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KP GA Bronze Virtual Complete 5500 Ded/1500 RxDed
Plan Summary
Plan Type HMO
Metal Level Bronze
Office Visit for Primary Doctor
Find Doctors 		$60 Copay for first 3 visits then $60 Copay after deductible
Office Visit for Specialist $80 Copay after deductible
Office Visit for Other Practitioner (Nurse, Physician Assistant) $60 Copay after deductible, first 3 visits deductible waived
Annual Deductible Individual: $5,500
Separate Prescription Drugs Deductible $1500 per person | $3000 per group
Coinsurance 30%
Retail Prescription Drugs Generic Drugs: $30 Copay;
Preferred Brand Drugs: 30% Coinsurance after deductible;
Non-Preferred Brand Drugs: 50% Coinsurance after deductible;
Specialty Drugs: 50% Coinsurance after deductible;
Annual Out-of-Pocket Limit Individual: $9,100
Includes deductible
Lifetime Maximum Unlimited
Health Savings Account (HSA) Eligible No
Out-of-Network Coverage Emergency Care Only 
Out-of-Country Coverage Yes. Urgent and Emergency Care only 
Office Visit
Primary Care Physician Required Yes
Specialist Referrals Required Yes
Preventive Care Coverage
Periodic Health Exam No Charge
Periodic OB-GYN Exam No Charge
Well Baby Care No Charge
Emergency and Urgent Care
Emergency Room 30% Coinsurance after deductible
Emergency Ambulance Services 30% Coinsurance after deductible
Urgent Care Facility $100 Copay
Prescription Drug Coverage
Retail Prescription Drugs Generic Drugs: $30 Copay;
Preferred Brand Drugs: 30% Coinsurance after deductible;
Non-Preferred Brand Drugs: 50% Coinsurance after deductible;
Specialty Drugs: 50% Coinsurance after deductible;
Separate Prescription Drugs Deductible $1500 per person | $3000 per group
Mail Order Prescription Drugs N/A
Mail Order Supply N/A
Outpatient Coverage
Outpatient Surgery Outpatient Surgery Physician/Surgical Services:
30% Coinsurance after deductible
Outpatient Facility Fee:
30% Coinsurance after deductible
Outpatient Lab/X-Ray Outpatient Lab:
0% Coinsurance after deductible
X-rays:
30% Coinsurance after deductible
Imaging (CT and PET scans, MRIs) 30% Coinsurance after deductible
Outpatient Mental Health $60 Copay
Outpatient Substance Abuse $60 Copay
Outpatient Rehabilitation Services (PT, OT, ST) 30% Coinsurance after deductible
Inpatient Coverage
Hospitalization Inpatient Hospital Services:
30% Coinsurance after deductible
Inpatient Physician and Surgical Services:
30% Coinsurance after deductible
Skilled Nursing Facility 30% Coinsurance after deductible, limited to 150 Days per Year
Inpatient Mental Health 30% Coinsurance after deductible
Inpatient Substance Abuse 30% Coinsurance after deductible
Home Healthcare 30% Coinsurance after deductible, limited to 120 Visit(s) per Year
Maternity Coverage
Pre & Postnatal Office Visit 30% Coinsurance after deductible
Labor & Delivery Hospital Stay 30% Coinsurance after deductible
Pediatric Services
Dental Checkup for Children No Charge, limited to 1 Visit(s) per 6 Months
Vision Screening for Children $60 Copay, limited to 1 Exam(s) per Year
Eye Glasses for Children No Charge, limited to 1 Item(s) per Year
Major Dental Coverage (Pediatric) 50% Coinsurance after deductible
Additional Coverage
Chiropractic Coverage 30% Coinsurance after deductible, limited to 20 Visit(s) per Year
Durable Medical Equipment 30% Coinsurance after deductible
Hospice No Charge
Major Dental Coverage (Adult) Not Covered
Vision Coverage (Adult) $60 Copay, limited to 1 Exam(s) per Year
Out-of-Network Coverage
Out-of-Network Authorization Required N/A
Out-of-Network Annual Deductible N/A
Out-of-Network Annual Coinsurance N/A
Out-of-Network Annual Out-of-Pocket Limit N/A
Additional Information
A.M. Best Rating N/A as of 03/09/2025
Electronic Signature for Application Available Yes
Details and documents about this plan
View Plan Brochure Exclusions and Limitations

Important notices and disclaimers

  • The information shown here is a summary of benefits for informational purposes only. Review the official plan documents (such as evidence of coverage, plan brochure, or insurance policy) for a detailed description of coverage benefits, limitations, and exclusions. Only the terms and conditions of coverage benefits listed in the policy are binding.
  • The benefits listed may be contingent on your use of physicians, hospitals, and services within the specific insurance company's provider network.
  • The Copayment, Deductible, and Coinsurance amounts are your share of the costs for covered benefits. These amounts are subject to change.
  • Each insurance carrier may have unique Notices, Disclaimers, and Fees. Please check below for information regarding the plans and carriers you selected.
  • The quotes or rates shown above are estimates only. Your premium is subject to change based on the optional benefits you selected, if any, and other relevant factors, such as changes in rates that take effect before your coverage start date. The insurance company always determines your actual premium. Insurance companies reserve the right to change the terms of a policy upon proper notification.
  • The Summary of Benefits & Coverage can be found at healthcare.gov. A paper copy of this Summary of Benefits & Coverage is available upon request by calling our toll free number. Click here to view the Uniform Glossary of Coverage and Medical Terms.

Carrier specific notices, disclaimers and fees

  • - Our standard compensation is $28, per member per month, plus a potential bonus. To learn more, visit kp.org/brokercompensation. This compensation does not change the price of your plan.
  • - New for 2022: Prefer to get your care virtually? Our Virtual Complete plans offer virtual care at no charge and include unlimited access to chat*, email, e-visits, phone and video visits. Learn more about Virtual Complete plans.