Kaiser Foundation Health Plan of Washington · BHT Industry Health Trust
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All supported filed details, including known conditions and limits. This is not the entire insurance contract. Unknown does not mean $0 or not covered.
| Benefit | VP 5000 |
|---|---|
Medical deductible | Source answer: $5,000 Individual / $10,000 Family Benefit details: Generally, you must pay all of the costs from providers up to the deductible amount before this plan begins to pay. If you have other family members on the plan, each family member must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Benefit details: Summary (Inside Network): Individual deductible: $5,000 per calendar year Family deductible: $10,000 per calendar year |
| Benefit | VP 5000 |
|---|---|
Are there other deductibles for specific services? | Source answer: No. Benefit details: You don’t have to meet deductibles for specific services. |
Outpatient services (Office visits) | Inside Network: $40 copay primary/$80 copay specialty Deductible and coinsurance do not apply for authorized visits. Self-directed visits are subject to deductible and coinsurance, copay waived. Virtual visits are covered in full. |
Diabetic supplies | Inside Network: Insulin, needles, syringes and lancets-see Prescription drugs. External insulin pumps, blood glucose monitors, testing reagents and supplies-see Devices, equipment and supplies. When Devices, equipment and supplies or Prescription drugs are covered and have benefit limits, diabetic supplies are not subject to these limits. |
| Benefit | VP 5000 |
|---|---|
Maximum Out of Pocket for Medical and Drug Benefits (Total) | Source answer: $8,150 Individual / $16,300 Family Benefit details: The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. Benefit details: Summary (Inside Network): Individual out-of-pocket limit: $8,150 Family out-of-pocket limit: $16,300 Out-of-pocket expenses for the following covered services are included in the out-of-pocket limit: All cost shares for covered services |
Costs excluded from the out-of-pocket limit | Source answer: Premiums, balance-billing charges, health care this plan doesn’t cover, and services indicated in chart starting on page 2. Benefit details: Even though you pay these expenses, they don’t count toward the out-of-pocket limit. |
| Benefit | VP 5000 |
|---|---|
Primary Care Visit to Treat an Injury or Illness | In-network: Telehealth: No charge, deductible does not apply; In- person with authorization: $40 / visit, deductible does not apply; In-person without authorization: 30% coinsurance Out-of-network: Not covered |
Specialist Visit | In-network: Telehealth: No charge, deductible does not apply; In-person with authorization: $80 / visit, deductible does not apply; In-person without authorization: 30% coinsurance Out-of-network: Not covered |
Preventive Care/Screening/Immunization | In-network: No charge, deductible does not apply. Benefit details: You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. Benefit details: Summary (Inside Network): Covered in full Women's contraception is covered as preventive, and Men's contraception is covered in full Out-of-network: Not covered |
| Benefit | VP 5000 |
|---|---|
Diagnostic Test (X-Ray and Blood Work) | In-network: 30% coinsurance Benefit details: Summary (Inside Network): Inpatient: Covered under Hospital services Outpatient: Deductible and coinsurance apply High end radiology imaging services such as CT, MRI and PET must be determined Medically Necessary and require prior authorization except when associated with Emergency care or inpatient services. Out-of-network: Not covered |
Imaging (CT/PET Scans, MRIs) | In-network: 30% coinsurance Benefit details: Preauthorization required Out-of-network: Not covered |
| Benefit | VP 5000 |
|---|---|
Generic Drugs | In-network: $20 (retail); $5 (mail order) / prescription, deductible does not apply. Benefit details: Up to a 30-day supply (retail); up to a 90-day supply (mail order). No charge for contraceptives. Subject to formulary guidelines. After 1st fill, maintenance drugs must be filled through KFHPWA mail order. Out-of-network: Not covered |
