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- Gold $0 $25
- Gold $500 $20
- Gold $1000 $20
- Gold $1500 $30
- Gold $2000 $20
- Silver $3500 $30
- Silver $4500 $35
- Silver $6000 $50
- Bronze $7500 $50
- Gold $500 $20 Bridge Program
- Gold $3500 $0 HSA
- Silver $4000 $0 HSA
- Bronze $6500 40% HSA
- Silver $5000 $40 Virtual Complete
- Silver $5500 $50 Virtual Complete
- Bronze $5500 $60 Virtual Complete
- Catastrophic $10600 $0
- Signature Gold $0 $25
- Signature Gold $500 $20
- Signature Gold $1000 $20
- Signature Gold $1500 $30
- Signature Gold $2000 $20
- Signature Silver $3500 $30
- Signature Silver $4500 $35
- Signature Silver $6000 $50
- Signature Bronze $7500 $50
- Signature Gold $500 $20 Bridge Program
- Signature Gold $3500 $0 HSA
- Signature Silver $4000 $0 HSA
- Signature Bronze $6500 40% HSA
- Signature Silver $5000 $40 Virtual Complete
- Signature Silver $5500 $50 Virtual Complete
- Signature Bronze $5500 $60 Virtual Complete
- Signature Catastrophic $10600 $0
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.
- Traditional HMO
- Gold $500 $20
- Gold $1000 $20
- Gold $1500 $30
- Gold $2000 $20
- Silver $0 $0
- Silver $0 $5 A
- Silver $150 $5
- Silver $700 $20
- Silver $750 $20
- Silver $850 $15
- Silver $3000 $40
- Silver $3300 $30
- Silver $3500 $30
- Silver $3500 $35
- Silver $4500 $35
- Silver $6000 $50
- Bronze $7500 $50
- Bronze $6500 40% HSA
- Silver $0 $0 Virtual Complete
- Silver $500 $30 Virtual Complete
- Silver $3000 $40 Virtual Complete
- Silver $5000 $40 Virtual Complete
- Bronze $5500 $60 Virtual Complete
- Catastrophic $10600 $0
- Signature HMO
- Signature Gold $500 $20
- Signature Gold $1000 $20
- Signature Gold $1500 $30
- Signature Gold $2000 $20
- Signature Silver $0 $0
- Signature Silver $0 $5 A
- Signature Silver $150 $5
- Signature Silver $700 $20
- Signature Silver $750 $20
- Signature Silver $850 $15
- Signature Silver $3000 $40
- Signature Silver $3300 $30
- Signature Silver $3500 $30
- Signature Silver $3500 $35
- Signature Silver $4000 $35
- Signature Silver $4500 $35
- Signature Silver $6000 $50
- Signature Bronze $7500 $50
- Signature Bronze $6500 40% HSA
- Signature Silver $0 $0 Virtual Complete
- Signature Silver $500 $30 Virtual Complete
- Signature Silver $3000 $40 Virtual Complete
- Signature Silver $5000 $40 Virtual Complete
- Signature Bronze $5500 $60 Virtual Complete
- Signature Catastrophic $10600 $0
Archive
Review plan listings of previous evidence of coverage 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.