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 $15 / visit Not covered None an injury or illness If you visit a health Specialist visit $30 / visit 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 does Not covered preventive. Ask your provider if the services immunization not apply. needed are preventive. Then check what your plan will pay for. Diagnostic test (x-ray, No charge Not covered None If you have a test blood work) Imaging (CT/PET scans, $30/visit Not covered Preauthorization required or will not be MRIs) covered. $5 (retail); $10 (mail Value based drugs order)/prescription, deductible does not apply. Not covered Up to a 90-day supply (retail / mail order). Subject to formulary guidelines. Preferred generic drugs $20 (retail); $40 (mail order) / If you need drugs to prescription, deductible does treat your illness or not apply condition $40 (retail); $80 (mail Up to a 90-day supply (retail / mail order). More information Preferred brand drugs order)/prescription, deductible Not covered Subject to formulary guidelines. about prescription does not apply. drug coverage is 50% coinsurance up to available at Non-preferred drugs $250 (retail); 50% Not covered Up to a 90-day supply (retail / mail order). www.kp.org/formulary coinsurance up to $750 Subject to formulary guidelines . (mail order) / prescription Applicable Preferred Up to a 30-day supply (retail). Subject to Specialty drugs generic, Preferred brand or Not covered formulary guidelines, when approved through Non-Preferred cost shares the exception process. apply. If you have Facility fee (e.g., outpatient surgery ambulatory surgery $150 / visit Not covered None center) Page 2 of 6