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- Platinum 0/5
- Gold 0/40
- Bronze 6000/65
- Platinum 0/5 PedDent
- Gold 0/40 PedDent
- Bronze 6000/65 PedDent
- Platinum 0/5 Plus CAM
- Gold 0/40 Plus CAM
- Bronze 6000/65 Plus CAM
- Platinum 0/5 Plus CAM PedDent
- Gold 0/40 Plus CAM PedDent
- Bronze 6000/65 Plus CAM PedDent
- Gold 1000 Ded/250 Rx Ded
- Silver 3000 Ded/600 Rx Ded
- Silver 4000 Ded/600 Rx Ded
- 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
- Silver 3000 Ded/600 Rx Ded Plus CAM PedDent
- Standard Platinum 0/10
- Standard Gold 2000/30
- Standard Silver 6000/40
- Standard Bronze 7500/50
- Standard Platinum 0/10 PedDent
- Standard Gold 2000/30 PedDent
- Standard Silver 6000/40 PedDent
- Standard Bronze 7500/50 PedDent
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
- Bronze 6000/65 Plus CAM
- Platinum 0/5 Plus CAM AI/0
- Gold 0/40 Plus CAM AI/0
- Silver - Plus CAM AI/0
- Bronze 6000/65 Plus CAM AI/0
- Platinum 0/5 Plus CAM AI/LTD
- Gold 0/40 Plus CAM AI/LTD
- Bronze 6000/65 Plus CAM AI/AN LTD
- Gold 1000 Ded/250 Rx Ded
- Silver 4000 Ded/600 Rx Ded
- Gold 1000 Ded/250 Rx Ded AI/LTD
- Silver 4000 Ded/600 Rx Ded AI/LTD
- Silver 25/5 CSR94
- Silver 750/20 CSR87
- Silver 0/5 CSR94 Plus CAM
- Silver 2000 Ded/300 Rx Ded CSR73
- Silver 200 Ded/100 Rx Ded CSR87 Plus CAM
- Silver 2850 Ded/600 Rx Ded CSR73 Plus CAM
- Silver 3000 Ded/600 Rx Ded Plus CAM
- Silver 3000 Ded/600 Rx Ded Plus CAM AI/LTD
- Gold - AI/0
- Silver - AI/0
- Standard Platinum 0/10
- Standard Gold 2000/30
- Standard Silver 6000/40
- Standard Bronze 7500/50
- Standard Platinum 0/10 AI/0
- Standard Gold 2000/30 AI/0
- Standard Silver 6000/40 AI/0
- Standard Bronze 7500/50 AI/0
- Standard Platinum 0/10 AI/LTD
- Standard Gold 2000/30 AI/LTD
- Standard Silver 6000/40 AI/LTD
- Standard Bronze 7500/50 AI/LTD
- Standard Silver 0/0 CSR94
- Standard Silver 700/20 CSR87
- Standard Silver 3000/40 CSR73
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.