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KP OR Silver 4000/40

71287OR0420012
Silver
EPO

KP OR Silver 4000/40 is a Silver EPO plan by Kaiser Permanente.

IMPORTANT: You are viewing the 2024 version of KP OR Silver 4000/40 71287OR0420012. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.

Locations

KP OR Silver 4000/40 is offered in the following counties.

Plan Overview

This is a plan overview for 2024 version of KP OR Silver 4000/40 71287OR0420012.
Insurer: Kaiser Permanente
Network Type: EPO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 71287OR0420012

Cost-Sharing Overview

KP OR Silver 4000/40 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 4000/40?

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 4000/40 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 4000/40 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 4000/40 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 Not ApplicableNot Applicable 100.00%
Specialist Visit
Covered
$70.00 Not ApplicableNot Applicable 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
$0.00 Not ApplicableNot Applicable 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)
Urgent Care Centers or Facilities
Covered
$60.00 Not Applicable$60.00 Not Applicable
Home Health Care Services
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Emergency Room Services
Covered
$350.00 Copay after deductible Not Applicable$350.00 Copay after deductible Not Applicable
Emergency Transportation/Ambulance
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 35.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Cosmetic Surgery
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 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
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%60.0 Days per Year
Prenatal and Postnatal Care
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Mental/Behavioral Health Outpatient Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$40.00 Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$25.00 Not ApplicableNot Applicable 100.00% Insulin: $35 max out of pocket for 30 day supply prior to deductible
Preferred Brand Drugs
Covered
$65.00 Not ApplicableNot Applicable 100.00% Insulin: $35 max out of pocket for 30 day supply prior to deductible
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Insulin: $35 max out of pocket for 30 day supply prior to deductible
Specialty Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% Insulin: $35 max out of pocket for 30 day supply prior to deductible
Outpatient Rehabilitation Services
Covered
$70.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions.
Habilitation Services
Covered
$70.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions.
Chiropractic Care
Covered
$25.00 Not ApplicableNot Applicable 100.00%20.0 Visit(s) per Year
Durable Medical Equipment
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00% $5,000 limit on non-Essential Health Benefit Durable Medical equipment.
Hearing Aids
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%1.0 Item(s) per 3 Years
Imaging (CT/PET Scans, MRIs)
Covered
$350.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Preventive Care/Screening/Immunization
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Routine Foot Care
Covered
$70.00 Not ApplicableNot Applicable 100.00% Covered for patients with diabetes mellitus.
Acupuncture
Covered
$25.00 Not ApplicableNot Applicable 100.00%12.0 Visit(s) per Year
Weight Loss Programs
Routine Eye Exam for Children
Covered
$0.00 Not ApplicableNot Applicable 100.00% Supplemented with FEP BlueVision – High Option.
Eye Glasses for Children
Covered
$0.00 Not ApplicableNot Applicable 100.00% Supplemented with FEP BlueVision ? High Option.
Dental Check-Up for Children
Not Covered
Supplemented with OHP Plus.
Rehabilitative Speech Therapy
Covered
$70.00 Not ApplicableNot Applicable 100.00%30.0 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
$70.00 Not ApplicableNot Applicable 100.00%30.0 Visit(s) per Year Visit limit does not apply to treatment of mental health conditions.
Well Baby Visits and Care
Covered
$0.00 Not ApplicableNot Applicable 100.00%
Laboratory Outpatient and Professional Services
Covered
$60.00 Not ApplicableNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
$60.00 Not ApplicableNot Applicable 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 Not ApplicableNot Applicable 100.00%
Transplant
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Accidental Dental
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Dialysis
Covered
$70.00 Not ApplicableNot Applicable 100.00%
Allergy Testing
Covered
$70.00 Not ApplicableNot Applicable 100.00%
Chemotherapy
Covered
$70.00 Not ApplicableNot Applicable 100.00%
Radiation
Covered
$70.00 Not ApplicableNot Applicable 100.00%
Diabetes Education
Covered
$40.00 Not ApplicableNot Applicable 100.00%3.0 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
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 100.00%
Infusion Therapy
Covered
$70.00 Not ApplicableNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Nutritional Counseling
Covered
$40.00 Not ApplicableNot Applicable 100.00%5.0 Visit(s) per Lifetime Visit limit does not apply to treatment of mental health conditions.
Reconstructive Surgery
Covered
Not Applicable 35.00% Coinsurance after deductibleNot Applicable 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
Not Applicable Not ApplicableNot Applicable Not Applicable Information about gender affirming care can be found in plan documents.
Telehealth-Office Visit
Covered
$0.00 Not ApplicableNot Applicable 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 Not ApplicableNot Applicable 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 4000/40 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 4000/40 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 4000/40?

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

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