including prescription drugs
Out of Service Area Coverage: Yes
Out of Service Area Coverage Description: Emergency medical conditions, including prescription drugs
National Network: No

Additional Benefits and Cost-Sharing

KP OR Silver 3500/40 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Primary Care Visit to Treat an Injury or Illness
Covered
$40.00 100.00%
Specialist Visit
Covered
$65.00 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
35.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
35.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
$0.00 100.00% Respite care provided in a nursing facility subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30 days.
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Covered
$40.00 100.00%
Urgent Care Centers or Facilities
Covered
$60.00 100.00%
Home Health Care Services
Covered
35.00% Coinsurance after deductible 100.00%
Emergency Room Services
Covered
$350.00 Copay after deductible $350.00 Copay after deductible
Emergency Transportation/Ambulance
Covered
35.00% Coinsurance after deductible 35.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
35.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
35.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Cosmetic Surgery
Covered
35.00% Coinsurance after deductible 100.00% Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary.
Skilled Nursing Facility
Covered
35.00% Coinsurance after deductible 100.00%60 Days per Year
Prenatal and Postnatal Care
Covered
$0.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
35.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$40.00 100.00%
Mental/Behavioral Health Inpatient Services
Covered
35.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$40.00 100.00%
Substance Abuse Disorder Inpatient Services
Covered
35.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
$25.00 100.00% Insulin: $35 max out of pocket for 30 day supply prior to deductible
Preferred Brand Drugs
Covered
$65.00 100.00% Insulin: $35 max out of pocket for 30 day supply prior to deductible
Non-Preferred Brand Drugs
Covered
50.00% Coinsurance after deductible 100.00% Insulin: $35 max out of pocket for 30 day supply prior to deductible
Specialty Drugs
Covered
50.00% Coinsurance after deductible 100.00% Insulin: $35 max out of pocket for 30 day supply prior to deductible
Outpatient Rehabilitation Services
Covered
$65.00 100.00%30 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions.
Habilitation Services
Covered
$65.00 100.00%30 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions.
Chiropractic Care
Covered
$25.00 100.00%20 Visit(s) per Year
Durable Medical Equipment
Covered
35.00% Coinsurance after deductible 100.00% $5,000 limit on non-Essential Health Benefit Durable Medical equipment.
Hearing Aids
Covered
35.00% Coinsurance after deductible 100.00%1 Item(s) per 3 Years
Imaging (CT/PET Scans, MRIs)
Covered
$350.00 Copay after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
$0.00 100.00%
Routine Foot Care
Covered
$65.00 100.00% Covered for patients with diabetes mellitus.
Acupuncture
Covered
$25.00 100.00%12 Visit(s) per Year
Weight Loss Programs
Routine Eye Exam for Children
Covered
$0.00 100.00% Supplemented with FEP BlueVision – High Option.
Eye Glasses for Children
Covered
$0.00 100.00% Supplemented with FEP BlueVision ? High Option.
Dental Check-Up for Children
Not Covered
Supplemented with OHP Plus.
Rehabilitative Speech Therapy
Covered
$65.00 100.00%30 Visit(s) per Year 30 visits per condition per calendar year. Visit limit does not apply to treatment of mental health conditions.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$65.00 100.00%30 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions.
Well Baby Visits and Care
Covered
$0.00 100.00%
Laboratory Outpatient and Professional Services
Covered
$60.00 100.00%
X-rays and Diagnostic Imaging
Covered
$60.00 100.00%
Basic Dental Care – Child
Not Covered
Supplemented with OHP Plus.
Orthodontia – Child
Not Covered
Supplemented with OHP Plus.
Major Dental Care – Child
Not Covered
Supplemented with OHP Plus.
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Covered
$0.00 100.00%
Transplant
Covered
35.00% Coinsurance after deductible 100.00%
Accidental Dental
Covered
35.00% Coinsurance after deductible 100.00%
Dialysis
Covered
$65.00 100.00%
Allergy Testing
Covered
$65.00 100.00%
Chemotherapy
Covered
$65.00 100.00%
Radiation
Covered
$65.00 100.00%
Diabetes Education
Covered
$40.00 100.00%3 Hours per Year Covers three hours of education per year if there is a significant change in condition or treatment; covers one diabetes self-management education program at the time of diagnosis.
Prosthetic Devices
Covered
35.00% Coinsurance after deductible 100.00%
Infusion Therapy
Covered
$65.00 100.00%
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Covered
$40.00 100.00%5 Visit(s) per Lifetime Visit limit does not apply to treatment of mental health conditions.
Reconstructive Surgery
Covered
35.00% Coinsurance after deductible 100.00% Cosmetic or reconstructive surgery must take place within 18 months after the injury, surgery, scar, or defect first occurred unless medically necessary.
Gender Affirming Care
Covered
Information about gender affirming care can be found in plan documents.
Telehealth-Office Visit
Covered
$0.00 100.00% Telehealth allows a Member, or person acting on the Member?s behalf, to interact with a Participating Provider who is not physically at the same location. We cover telehealth Services at no Charge when all of the following are true: The Service is otherwise covered under this EOC. The Service is determined by a Participating Provider to be Medically Necessary. Medical Group determines the Service may be safely and effectively provided using telehealth, according to generally accepted health care practices and standards.
Telehealth-Specialist Visit
Covered
$0.00 100.00% Telehealth allows a Member, or person acting on the Member?s behalf, to interact with a Participating Provider who is not physically at the same location. We cover telehealth Services at no Charge when all of the following are true: The Service is otherwise covered under this EOC. The Service is determined by a Participating Provider to be Medically Necessary. Medical Group determines the Service may be safely and effectively provided using telehealth, according to generally accepted health care practices and standards.

Free Preventive Services

There is no copayment or coinsurance for any of the following KP OR Silver 3500/40 preventive services. This is true even if you haven’t met your yearly deductible.

Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.

Additional Resources

Below are additional resources for KP OR Silver 3500/40 including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.

Summary of Benefits: Summary of Benefits Link
Plan Brochure: Plan Brochure Link
Formulary: Formulary Link
Premium Payment Website: Premium Payment Link
Ready to sign up for KP OR Silver 3500/40?

Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904

Table of Contents