Medical

Medical coverage offers healthcare protection for you and your family. You may visit any medical provider you choose, but in-network providers offer the highest level of benefits and lower out-of-pocket costs. Network providers charge members reduced, contracted fees instead of their typical fees. Providers outside the plan’s network set their own rates, so you may be responsible for the difference if a provider’s fees are above the Reasonable and Customary (R&C) limits.

Preventive Care – like physical exams, flu shots, and screenings – is always covered 100% when you use in-network providers. The key difference between the plans is the amount of money you’ll pay each pay period and when you need care.

    Each plan has different:

    • Annual deductible amounts – the amount you pay each year for eligible in-network and out-of-network charges before the plan begins to pay.
    • Out-of-pocket maximums – the most you will pay each year for eligible network services and/or prescriptions. After you reach your out-of-pocket maximum, the plan picks up the full cost of covered medical care for the remainder of the year.
    • Copays – A copay is a fixed amount you pay for a health care service. Copays do not count toward your deductible but do count toward your annual out-of-pocket maximum.
    • Coinsurance – Once you’ve met your deductible, you and the plan share the cost of care, which is called coinsurance. For example, you pay 20% for services and the plan will pay 80% of the cost until you have reached your out-of-pocket maximum.

    Providence Gold 

    Plan Information

    Plan Name:  Providence Gold 

    Effective Date:  04/01/2025 

    Network:  Signature PPO 

    Benefit Highlights
    In-Network

    Deductible (Individual/Family)
    $1,000 / $2,000

    Out-of-Pocket Max (Individual/Family)
    $7,350 / $14,700

    Preventive Care
    $0 (deductible waived)

    Primary Care Visit
    1st 3 visits $5 copay, then $35 copay (deductible waived)

    Specialist Visit
    $45 copay (deductible waived)

    Urgent Care
    $45 copay (deductible waived)

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    $10 copay (deductible waived)

    Preferred Brand
    $15 copay (deductible waived)

    Non-Preferred Brand
    $45 copay (deductible waived)

    Specialty
    50% coinsurance, up to $200 (deductible waived)

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    $20 copay (deductible waived)

    Preferred Brand
    $30 copay (deductible waived)

    Non-Preferred Brand
    $90 copay (deductible waived)

    Specialty
    Not covered

    Out-of-Network

    Deductible (Individual/Family)
    $2,000 / $4,000

    Out-of-Pocket Max (Individual/Family)
    $14,700 / $29,400

    Preventive Care
    40% coinsurance

    Primary Care Visit
    40% coinsurance (deductible waived)

    Specialist Visit
    40% coinsurance (deductible waived)

    Urgent Care
    40% coinsurance (deductible waived)

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Plan Documents

    2025-26 Providence Gold Benefit Summary

    2025-26 Providence Gold Summary of Benefits & Coverage

    2025-26 Providence Prescription Drug Plan Benefit Summary

    Contact Information

    (800) 878–4445 

    providence.org 

    Providence Silver

    Plan Information

    Plan Name:  Providence Silver 

    Effective Date:  04/01/2025

    Network:  Signature PPO 

    Benefit Highlights
    In-Network

    Deductible (Individual/Family)
    $2,500 / $5,000

    Out-of-Pocket Max (Individual/Family)
    $7,350 / $14,700

    Preventive Care
    $0 (deductible waived)

    Primary Care Visit
    1st 3 visits $5 copay, then $35 copay (deductible waived)

    Specialist Visit
    $45 copay (deductible waived)

    Urgent Care
    $45 copay (deductible waived)

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    $10 copay (deductible waived)

    Preferred Brand
    $15 copay (deductible waived)

    Non-Preferred Brand
    $45 copay (deductible waived)

    Specialty
    50% coinsurance, up to $200 (deductible waived)

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    $20 copay (deductible waived)

    Preferred Brand
    $30 copay (deductible waived)

    Non-Preferred Brand
    $90 copay (deductible waived)

    Specialty
    Not covered

    Out-of-Network

    Deductible (Individual/Family)
    $5,000 / $10,000

    Out-of-Pocket Max (Individual/Family)
    $14,700 / $29,400

    Preventive Care
    50% coinsurance

    Primary Care Visit
    50% coinsurance (deductible waived)

    Specialist Visit
    50% coinsurance (deductible waived)

    Urgent Care
    50% coinsurance (deductible waived)

