|In Network||Out of Network1|
|Primary care visit||$10||$30|
|Most lab tests and X-rays||$0||$20|
|Generic (in-network/community pharmacy)2||$5 / $15||$25|
|Preferred brand (in-network/community pharmacy)2||$15 / $25||$45|
|Non-preferred brand (in-network/community pharmacy)2||$15/$25||$70|
|Emergency room services||$150|
|Routine prenatal care, first postpartum visit||$20||Not covered|
|In-patient delivery||$0||Not covered|
|Outpatient surgery||$20||Not covered|
|Inpatient hospital care (per admission)||$0||Not covered|
For illustrative purposes only.
1This plan covers up to 10 out-of-network medical visits for certain physician, laboratory and radiology services, and 5 pharmacy refills a year with any licensed provider outside of the Kaiser Permanente care delivery system, anywhere in the United States.
2For more information about prescription drugs and other common medical events, including exclusions and limitations, read Summary of Benefits and Coverage below.
3Out-of-network urgent care available when out of service area.
Medicare retirees enrolled in Kaiser Permanente Medicare Advantage (HMO)
|Primary care visit copay (waived for children through age 5)||$10|
|Medicare-covered preventive care/screening/immunization||$0|
|Diagnostic test (xray, blood work)||$0|
|Imaging (CT/PETscans, MRI)||$0|
Mail Order (up to a 90-day supply)–$3
Plan Pharmacies (up to a 60-day supply)–$5
Participating retail pharmacies (up to a 60-day supply)–$10
|Emergency room services, per visit (waived if admitted)||$50|
|Urgent care, per visit||$10|
|Hospitalization, facility or surgeon||$0|
|Video appointments with the doctor||$0|
All copays and costs with preferred providers.
1For more information about prescription drugs and other common medical events, including exclusions and limitations, read Summary of Benefits below.
*In the National Committee for Quality Assurance (NCQA) 2019–2020 Health Insurance Plan Ratings, Kaiser Permanente of the Mid-Atlantic States’ private health plan is rated 5 out of 5, among the top 1% in the nation, and our Medicare health plan is rated 4.5 out of 5, the highest rating in DC, MD, and VA. The 2019 Commission on Cancer, a program of the American College of Surgeons, granted Three-Year Accreditation with Commendation to the Kaiser Permanente cancer care program. The Mid-Atlantic Permanente Medical Group is the largest medical group in the Washington, DC, and Baltimore areas and exclusively treats Kaiser Permanente members. Permanente doctors are recognized as Top Doctors in Northern Virginia Magazine (2020), Washingtonian magazine (2019), Baltimore magazine (2019), and Washington Consumers’ CHECKBOOK magazine (2018). According to NCQA’s Quality Compass® 2019, we lead DC, MD, and VA in the following categories: colorectal screening, breast cancer screening, childhood immunizations combo 9, cervical cancer screening, and timeliness of prenatal and postpartum care for women. Quality Compass is a registered trademark of the NCQA.