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- Gold HMO $0 $25
- Gold HMO $500 $25
- Gold HMO $1000 $25
- Gold HMO $1500 $30
- Gold HMO $2000 $30
- Gold HMO $4000 $25
- Silver HMO $3600 $35
- Silver HMO $4500 $35
- Silver HMO $6000 $50
- Silver HMO $6500 $60
- Bronze HMO $7500 $50
- Gold HMO $0 $25 Bridge Program
- Gold HMO $3600 $0 HSA
- Silver HMO $4500 $0 HSA
- Silver HMO $5500 $0 HSA
- Bronze HMO $6500 40% HSA
- Silver HMO $5000 $40 Virtual Complete
- Silver HMO $5500 $50 Virtual Complete
- Bronze HMO $5500 $60 Virtual Complete
- Catastrophic HMO $12000 $0
- Signature Gold HMO $0 $25
- Signature Gold HMO $500 $25
- Signature Gold HMO $1000 $25
- Signature Gold HMO $1500 $30
- Signature Gold HMO $2000 $30
- Signature Gold HMO $4000 $25
- Signature Silver HMO $3600 $35
- Signature Silver HMO $4500 $35
- Signature Silver HMO $6000 $50
- Signature Silver HMO $6500 $60
- Signature Bronze HMO $7500 $50
- Signature Gold HMO $0 $25 Bridge Program
- Signature Gold HMO $3600 $0 HSA
- Signature Silver HMO $4500 $0 HSA
- Signature Silver HMO $5500 $0 HSA
- Signature Bronze HMO $6500 40% HSA
- Signature Silver HMO $5000 $40 Virtual Complete
- Signature Silver $5500 $50 Virtual Complete
- Signature Bronze HMO $5500 $60 Virtual Complete
- Signature Catastrophic HMO $12000 $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 HMO $500 $25
- Gold HMO $1000 $25
- Gold HMO $1500 $30
- Gold HMO $2000 $30
- Silver HMO $0 $0
- Silver HMO $0 $5 A
- Silver HMO $150 $5
- Silver HMO $700 $20
- Silver HMO $750 $20
- Silver HMO $850 $15
- Silver HMO $3000 $40
- Silver HMO $3300 $30
- Silver HMO $3500 $35
- Silver HMO $3600 $35
- Silver HMO $4500 $35
- Silver HMO $6000 $50
- Bronze HMO $6500 40% HSA
- Bronze HMO $7500 $50 HSA
- Silver HMO $0 $0 Virtual Complete
- Silver HMO $500 $30 Virtual Complete
- Silver HMO $3000 $40 Virtual Complete
- Silver HMO $5000 $40 Virtual Complete
- Bronze HMO $5500 $60 Virtual Complete HSA
- Catastrophic HMO $12000 $0 HSA
- Signature Traditional HMO
- Signature Gold HMO $500 $25
- Signature Gold HMO $1000 $25
- Signature Gold HMO $1500 $30
- Signature Gold HMO $2000 $30
- Signature Silver HMO $0 $0
- Signature Silver HMO $0 $5 A
- Signature Silver HMO $150 $5
- Signature Silver HMO $700 $20
- Signature Silver HMO $750 $20
- Signature Silver HMO $850 $15
- Signature Silver HMO $3000 $40
- Signature Silver HMO $3300 $30
- Signature Silver HMO $3500 $35
- Signature Silver HMO $3600 $35
- Signature Silver HMO $4500 $35
- Signature Silver HMO $6000 $50
- Signature Bronze HMO $6500 40% HSA
- Signature Bronze HMO $7500 $50 HSA
- Signature Silver HMO $0 $0 Virtual Complete
- Signature Silver HMO $500 $30 Virtual Complete
- Signature Silver HMO $3000 $40 Virtual Complete
- Signature Silver HMO $5000 $40 Virtual Complete
- Signature Bronze HMO $5500 $60 Virtual Complete HSA
- Signature Catastrophic HMO $12000 $0 HSA
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.