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Plan Documents

    2025-26 Providence Silver Benefit Summary

    2025-26 Providence Silver Summary of Benefits & Coverage

    2025-26 Providence Prescription Drug Plan Benefit Summary

    Contact Information

    (800) 878–4445

    providence.org

    Providence HSA E 1650

    Plan Information

    Plan Name:  Providence HSA 1650

    Effective Date:  04/01/2025 

    Network:  Signature PPO 

    Benefit Highlights
    In-Network

    Deductible (Individual/Family)
    $1,650 / $3,300

    Out-of-Pocket Max (Individual/Family)
    $3,300 / $6,600 

    Preventive Care
    $0 (deductible waived) 

    Primary Care Visit
    20% coinsurance 

    Specialist Visit
    20% coinsurance 

    Urgent Care
    20% coinsurance 

    Emergency Room
    20% coinsurance 

    Retail Rx (Up to 30-Day Supply) 

    Generic
    20% coinsurance 

    Preferred Brand
    20% coinsurance 

    Non-Preferred Brand
    20% coinsurance 

    Specialty
    20% coinsurance, up to $200 

    Mail-Order Rx (Up to 90-Day Supply) 

    Generic
    20% coinsurance 

    Preferred Brand
    20% coinsurance 

    Non-Preferred Brand
    20% coinsurance 

    Specialty
    Not covered

    Out-of-Network

    Deductible (Individual/Family)
    $3,300 / $6,600 

    Out-of-Pocket Max (Individual/Family)
    $6,600 / $13,200 

    Preventive Care
    40% coinsurance  

    Primary Care Visit
    40% coinsurance  

    Specialist Visit
    40% coinsurance  

    Urgent Care
    40% coinsurance  

    Emergency Room
    40% coinsurance  

    Retail Rx (Up to 30-Day Supply) 

    Generic
    Not covered 

    Preferred Brand
    Not covered 

    Non-Preferred Brand
    Not covered 

    Specialty
    Not covered 

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered 

    Non-Preferred Brand
    Not covered 

    Specialty
    Not covered 

    Plan Documents

    2025-26 Providence HSA 1650 Benefit Summary

    2025-26 Providence HSA 1650 Summary of Benefits & Coverage

    Contact Information

    (800) 878–4445 

    providence.org 

    Providence HSA 6650

    Plan Information

    Plan Name:  Providence HSA 6650 

    Effective Date:  04/01/2025 

    Network:  Signature PPO 

    Benefit Highlights
    In-Network

    Deductible (Individual/Family)
    $6,650 / $13,300

    Out-of-Pocket Max (Individual/Family)
    $6,650 / $13,300

    Preventive Care
    $0 after deductible

    Primary Care Visit
    $0 after deductible

    Specialist Visit
    $0 after deductible

    Urgent Care
    $0 after deductible

    Emergency Room
    $0 after deductible

    Retail Rx (Up to 30-Day Supply)

    Generic
    $0 after deductible

    Preferred Brand
    $0 after deductible

    Non-Preferred Brand
    $0 after deductible

    Specialty
    $0 after deductible

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    $0 after deductible

    Preferred Brand
    $0 after deductible

    Non-Preferred Brand
    $0 after deductible

    Specialty
    Not covered

    Out-of-Network

    Deductible (Individual/Family)
    $13,300 / $26,600

    Out-of-Pocket Max (Individual/Family)
    $13,300 / $26,600

    Preventive Care
    $0 after deductible

    Primary Care Visit
    $0 after deductible

    Specialist Visit
    $0 after deductible

    Urgent Care
    $0 after deductible

    Emergency Room
    $0 after deductible

    Retail Rx (Up to 30-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Plan Documents

    2025-26 Providence HSA 6650 Benefit Summary

    2025-26 Providence HSA 6650 Summary of Benefits & Coverage

    Contact Information

    (800) 878–4445 

    providence.org 

    Providence Gold Extend PPO

    Plan Information

    Plan Name:  Providence Gold Extend PPO 

    Effective Date:  04/01/2025

    Network:  Extend PPO 

    Benefit Highlights
    In-Network

    Deductible (Individual/Family)
    $1,000 / $2,000

    Out-of-Pocket Max (Individual/Family)
    $7,350 / $14,700

    Preventive Care
    $0 (deductible waived)

    Primary Care Visit
    1st 3 visits $5 copay, then $35 copay (deductible waived)

    Specialist Visit
    $45 copay (deductible waived)

    Urgent Care
    $45 copay (deductible waived)

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    $10 copay (deductible waived)

    Preferred Brand
    $15 copay (deductible waived)

    Non-Preferred Brand
    $45 copay (deductible waived)

