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- Gold 500/30
- Gold 1500/20
- Gold 2000/20
- Silver 2500/30 X
- Silver 4000/25
- Silver 5500/30
- Bronze 6500/50
- Bronze 8500/50
- Gold 0/25 RX Copay
- Silver 4500/35 RX Copay
- Bronze 7500/60 RX Copay
- Gold 3400/15%/HSA
- Silver 5000/20%/HSA
- Silver 3800/25%/HSA
- Bronze 6500/35%/HSA
- Catastrophic
- Colorado Option Gold
- Colorado Option Silver
- Colorado Option Bronze
- Select Gold 500/30
- Select Gold 1500/20
- Select Gold 2000/20
- Select Silver 2500/30 X
- Select Silver 4000/25
- Select Silver 5500/30
- Select Bronze 6500/50
- Select Bronze 8500/50
- Select Gold 0/25 RX Copay
- Select Silver 4500/35 RX Copay
- Select Bronze 7500/60 RX Copay
- Select Gold 3400/15%/HSA
- Select Silver 5000/20%/HSA
- Select Silver 3800/25%/HSA
- Select Bronze 6500/35%/HSA
- Select Catastrophic
Individual & Family Plan Documents
These are sample evidence of coverage (EOC) plan documents that may assist you in making an informed decision on which plan to choose. After enrollment, you will receive the most current version that should be used to determine terms of coverage for your plan.
- American Indian/Alaskan Native 100%
- American Indian/Alaskan Native LTD
- Gold 1500/20
- Gold 2000/20
- Silver 2500/30
- Silver 4000/25
- Bronze 6500/50
- Bronze 8500/50
- Gold 3400/15%/AI/LTD
- Gold 1500/20/AIAN
- Gold 2000/20/AIAN
- Gold 3400/15%/AIAN
- Silver 2500/30/AIAN
- Silver 3800/25%/AIAN
- Silver 4000/25/AIAN
- Bronze 6500/35%/AIAN
- Bronze 6500/50/AIAN
- Bronze 8500/50/AIAN
- Silver 50/5/94% CSR
- Silver 200/5%/94% CSR
- Silver 75/10/94% CSR
- Silver 900/10%/87% CSR
- Silver 1000/20/87% CSR
- Silver 2900/20%/73% CSR
- Silver 3500/20/73% CSR
- Silver 275/25/87% CSR
- Silver 2200/25/73% CSR
- Gold 3400/15%/HSA
- Silver 3800/25%/HSA
- Bronze 6500/35%/HSA
- Gold 1500/20/LTD
- Gold 2000/20/LTD
- Silver 2500/30/LTD
- Silver 3800/25%/LTD
- Silver 4000/25/LTD
- Bronze 6500/35%/LTD
- Bronze 6500/50/LTD
- Bronze 8500/50/LTD
- Gold 0/25 RX Copay
- Silver 4500/35 RX Copay
- Bronze 7500/60 RX Copay
- Gold 0/25 RX Copay/AI/LTD
- Gold 0/25 RX Copay/AIAN
- Silver 4500/35 RX Copay/AIAN
- Bronze 7500/60 RX Copay/AIAN
- Silver 50/5 RX Copay 94% CSR
- Silver 500/20 RX Copay 87% CSR
- Silver 4500/30 RX Copay 73% CSR
- Silver 4500/35 RX Copay/LTD
- Bronze 7500/60 RX Copay/LTD
- Catastrophic
- Colorado Option Gold
- Colorado Option Silver
- Colorado Option Bronze
- Colorado Option Gold/AIAN
- Colorado Option Silver/AIAN
- Colorado Option Bronze/AIAN
- Colorado Option Gold/LTD
- Colorado Option Silver/LTD
- Colorado Option Bronze/LTD
- Colorado Option Silver 94% AV
- Colorado Option Silver 87% AV
- Colorado Option Silver 73% AV
- Select American Indian/Alaskan Native 100%
- Select American Indian/Alaskan Native LTD
- Select Gold 1500/20
- Select Gold 2000/20
- Select Silver 2500/30
- Select Silver 4000/25
- Select Bronze 6500/50
- Select Bronze 8500/50
- Select Gold 3400/15%/AI/LTD
- Select Gold 1500/20/AIAN
- Select Gold 2000/20/AIAN
- Select Gold 3400/15%/AIAN
- Select Silver 2500/30/AIAN
- Select Silver 3800/25%/AIAN
- Select Silver 4000/25/AIAN
- Select Bronze 6500/35%/AIAN
- Select Bronze 6500/50/AIAN
- Select Bronze 8500/50/AIAN
- Select Silver 50/5/94% CSR
- Select Silver 200/5%/94% CSR
- Select Silver 75/10/94% CSR
- Select Silver 900/10%/87% CSR
- Select Silver 1000/20/87% CSR
- Select Silver 2900/20%/73% CSR
- Select Silver 3500/20/73% CSR
- Select Silver 275/25/87% CSR
- Select Silver 2200/25/73% CSR
- Select Gold 3400/15% HSA
- Select Silver 3800/25%/HSA
- Select Bronze 6500/35%/HSA
- Select Gold 1500/20/LTD
- Select Gold 2000/20/LTD
- Select Silver 2500/30/LTD
- Select Silver 3800/25%/LTD
- Select Silver 4000/25/LTD
- Select Bronze 6500/35%/LTD
- Select Bronze 6500/50/LTD
- Select Bronze 8500/50/LTD
- Select Gold 0/25 RX Copay
- Select Silver 4500/35 RX Copay
- Select Bronze 7500/60 RX Copay
- Select Gold 0/25 RX Copay/AI/LTD
- Select Gold 0/25 RX Copay/AIAN
- Select Silver 4500/35 RX Copay/AIAN
- Select Bronze 7500/60 RX Copay/AIAN
- Select Silver 50/5 RX Copay 94% CSR
- Select Silver 500/20 RX Copay 87% CSR
- Select Silver 4500/30 RX Copay 73% CSR
- Select Silver 4500/35 RX Copay/LTD
- Select Bronze 7500/60 RX Copay/LTD
- Select Catastrophic
If your plan is not listed above, please access these additional EOCs.
Archive
Review plan listings of previous evidence of coverage (EOC) documents.
Questions?
Have questions about the sample plan documents? Visit buykp.org or call 1-800-488-3590 (TTY 711).
Kaiser Permanente Member
The sample documents may vary from your actual benefits. To view a copy of your specific plan documents, please log into www.kp.org or contact Member Services.