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- Platinum 0/10
- Gold 0/40
- Bronze 6000/65
- Platinum 0/10 PedDent
- Gold 0/40 PedDent
- Bronze 6000/65 PedDent
- Gold 1000 Ded/250 Rx Ded
- Silver 3000 Ded/600 Rx Ded
- Silver 4000 Ded/600 Rx Ded
- Platinum 0/10 Plus CAM
- Gold 0/40 Plus CAM
- Platinum 0/10 Plus CAM PedDent
- Gold 0/40 Plus CAM PedDent
- Bronze 6000/65 Plus CAM PedDent
- Bronze 6000/65 Plus CAM HSA
- Silver 3000 Ded/600 Rx Ded Plus CAM
- Gold 1000 Ded/250 Rx Ded PedDent
- Silver 3000 Ded/600 Rx Ded PedDent
- Silver 4000 Ded/600 Rx Ded PedDent
- Silver 3000 Ded/600 Rx Ded Plus CAM PedDent
- Standard Platinum 0/20
- Standard Gold 2500/30
- Standard Silver 6000/40
- Standard Platinum 0/20 PedDent
- Standard Gold 2500/30 PedDent
- Standard Silver 6000/40 PedDent
- Standard Bronze 7500/50 PedDent
- Standard Bronze 7500/50 HSA
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.
- Platinum 0/10 Plus CAM
- Gold 0/40 Plus CAM
- Silver 3000 Ded/600 Rx Ded Plus CAM
- Bronze 6000/65 Plus CAM HSA
- Gold 1000 Ded/250 Rx Ded
- Silver 4000 Ded/600 Rx Ded
- Silver 0/5 CSR94 Plus CAM
- Silver 200 Ded/100 Rx Ded CSR87 Plus CAM
- Silver 2850 Ded/600 Rx Ded CSR73 Plus CAM
- Silver 25/5 CSR94
- Silver 750/20 CSR87
- Silver 2000 Ded/300 Rx Ded CSR73
- Gold - AI/0
- Silver - AI/0
- Platinum - Plus CAM - AI/0
- Gold - Plus CAM - AI/0
- Silver - Plus CAM AI/0
- Platinum 0/10 Plus CAM AI/LTD
- Gold 0/40 Plus CAM AI/LTD
- Silver 3000 Ded/600 Rx Ded Plus CAM AI/LTD
- Gold 1000 Ded/250 Rx Ded AI/LTD
- Silver 4000 Ded/600 Rx Ded AI/LTD
- Bronze 6000/65 Plus CAM AI/AN
- Bronze 6000/65 Plus CAM AI/AN/LTD
- Standard Platinum 0/20
- Standard Gold 2500/30
- Standard Silver 6400/40
- Standard Silver 0/0 CSR94
- Standard Silver 800/20 CSR87
- Standard Silver 2900/40 CSR73
- Standard Bronze 7500/50 HSA
- Standard Platinum - AI/0
- Standard Gold - AI/0
- Standard Silver - AI/0
- Standard Bronze - AI/0
- Standard Platinum 0/20 AI/LTD
- Standard Gold 2500/30 AI/LTD
- Standard Silver 6400/40 AI/LTD
- Standard Bronze 7500/50 AI/LTD
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.