    Specialty
    50% coinsurance, up to $200 (deductible waived)

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    $20 copay (deductible waived)

    Preferred Brand
    $30 copay (deductible waived)

    Non-Preferred Brand
    $90 copay (deductible waived)

    Specialty
    Not covered

    Out-of-Network

    Deductible (Individual/Family)
    $2,000 / $4,000

    Out-of-Pocket Max (Individual/Family)
    $14,700 / $29,400

    Preventive Care
    40% coinsurance

    Primary Care Visit
    40% coinsurance (deductible waived)

    Specialist Visit
    40% coinsurance (deductible waived)

    Urgent Care
    40% coinsurance (deductible waived)

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Plan Documents

    2025-26 Providence Gold Extend PPO Benefit Summary

    2025-26 Providence Gold Extend PPO Summary of Benefits & Coverage

    2025-26 Providence Prescription Drug Plan Benefit Summary

    Contact Information

    (800) 878–4445 

    providence.org 

    Providence Silver Extend PPO

    Plan Information

    Plan Name:  Providence Silver Extend PPO 

    Effective Date:  04/01/2025

    Network:  Extend PPO 

    Benefit Highlights
    In-Network

    Deductible (Individual/Family)
    $2,500 / $5,000

    Out-of-Pocket Max (Individual/Family)
    $7,350 / $14,700

    Preventive Care
    $0 (deductible waived)

    Primary Care Visit
    1st 3 visits $5 copay, then $35 copay (deductible waived)

    Specialist Visit
    $45 copay (deductible waived)

    Urgent Care
    $45 copay (deductible waived)

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    $10 copay (deductible waived)

    Preferred Brand
    $15 copay (deductible waived)

    Non-Preferred Brand
    $45 copay (deductible waived)

    Specialty
    50% coinsurance, up to $200 (deductible waived)

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    $20 copay (deductible waived)

    Preferred Brand
    $30 copay (deductible waived)

    Non-Preferred Brand
    $90 copay (deductible waived)

    Specialty
    Not covered

    Out-of-Network

    Deductible (Individual/Family)
    $5,000 / $10,000

    Out-of-Pocket Max (Individual/Family)
    $14,700 / $29,400

    Preventive Care
    50% coinsurance

    Primary Care Visit
    50% coinsurance (deductible waived)

    Specialist Visit
    50% coinsurance (deductible waived)

    Urgent Care
    50% coinsurance (deductible waived)

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Plan Documents

    2025-26 Providence Silver Extend PPO Benefit Summary

    2025-26 Providence Silver Extend PPO Summary of Benefits & Coverage

    2025-26 Providence Prescription Drug Plan Benefit Summary

    Contact Information

    (800) 878–4445 

    providence.org 

    Providence Platinum Connect 

    Plan Information

    Plan Name:  Providence Platinum Connect 

    Effective Date:  04/01/2025 

    Network:  Connect PPO 

    Benefit Highlights
    In-Network

    Deductible (Individual/Family)
    $500 / $1,000

    Out-of-Pocket Max (Individual/Family)
    $5,850 / $11,700

    Preventive Care
    $0 (deductible waived)

    Primary Care Visit
    1st 3 visits $5 copay, then $20 copay (deductible waived)

    Specialist Visit
    $40 copay (deductible waived)

    Urgent Care
    $40 copay (deductible waived)

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    $10 copay (deductible waived)

    Preferred Brand
    $15 copay (deductible waived)

    Non-Preferred Brand
    $45 copay (deductible waived)

    Specialty
    50% coinsurance, up to $200 (deductible waived)

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    $20 copay (deductible waived)

    Preferred Brand
    $30 copay (deductible waived)

    Non-Preferred Brand
    $90 copay (deductible waived)

    Specialty
    Not covered

    Out-of-Network

    Deductible (Individual/Family)
    $1,000 / $2,000

    Out-of-Pocket Max (Individual/Family)
    $11,700 / $23,400

    Preventive Care
    50% coinsurance

    Primary Care Visit
    50% coinsurance

    Specialist Visit
    50% coinsurance

    Urgent Care
    50% coinsurance

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Plan Documents

    2025-26 Providence Platinum Connect Benefit Summary

    2025-26 Providence Platinum Connect Summary of Benefits & Coverage

    2025-26 Providence Prescription Drug Plan Benefit Summary

    Contact Information

    (800) 878–4445 

    providence.org 

    Providence Gold Connect

    Plan Information

    Plan Name:  Providence Gold Connect 

    Effective Date:  04/01/2025

    Network:  Connect PPO 

    Benefit Highlights
    In-Network

    Deductible (Individual/Family)
    $1,500 / $3,000

    Out-of-Pocket Max (Individual/Family)
    $7,350 / $14,700

    Preventive Care
    $0 (deductible waived)

