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- Platinum 0/5
- Platinum 0/5 Pediatric Dental
- Platinum 0/5 Plus CAM
- Platinum 0/5 Plus CAM Pediatric Dental
- Gold 0/40
- Gold 0/40 Pediatric Dental
- Gold 0/40 Plus CAM
- Gold 0/40 Plus CAM Pediatric Dental
- Gold 1000 Deductible/250 Rx Deductible
- Gold 1000 Deductible/250 Rx Deductible Pediatric Dental
- Silver 3000 Deductible/600 Rx Deductible
- Silver 3000 Deductible/600 Rx Deductible Plus CAM
- Silver 3000 Deductible/600 Rx Deductible Pediatric Dental
- Silver 3000 Deductible/600 Rx Deductible Plus CAM Pediatric Dental
- Silver 4000 Deductible/600 Rx Deductible
- Silver 4000 Deductible/600 Rx Deductible Pediatric Dental
- Bronze 6000/65
- Bronze 6000/65 Pediatric Dental
- Bronze 6000/65 Plus CAM
- Bronze 6000/65 Plus CAM Pediatric Dental
- Standard Platinum 0/10
- Standard Platinum 0/10 Pediatric Dental
- Standard Gold 1500/30
- Standard Gold 1500/30 Pediatric Dental
- Standard Silver 5000/40
- Standard Silver 5000/40 Pediatric Dental
- Standard Bronze 7500/50
- Standard Bronze 7500/50 Pediatric Dental
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 0/5 Plus CAM
- Gold 0/40 Plus CAM
- Gold 1000 Deductible/250 Rx Deductible
- Silver 3000 Deductible/600 Rx Deductible Plus CAM
- Silver 4000 Deductible/600 Rx Deductible
- Silver 2000 Deductible/300 Rx Deductible/73 CSR
- Silver 2850 Deductible/600 Rx Deductible/73 CSR Plus CAM
- Silver 200 Deductible/100 Rx Deductible/87 CSR Plus CAM
- Silver 750/20/87 CSR
- Silver 0/5/94 CSR Plus CAM
- Silver 25/5/94 CSR
- Bronze 6000/65 Plus CAM
- Standard Platinum 0/10
- Standard Gold 1500/30
- Standard Silver 5000/40
- Standard Silver 3000/40/73 CSR
- Standard Silver 500/20/87 CSR
- Standard Silver 0/0/94 CSR
- Standard Bronze 7500/50
- Platinum 0/5 Plus CAM AI-AN
- Platinum 0/5 Plus CAM AI-AN LTD
- Gold - AI-AN
- Gold 0/40 Plus CAM AI-AN
- Gold 0/40 Plus CAM AI-AN LTD
- Gold 1000 Deductible/250 Rx Deductible AI-AN LTD
- Silver - AI-AN
- Silver - Plus CAM AI-AN
- Silver 3000 Deductible/600 Rx Deductible Plus CAM AI-AN LTD
- Silver 4000 Deductible/600 Rx Deductible AI-AN LTD
- Bronze 6000/65 Plus CAM AI-AN
- Bronze 6000/65 Plus CAM AI-AN LTD
- Standard Platinum 0/10 AI-AN
- Standard Platinum 0/10 AI-AN LTD
- Standard Gold 1500/30 AI-AN
- Standard Gold 1500/30 AI-AN LTD
- Standard Silver 5000/40 AI-AN
- Standard Silver 5000/40 AI-AN LTD
- Standard Bronze 7500/50 AI-AN
- Standard Bronze 7500/50 AI-AN LTD
If your plan is not listed above, please access these additional EOCs.
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.