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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
Review plan listings of previous evidence of coverage documents.
- 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
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.