    Primary Care Visit
    1st 3 visits $5 copay, then $35 copay (deductible waived)

    Specialist Visit
    $70 copay (deductible waived)

    Urgent Care
    $70 copay (deductible waived)

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    $10 copay (deductible waived)

    Preferred Brand
    $15 copay (deductible waived)

    Non-Preferred Brand
    $45 copay (deductible waived)

    Specialty
    50% coinsurance, up to $200 (deductible waived)

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    $20 copay (deductible waived)

    Preferred Brand
    $30 copay (deductible waived)

    Non-Preferred Brand
    $90 copay (deductible waived)

    Specialty
    Not covered

    Out-of-Network

    Deductible (Individual/Family)
    $3,000 / $6,000

    Out-of-Pocket Max (Individual/Family)
    $14,700 / $29,400

    Preventive Care
    50% coinsurance

    Primary Care Visit
    50% coinsurance

    Specialist Visit
    50% coinsurance

    Urgent Care
    50% coinsurance

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Plan Documents

    2025-26 Providence Gold Connect Benefit Summary

    2025-26 Providence Gold Connect Summary of Benefits & Coverage

    2025-26 Providence Prescription Drug Plan Benefit Summary

    Contact Information

    (800) 878–4445 

    providence.org 

    Providence Platinum Choice

    Plan Information

    Plan Name:  Providence Platinum Choice  

    Effective Date:  04/01/2025

    Network:  Choice PPO 

    Benefit Highlights
    In-Network

    Deductible (Individual/Family)
    $500 / $1,000

    Out-of-Pocket Max (Individual/Family)
    $5,850 / $11,700

    Preventive Care
    $0 (deductible waived)

    Primary Care Visit
    1st 3 visits $5 copay, then $20 copay (deductible waived)

    Specialist Visit
    $40 copay (deductible waived)

    Urgent Care
    $40 copay (deductible waived)

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    $10 copay (deductible waived)

    Preferred Brand
    $15 copay (deductible waived)

    Non-Preferred Brand
    $45 copay (deductible waived)

    Specialty
    50% coinsurance, up to $200 (deductible waived)

    Mail-Order Rx (Up to 90-Day Supply

    Generic
    $20 copay (deductible waived)

    Preferred Brand
    $30 copay (deductible waived)

    Non-Preferred Brand
    $90 copay (deductible waived)

    Specialty
    Not covered

    Out-of-Network

    Deductible (Individual/Family)
    $1,000 / $2,000

    Out-of-Pocket Max (Individual/Family)
    $11,700 / $23,400

    Preventive Care
    50% coinsurance

    Primary Care Visit
    50% coinsurance

    Specialist Visit
    50% coinsurance

    Urgent Care
    50% coinsurance

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Plan Documents

    2025-26 Providence Platinum Choice Benefit Summary

    2025-26 Providence Platinum Choice Summary of Benefits & Coverage

    2025-26 Providence Prescription Drug Plan Benefit Summary

    Contact Information

    (800) 878–4445 

    providence.org 

    Providence Gold Choice 4000

    Plan Information

    Plan Name:  Providence Gold Choice 4000

    Effective Date:  04/01/2025 

    Network:  Choice PPO 

    Benefit Highlights
    In-Network

    Deductible (Individual/Family)
    $4,000 / $8,000

    Out-of-Pocket Max (Individual/Family)
    $9,200 / $18,400

    Preventive Care
    $0 (deductible waived)

    Primary Care Visit
    $20 copay (deductible waived)

    Specialist Visit
    $40 copay (deductible waived)

    Urgent Care
    $40 copay (deductible waived)

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    $10 copay (deductible waived)

    Preferred Brand
    $15 copay (deductible waived)

    Non-Preferred Brand
    $45 copay (deductible waived)

    Specialty
    50% coinsurance, up to $200 (deductible waived)

    Mail-Order Rx (Up to 90-Day Supply

    Generic
    $20 copay (deductible waived)

    Preferred Brand
    $30 copay (deductible waived)

    Non-Preferred Brand
    $90 copay (deductible waived)