Preferred Brand Drugs | In-network: $40 (retail); $80 (mail order) / prescription, deductible does not apply. Benefit details: Up to a 30-day supply (retail); up to a 90-day supply (mail order). Subject to formulary guidelines. After 1st fill, maintenance drugs must be filled through KFHPWA mail order. Out-of-network: Not covered |
Non-Preferred Brand Drugs | In-network: Applicable preferred generic or Preferred brand cost shares apply. Benefit details: Up to a 30-day supply (retail); up to a 90-day supply (mail order). Subject to formulary guidelines , when approved through the exception process.. After 1st fill, maintenance drugs must be filled through KFHPWA mail order. Out-of-network: Not covered |
Specialty Drugs | In-network: $150 (retail) / prescription, deductible does not apply Benefit details: Up to a 30-day supply (retail). Subject to formulary guidelines. Out-of-network: Not covered |
Prescription drugs (some injectable drugs may be covered under Outpatient services) | Inside Network: Preferred generic/preferred brand/preferred specialty $20/$40/$150 up to a 30 day supply |
Prescription mail order | Inside Network: $5 copay/2x prescription cost share up to a 90 day supply; After 1st fill, maintenance drugs must be filled through KFHPWA mail order or KP retail pharmacies |
| Benefit | VP 5000 |
|---|---|
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) | In-network: 30% coinsurance Out-of-network: Not covered |
Outpatient Surgery Physician/Surgical Services | In-network: 30% coinsurance Out-of-network: Not covered |
Inpatient Hospital Services (e.g., Hospital Stay) | In-network: 30% coinsurance Benefit details: Preauthorization required Out-of-network: Not covered |
Inpatient Physician and Surgical Services | In-network: 30% coinsurance Benefit details: Preauthorization required Out-of-network: Not covered |
Hospital services | Inside Network: Inpatient services: Deductible and coinsurance apply Outpatient surgery: Deductible and coinsurance apply |
Organ transplants | Inside Network: Unlimited, no waiting period Inpatient: Deductible and coinsurance apply Outpatient: $40 copay Deductible and coinsurance do not apply |
Cosmetic SurgeryNotes & sourceListed in the source exclusion summary. Check its exceptions and the issued contract for the exact terms. | Source statement: Cosmetic Surgery is listed in the source exclusions; review the qualifications. Source exclusion context: • Bariatric surgery • Children’s glasses • Cosmetic surgery • Dental care (Adult and child) • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Private-duty nursing • Routine foot care • Weight loss programs |
| Benefit | VP 5000 |
|---|---|
Emergency Room Services | In-network: $200 / visit, then 30% coinsurance Benefit details: You must notify Kaiser Permanente within 24 hours if admitted to a Non-network provider; limited to initial emergency only. Copayment waived if admitted directly to the hospital as an inpatient. Benefit details: Summary (Inside Network): $200 copay at a designated facility $200 copay at a non designated facility Deductible and coinsurance apply Out-of-network: $200 / visit, then 30% coinsurance |
Emergency Transportation/Ambulance | In-network: 20% coinsurance, deductible does not apply. Benefit details: Summary (Inside Network): Plan pays 80%, you pay 20% Out-of-network: 20% coinsurance, deductible does not apply. |
Urgent Care Centers or Facilities | In-network: $40 / visit for primary care or $80 / visit for Specialty care, deductible does not apply. Benefit details: Non-network providers covered when temporarily outside the service area. Out-of-network: $200 / visit, then 30% coinsurance |
| Benefit | VP 5000 |
|---|---|
Mental health and substance use outpatient services (SBC) | In-network: Telehealth: No charge, deductible does not apply; In-person with authorization: $40 / visit, deductible does not apply; In-person without authorization: 30% coinsurance Out-of-network: Not covered |
Mental health and substance use inpatient services (SBC) | In-network: 30% coinsurance Benefit details: Preauthorization required Out-of-network: Not covered |
