$40/$3,000 Deductible Plan NM1
Features
Individual plan annual deductible (subscriber only)
$3,000
Family plan annual deductible (individual/family)
No dependent coverage
Individual plan annual out-of-pocket maximum (subscriber only)
$6,000
Family plan annual out-of-pocket maximum (individual/family)
No dependent coverage
Lifetime benefit maximum
$5 million
Benefits - Services not subject to deductible unless otherwise indicated
Preventive Care
Immunization
No charge
Routine physical exam
$40 copay
Well-child visit (0-23 months)
$30 copay
Well-woman visit
$40 copay
Mamogram
$10 copay
Outpatient services (per visit or procedure)
Primary care/Specialty office visit
$40 copay
Most X-rays and lab tests
$10 copay (after deductible)
MRI, CT, and PET
$50 copay (after deductible)
Outpatient surgery
20% coinsurance (after deductible)
Inpatient hospital care
Room and board, surgery, anesthesia, X-rays, lab tests, and medication
20% coinsurance (after deductible)
Maternity
Maternity care
Not covered
Emergency and urgent care
Emergency Department visit (waived if admitted)
$150 copay (after deductible)
Urgent care visit
$40 copay
Ambulance service
$150 copay (after deductible)
Prescription drugs
Plan Pharmacy (up to a 30-day supply)
Generic: $10 copay/Brand: $35 copay
Mail-order (up to a 100-day supply)
Generic: $20 copay/Brand: $70 copay
1These plans are offered by Kaiser Permanente Insurance Company (KPIC),
a subsidiary of Kaiser Foundation Health Plan, Inc.