    Specialty
    Not covered

    Out-of-Network

    Deductible (Individual/Family)
    $8,000 / $16,000

    Out-of-Pocket Max (Individual/Family)
    $18,400 / $36,800

    Preventive Care
    50% coinsurance

    Primary Care Visit
    50% coinsurance

    Specialist Visit
    50% coinsurance

    Urgent Care
    50% coinsurance

    Emergency Room
    $250 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Specialty
    Not covered

    Plan Documents

    2025-26 Providence Gold Choice Benefit Summary

    2025-26 Providence Gold Choice Summary of Benefits & Coverage

    2025-26 Providence Prescription Drug Plan Benefit Summary

    Contact Information

    (800) 878–4445 

    providence.org 

    Kaiser Gold PPO

    Plan Information

    Plan Name:  Kaiser Gold PPO

    Effective Date:  04/01/2025

    Network:  Kaiser 

    Benefit Highlights
    In-Network

    Deductible (Individual/Family)
    $1,000 / $3,000

    Out-of-Pocket Max (Individual/Family)
    $4,000 / $8,000

    Preventive Care
    $0 (deductible waived)

    Primary Care Visit
    1st 3 visits $5 copay, then $25 copay (deductible waived)

    Specialist Visit
    $35 copay (deductible waived)

    Urgent Care
    $45 copay (deductible waived)

    Emergency Room
    $200 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    $15 copay (deductible waived)

    Preferred Brand
    $30 copay (deductible waived)

    Non-Preferred Brand
    $50 copay (deductible waived)

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    $30 copay (deductible waived)

    Preferred Brand
    $60 copay (deductible waived)

    Non-Preferred Brand
    $100 copay (deductible waived)

    Vision Service

    Routine Eye Exam
    $25 copay

    Vision Hardware (Lenses and Frames)
    $150 allowance

    PPO Provider

    Deductible (Individual/Family)
    $2,000 / $6,000

    Out-of-Pocket Max (Individual/Family)
    $6,000 / $12,000

    Preventive Care
    $0 (deductible waived)

    Primary Care Visit
    1st 3 visits $5 copay, then $35 copay (deductible waived)

    Specialist Visit
    $45 copay (deductible waived)

    Urgent Care
    $55 copay (deductible waived)

    Emergency Room
    $200 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    $20 copay (deductible waived)

    Preferred Brand
    $40 copay (deductible waived)

    Non-Preferred Brand
    $60 copay (deductible waived)

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    $60 copay (deductible waived)

    Preferred Brand
    $120 copay (deductible waived)

    Non-Preferred Brand
    $180 copay (deductible waived)

    Vision Services

    Routine Eye Exam
    $35 copay

    Vision Hardware (Lenses and Frames)
    $150 allowance

    Out-of-Network

    Deductible (Individual/Family)
    $3,000 / $9,000

    Out-of-Pocket Max (Individual/Family)
    $7,500 / $15,000

    Preventive Care
    40% coinsurance

    Primary Care Visit
    40% coinsurance

    Specialist Visit
    40% coinsurance

    Urgent Care
    40% coinsurance

    Emergency Room
    $200 copay

    Retail Rx (Up to 30-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    Not covered

    Preferred Brand
    Not covered

    Non-Preferred Brand
    Not covered

    Plan Documents

    2025-26 Kaiser Gold PPO Benefit Summary

    2025-26 Kaiser Gold PPO Summary of Benefits & Coverage

    Contact Information

    (800) 813–2000 

    kp.org 

    Kaiser Gold

    Plan Information

    Plan Name:  Kaiser Gold 

    Effective Date:  04/01/2025

    Network:  Kaiser 

    Benefit Highlights
    In-Network Only

    Deductible (Individual/Family)
    $1,000 / $3,000 

    Out-of-Pocket Max (Individual/Family)
    $4,000 / $12,000 

    Preventive Care
    $0 (deductible waived) 

    Primary Care Visit
    $25 copay (deductible waived) 

    Specialist Visit
    $35 copay (deductible waived) 

    Urgent Care
    $45 copay (deductible waived) 

    Emergency Room
    20% coinsurance

    Retail Rx (Up to 30-Day Supply) 

    Generic
    $20 copay (deductible waived) 

    Preferred Brand
    $40 copay (deductible waived) 

    Non-Preferred Brand
    $60 copay (deductible waived)

    Mail-Order Rx (Up to 90-Day Supply 

    Generic
    $40 copay (deductible waived) 

    Preferred Brand
    $80 copay (deductible waived) 

    Non-Preferred Brand
    $120 copay (deductible waived) 