Substance Abuse Disorder Inpatient Services | Inside Network: Deductible and coinsurance apply |
Substance Abuse Disorder Outpatient Services | Inside Network: $40 copay |
Mental/Behavioral Health Inpatient Services | Inside Network: Deductible and coinsurance apply |
Mental/Behavioral Health Outpatient Services | Inside Network: $40 copay |
| Benefit | VP 5000 |
|---|---|
Prenatal and Postnatal Care | In-network: 30% coinsurance Benefit details: Cost sharing does not apply for preventive services. Maternity care may include tests and services described elsewhere in the SBC (i.e. ultrasound). Out-of-network: Not covered |
Delivery and All Inpatient Services for Maternity Care (Professional) | In-network: 30% coinsurance Benefit details: You must notify Kaiser Permanente within 24 hours of admission, or as soon thereafter as medically possible. Newborn services cost shares are separate from that of the mother. Out-of-network: Not covered |
Delivery and All Inpatient Services for Maternity Care | In-network: 30% coinsurance Benefit details: You must notify Kaiser Permanente within 24 hours of admission, or as soon thereafter as medically possible. Newborn services cost shares are separate from that of the mother. Out-of-network: Not covered |
Maternity services | Inside Network: Inpatient: Deductible and coinsurance apply Outpatient: $40 copay. Routine care not subject to outpatient services copay. |
Newborn Services | Inside Network: Initial hospital stay: See Hospital Services; Office visits: See Outpatient Services; Routine well care: See Preventive care. Any applicable cost share for newborn services is separate from that of the mother. |
| Benefit | VP 5000 |
|---|---|
Home Health Care Services | In-network: No charge, deductible does not apply. Benefit details: Preauthorization required Benefit details: Summary (Inside Network): Covered in full. No visit limit. Out-of-network: Not covered |
Rehabilitation Services | In-network: Outpatient: Telehealth: No charge, deductible does not apply; In-person with authorization: $80 / visit, deductible does not apply; In- person without authorization: 30% coinsurance Inpatient: 30% coinsurance Benefit details: Combined with Habilitation services: Outpatient: 45 visit limit / year. Inpatient: 30- day limit / year, preauthorization required. Benefit details: Summary (Inside Network): Inpatient: 30 days per calendar year. Services with mental health diagnoses are covered with no limit. Deductible and coinsurance apply Outpatient: 45 visits per calendar year. Services with mental health diagnoses are covered with no limit. $40 copay primary/$80 copay specialty Out-of-network: Not covered |
Habilitation Services | In-network: Outpatient: Telehealth: No charge, deductible does not apply; In-person with authorization: $80 / visit, deductible does not apply; In- person without authorization: 30% coinsurance Inpatient: 30% coinsurance Benefit details: Combined with Rehabilitation services: Outpatient: 45 visit limit / year. Inpatient: 30- day limit / year, preauthorization required. Out-of-network: Not covered |
Skilled Nursing Facility | In-network: 30% coinsurance Benefit details: 60-day limit / year. Preauthorization required Benefit details: Summary (Inside Network): Up to 60 days per calendar year, deductible and coinsurance apply Out-of-network: Not covered |
Durable Medical Equipment | In-network: 20% coinsurance, deductible does not apply. Benefit details: Subject to formulary guidelines. Preauthorization required Benefit details: Summary (Inside Network): Covered at 80% Out-of-network: Not covered |
Hospice Services | In-network: No charge, deductible does not apply. Benefit details: Preauthorization required Benefit details: Summary (Inside Network): Covered in full Out-of-network: Not covered |
Massage Therapy | Inside Network: See Rehabilitation services Benefit details: Referenced summary Rehabilitation services: Inpatient: 30 days per calendar year. Services with mental health diagnoses are covered with no limit. Deductible and coinsurance apply Outpatient: 45 visits per calendar year. Services with mental health diagnoses are covered with no limit. $40 copay primary/$80 copay specialty |
