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- Gold 0/25 RX Copay
- Gold 1500/20
- Gold 2000/20
- Silver 2200/25
- Silver 3700/20/HSA
- Silver 4000/25
- Silver 4500/30 RX Copay
- Silver 5500/25
- Bronze 6500/35/HSA
- Bronze 6500/50
- Bronze 7500/60 RX Copay
- Bronze 8500/50
- Catastrophic
- Colorado Option Gold
- Colorado Option Silver
- Colorado Option Bronze
- Select Gold 0/25 RX Copay
- Select Gold 1500/20
- Select Gold 2000/20
- Select Silver 2200/25
- Select Silver 3700/20/HSA
- Select Silver 4000/25
- Select Silver 4500/30 RX Copay
- Select Silver 5500/25
- Select Bronze 6500/50
- Select Bronze 6500/35/HSA
- Select Bronze 7500/60 RX Copay
- Select Bronze 8500/50
- Select Catastrophic
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.
- Gold 0/25 RX Copay
- Gold 1500/20
- Gold 2000/20
- Silver 1000/20/87 CSR
- Silver 200/5/94 CSR
- Silver 2200/25
- Silver 2200/25/73 CSR
- Silver 275/25/87 CSR
- Silver 2900/20/73 CSR
- Silver 3000/20/73 CSR
- Silver 3700/20/HSA
- Silver 4000/25
- Silver 4500/30 RX Copay
- Silver 4000/30 RX Copay 73 CSR
- Silver 50/5 RX Copay 94 CSR
- Silver 50/5/94 CSR
- Silver 500/20 RX Copay 87 CSR
- Silver 75/10/94 CSR
- Silver 850/10/87 CSR
- Bronze 6500/50
- Bronze 6500/35/HSA
- Bronze 7500/60 RX Copay
- Bronze 8500/50
- Catastrophic
- Colorado Option Gold
- Colorado Option Silver
- Colorado Option Silver 73
- Colorado Option Silver 87
- Colorado Option Silver 94
- Colorado Option Bronze
- Select Gold 0/25 RX Copay
- Select Gold 1500/20
- Select Gold 2000/20
- Select Silver 1000/20/87 CSR
- Select Silver 200/5/94 CSR
- Select Silver 2200/25
- Select Silver 2200/25/73 CSR
- Select Silver 275/25/87 CSR
- Select Silver 2900/20/73 CSR
- Select Silver 3000/20/73 CSR
- Select Silver 3700/20/HSA
- Select Silver 4000/25
- Select Silver 4000/30 RX Copay 73 CSR
- Select Silver 4500/30 RX Copay
- Select Silver 50/5 RX Copay 94 CSR
- Select Silver 50/5/94 CSR
- Select Silver 500/20 RX Copay 87 CSR
- Select Silver 75/10/94 CSR
- Select Silver 850/10/87 CSR
- Select Bronze 6500/35/HSA
- Select Bronze 6500/50
- Select Bronze 7500/60 RX Copay
- Select Bronze 8500/50
- Select Catastrophic
- Gold 0/25 RX Copay - AI-AN
- Gold 0/25 RX Copay - AI-AN LTD
- Gold 1500/20 - AI-AN
- Gold 1500/20 AI-AN LTD
- Gold 2000/20 - AI-AN
- Gold 2000/20- AI-AN LTD
- Silver 2200/25 - AI-AN
- Silver 2200/25 - AI-AN LTD
- Silver 3700/20 - AI-AN
- Silver 3700/20 - AI-AN LTDSilver 4000/25 - AI-AN
- Silver 4500/30 RX Copay - AI-AN
- Silver 4500/30 RX Copay - AI-AN LTD
- Silver 5000/25 - AI-AN LTD
- Bronze 6500/35 - AI-AN
- Bronze 6500/35 - AI-AN LTD
- Bronze 6500/50 - AI-AN
- Bronze 6500/50 - AI-AN LTD
- Bronze 7500/60 RX Copay - AI-AN
- Bronze 7500/60 RX Copay - AI-AN LTD
- Bronze 8500/50 - AI-AN
- Bronze 8500/50 - AI-AN LTD
- American Indian/Alaskan Native
- American Indian/Alaskan Native LTD
- Colorado Option Gold - AI-AN
- Colorado Option Gold - AI-AN LTD
- Colorado Option Silver - AI-AN
- Colorado Option Silver - AI-AN LTD
- Colorado Option Bronze - AI-AN
- Colorado Option Bronze - AI-AN LTD
- Select Gold 0/25 RX Copay - AI-AN
- Select Gold 0/25 RX Copay - AI-AN LTD
- Select Gold 1500/20 - AI-AN
- Select Gold 1500/20 - AI-AN LTD
- Select Gold 2000/20 - AI-AN LTD
- Select Gold 2000/20- AI-AN
- Select Silver 2200/25 - AI-AN
- Select Silver 2200/25 - AI-AN LTD
- Select Silver 3700/20 - AI-AN
- Select Silver 3700/20 - AI-AN LTD
- Select Silver 4000/25 - AI-AN
- Select Silver 4500/30 RX Copay - AI-AN
- Select Silver 4500/30 RX Copay - AI-AN LTD
- Select Silver 5000/25 - AI-AN LTD
- Select Bronze 6500/35 - AI-AN
- Select Bronze 6500/35 - AI-AN LTD
- Select Bronze 6500/50 - AI-AN
- Select Bronze 6500/50 - AI-AN LTD
- Select Bronze 7500/60 RX Copay - AI-AN
- Select Bronze 7500/60 RX Copay- AI-AN LTD
- Select Bronze 8500/50 - AI-AN
- Select Bronze 8500/50 - AI-AN LTD
- Select American Indian/Alaskan Native
- Select American Indian/Alaskan Native 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.