All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical What You Will Pay Limitations, Exceptions, & Other Important Event Services You May Need Network Provider Non-Network Provider Information (You will pay the least) (You will pay the most) Primary care visit to treat 10% coinsurance Not covered None an injury or illness If you visit a health Specialist visit 10% coinsurance Not covered None care provider’s office or clinic Preventive You may have to pay for services that aren’t care/screening/ No charge, deductible Not covered preventive. Ask your provider if the services immunization does not apply. needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, 10% coinsurance Not covered None If you have a test blood work) Imaging (CT/PET scans, 10% coinsurance Not covered Preauthorization required or will not be MRIs) covered. Preferred generic drugs $20 (retail); $40 (mail order) / Not covered Up to a 90-day supply (retail / mail order). prescription Subject to formulary guidelines. If you need drugs to Preferred brand drugs $40 (retail); $80 (mail Not covered Up to a 90-day supply (retail / mail order). treat your illness or order) / prescription Subject to formulary guidelines. condition 50% coinsurance up to More information Non-preferred drugs $250 (retail); 50% Not covered Up to a 90-day supply (retail / mail order). about prescription coinsurance up to $750 Subject to formulary guidelines . drug coverage is (mail order) / prescription available at Applicable Preferred Up to a 30-day supply (retail). Subject to www.kp.org/formulary Specialty drugs generic, Preferred brand Not covered formulary guidelines, when approved through or Non-Preferred cost the exception process. shares apply Facility fee (e.g., If you have ambulatory surgery 10% coinsurance Not covered None outpatient surgery center) Physician/surgeon fees 10% coinsurance Not covered None If you need You must notify Kaiser Permanente within 24 immediate medical Emergency room care 10% coinsurance 10% coinsurance hours if admitted to a Non-network provider; attention limited to initial emergency only. Page 2 of 6