| Benefit | VP 5000 |
|---|---|
Routine Eye Exam for Children | In-network: $40 / visit for refractive exam, deductible does not apply. Benefit details: Limited to 1 exam / 12 months Out-of-network: Not covered |
Eye Glasses for Children | In-network: Not covered Out-of-network: Not covered |
Dental Check-Up for Children | In-network: Not covered Out-of-network: Not covered |
Routine vision care (1 visit every 12 months) | Inside Network: $40 copay, deductible and coinsurance waived |
Optical hardware Lenses, including contact lenses and frames | Inside Network: Not covered |
| Benefit | VP 5000 |
|---|---|
Specialist referrals | Source answer: Yes, but you may self-refer to certain specialists. Benefit details: This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. |
Provider network terms | Source answer: Yes. See www.kp.org or call 1-888- 901-4636 (TTY: 711) for a list of network providers. Benefit details: This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. |
International coverage | Benefit details: Non-emergency care when traveling outside the U.S. Listed under services the plan generally does not cover; see the EOC for emergency and other travel terms. |
Plan network family (summary) | Virtual Plus Benefit details: Health Plan label from the exact January 2027 summary. EOC booklets are marked tbd; confirm the detailed provider network and current participation. |
| Benefit | VP 5000 |
|---|---|
Pre-existing condition (PEC) waiting period | Inside Network: No PEC |
Lifetime maximum | Inside Network: Unlimited |
Plan exclusions | Benefit details: • Bariatric surgery • Children’s glasses • Cosmetic surgery • Dental care (Adult and child) • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Private-duty nursing • Routine foot care • Weight loss programs |
Other covered services | Benefit details: Limitations may apply; this is not a complete list. See the plan document. • Acupuncture (12 visit limit / year) • Chiropractic care (10 visit limit / year) • Hearing aids (1 aid / ear / 36 months) • Routine eye care (Adult) |
| Benefit | VP 5000 |
|---|---|
Having a baby example | Deductibles: $5,000 Copayments: $10 Coinsurance: $2,000 Limits or exclusions: $20 Benefit details: Standardized self-only illustration, not a cost estimator. Actual care and costs differ. |
Managing diabetes example | Deductibles: $40 Copayments: $900 Coinsurance: $0 Limits or exclusions: $0 Benefit details: Standardized self-only illustration, not a cost estimator. Actual care and costs differ. |
Simple fracture example | Deductibles: $900 Copayments: $10 Coinsurance: $200 Limits or exclusions: $0 Benefit details: Standardized self-only illustration, not a cost estimator. Actual care and costs differ. |
| Benefit | VP 5000 |
|---|---|
Sterilization (vasectomy, tubal ligation) | Inside Network: Covered in full |
Acupuncture | Inside Network: Covered up to 12 visits per calendar year $40 copay Deductible and coinsurance do not apply |
Routine Hearing Exam (Adult) | Inside Network: $40 copay |
Hearing Aids | Inside Network: 1 aid per ear every 36 months; Covered at 80% |
Infertility Treatment | Inside Network: Not covered |
Chiropractic Care | Inside Network: Covered up to 10 visits per calendar year without prior authorization $40 copay Deductible and coinsurance do not apply |
Naturopathy | Inside Network: Covered up to 3 visits per medical diagnosis per calendar year without prior authorization; additional visits when approved by the plan $40 copay Deductible and coinsurance do not apply |
Bariatric Surgery | Inside Network: Not covered |
Temporomandibular joint (TMJ) treatment | Inside Network: Inpatient: Deductible and coinsurance apply Outpatient: $40 copay Deductible and coinsurance do not apply |
Tobacco Cessation Counseling | Inside Network: Quit for Life Program - covered in full |
Routine Foot CareNotes & sourceListed in the source exclusion summary. Check its exceptions and the issued contract for the exact terms. | Source statement: Routine Foot Care is listed in the source exclusions; review the qualifications. Source exclusion context: • Bariatric surgery • Children’s glasses • Cosmetic surgery • Dental care (Adult and child) • Infertility treatment • Long-term care • Non-emergency care when traveling outside the U.S. • Private-duty nursing • Routine foot care • Weight loss programs |