    Specialty
    Not covered

    Vision Services 

    Routine Eye Exam
    $25 copay 

    Vision Hardware (Lenses and Frames)
    $150 allowance 

    Plan Documents

    2025-26 Kaiser Gold Benefit Summary

    2025-26 Kaiser Gold Summary of Benefits & Coverage

    Contact Information

    (800) 813–2000 

    kp.org 

    Kaiser Silver

    Plan Information

    Plan Name:  Kaiser Silver 

    Effective Date:  04/01/2025

    Network:  Kaiser 

    Benefit Highlights
    In-Network Only

    Deductible (Individual/Family)
    $1,500 / $4,500 

    Out-of-Pocket Max (Individual/Family)
    $4,000 / $12,000 

    Preventive Care
    $0  

    Primary Care Visit
    1st 3 visits $5 copay, then $20 copay (deductible waived) 

    Specialist Visit
    $20 copay (deductible waived) 

    Urgent Care
    $20 copay (deductible waived) 

    Emergency Room
    $200 copay 

    Retail Rx (Up to 30-Day Supply) 

    Generic
    $20 copay (deductible waived) 

    Preferred Brand
    $40 copay (deductible waived) 

    Non-Preferred Brand
    $60 copay (deductible waived) 

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    $40 copay (deductible waived) 

     Preferred Brand
    $80 copay (deductible waived) 

    Non-Preferred Brand
    $120 copay (deductible waived) 

    Vision Services 

    Routine Eye Exam
    $20 copay 

     Vision Hardware (Lenses and Frames)
    $150 allowance 

    Plan Documents

    2025-26 Kaiser Silver Benefit Summary

    2025-26 Kaiser Silver Summary of Benefits & Coverage

    Contact Information

    (800) 813–2000 

    kp.org 

    Kaiser Bronze

    Plan Information

    Plan Name:  Kaiser Bronze 

    Effective Date:  04/01/2025 

    Network:  Kaiser 

    Benefit Highlights
    In-Network Only

    Deductible (Individual/Family)
    $3,000 / $9,000 

    Out-of-Pocket Max (Individual/Family)
    $7,350 / $14,700 

    Preventive Care
    $0 (deductible waived) 

    Primary Care Visit
    1st 3 visits $5 copay, then $30 copay (deductible waived) 

    Specialist Visit
    $40 copay (deductible waived) 

    Urgent Care
    $50 copay (deductible waived) 

    Emergency Room
    20% coinsurance 

    Retail Rx (Up to 30-Day Supply) 

    Generic
    $20 copay 

    Preferred Brand
    $40 copay 

    Non-Preferred Brand
    $60 copay

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    $40 copay (deductible waived) 

     Preferred Brand
    $80 copay (deductible waived) 

    Non-Preferred Brand
    $120 copay (deductible waived) 

    Vision Services 

    Routine Eye Exam
    $30 copay 

     Vision Hardware (Lenses and Frames)
    $150 allowance 

    Plan Documents

    2025-26 Kaiser Bronze Benefit Summary

    2025-26 Kaiser Bronze Summary of Benefits & Coverage

    Contact Information

    (800) 813–2000 

    kp.org 

    Kaiser HSA

    Plan Information

    Plan Name:  Kaiser HSA 

    Effective Date:  04/01/2025 

    Network:  Kaiser 

    Benefit Highlights
    In-Network Only

    Deductible (Individual/Family)
    $5,000 / $10,000

    Out-of-Pocket Max (Individual/Family)
    $6,750 / $13,500

    Preventive Care
    $0 (deductible does not apply) 

    Primary Care Visit
    1st 3 visits $5 copay, then 50% coinsurance 

    Specialist Visit
    50% coinsurance 

    Urgent Care
    50% coinsurance 

    Emergency Room
    50% coinsurance 

    Retail Rx (Up to 30-Day Supply) 

    Generic
    $15 copay 

    Preferred Brand
    $30 copay 

    Non-Preferred Brand
    $50 copay  

    Mail-Order Rx (Up to 90-Day Supply)

    Generic
    $30 copay (deductible waived) 

    Preferred Brand
    $60 copay (deductible waived) 

    Non-Preferred Brand
    $100 copay (deductible waived) 

    Vision Services 

    Routine Eye Exam
    50% coinsurance 

    Vision Hardware (Lenses and Frames)
    $150 allowance 

    Plan Documents

    2025-26 Kaiser HSA Benefit Summary

    2025-26 Kaiser HSA Summary of Benefits & Coverage

    Contact Information

    (800) 813–2000 

    kp.org