| Benefit | VP 5000 |
|---|---|
Virtual care (summary) | Inside Network: Covered in full |
Telemedicine with Traditional Providers | Inside Network: Covered in full Benefit details: Virtual Care Including Telemedicine, Telephone Services and Online (E-Visits). Exact 2027 summary wording; EOC booklets are marked tbd. Confirm the issued contract and deductible conditions. |
Virtual General Medical | Inside Network: Covered in full Benefit details: Virtual Care Including Telemedicine, Telephone Services and Online (E-Visits). Exact 2027 summary wording; EOC booklets are marked tbd. Confirm the issued contract and deductible conditions. |
Virtual Mental Health | In-network: Telehealth: No charge, deductible does not apply; In-person with authorization: $40 / visit, deductible does not apply; In-person without authorization: 30% coinsurance Out-of-network: Not covered |
Virtual Chemical Dependency | In-network: Telehealth: No charge, deductible does not apply; In-person with authorization: $40 / visit, deductible does not apply; In-person without authorization: 30% coinsurance Out-of-network: Not covered |
| Benefit | VP 5000 |
|---|---|
IHT source ID | iht-2027-kaiser-vp-5000 |
Plan name | VP 5000 |
Legal issuer | Kaiser Foundation Health Plan of Washington |
Plan type | HMO |
Effective date | 2027-01-01 |
Expiration date | 2027-12-31 |
BHT metal classificationNotes & sourceBHT plan-design similarity classification, not a carrier metal designation or actuarial-value calculation. Unknown is retained when reference evidence is insufficient or disagrees. | BHT classification: N/A (similar to Silver) |
| Benefit | VP 5000 |
|---|---|
HSA in source plan nameNotes & sourceWhether the IHT source plan name contains HSA, including PHSA or HHSA. | No |
HSA-compatible planNotes & sourceBHT IHT name rule: HSA anywhere (including PHSA/HHSA) means Yes; otherwise No. Personal contribution eligibility is separate. | No |
| Benefit | VP 5000 |
|---|---|
Are there services covered before you meet your deductible? | Source answer: Yes. Preventive care and services indicated in chart starting on page 2. Benefit details: This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at www.healthcare.gov/coverage/preventive-care-benefits. |
Individual deductible carryover | Inside Network: 4th quarter carryover does not apply |
Plan coinsurance | Inside Network: Plan pays 70%, you pay 30% |
Deductible and/or coinsurance waiver riders | Inside Network: All services delivered via telehealth and 1st non-preventative primary care office visit are covered in full. Deductible and coinsurance do not apply to authorized outpatient visits in the clinic but do apply to all non-authorized outpatient services, including all surgical services. All other services covered at applicable cost shares. |
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2027 · IHT plan ID iht-2027-kaiser-vp-5000
January 2027 IHT plan. EOC booklets and the side-by-side comparison are marked tbd. Confirm the employer agreement, trust, detailed network and renewal; no IHT rates are supplied.
January 2027 IHT plan. EOC booklets and the side-by-side comparison are marked tbd. Confirm the employer agreement, trust, detailed network and renewal; no IHT rates are supplied. Issuer discrepancy: summary footer says Options, Inc.; the exact SBC says Kaiser Foundation Health Plan of Washington. Catalog issuer follows the SBC.
January 2027 IHT plan. EOC booklets and the side-by-side comparison are marked tbd. Confirm the employer agreement, trust, detailed network and renewal; no IHT rates are supplied. General large-group renewal changes; the notice does not establish all terms of this exact IHT design. Confirm the issued agreement.
January 2027 IHT plan. EOC booklets and the side-by-side comparison are marked tbd. Confirm the employer agreement, trust, detailed network and renewal; no IHT rates are supplied. Publisher creditable-coverage notice only; confirm the applicable notice with the administrator.