KP Gold Access PPO 2000 LX

Kaiser Foundation Health Plan of Washington Options, Inc

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Annual in-network deductible: $2,000
Metal level: Gold
Plan type: PPO
HSA-compatible plan: No (most common)

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Plan benefits

All supported filed details, including known conditions and limits. This is not the entire insurance contract. Unknown does not mean $0 or not covered.

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127 benefit rows

Access PPO includes Kaiser Permanente, regional and national contracted providers; nonparticipating care generally costs more and may involve balance billing. Some office-visit and pharmacy benefits cost less through Kaiser’s preferred providers. Referral rules differ across the documents, so confirm them with Kaiser.

Notes & source

Kaiser · Access PPO · Issuer 25768. Confirm current provider participation and exact coverage in the plan documents.

Annual deductibles: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Medical and prescription drug deductible Notes & source 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 individual: $2,000 In-network tier 1 family: $2,000 per person \| $4,000 per group In-network tier 1 coinsurance: 25.00% Out-of-network individual: $4,000 Out-of-network family: $4,000 per person \| $8,000 per group Combined in/out-of-network individual: Not Applicable Combined in/out-of-network family: per person not applicable \| per group not applicable

Annual out-of-pocket limits: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Maximum Out of Pocket for Medical and Drug Benefits (Total) Notes & source 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 individual: $7,500 In-network tier 1 family: $7,500 per person \| $15,000 per group Out-of-network individual: Not Applicable Out-of-network family: per person not applicable \| per group not applicable Combined in/out-of-network individual: Not Applicable Combined in/out-of-network family: per person not applicable \| per group not applicable

How costs are shared: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Combined medical and drug deductible Notes & source Whether covered medical and prescription costs count toward the same deductible. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Yes
Combined medical and drug spending limit Notes & source Whether covered medical and prescription costs count toward the same out-of-pocket limit. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Yes
Specialty drug coinsurance cap Notes & source A filed cap on the member’s percentage-based specialty drug cost, if supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Not supplied in selected filing
Hospital copay day limit Notes & source The maximum number of hospital days charged a daily copay under the filed rule. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Unknown
Primary care visits before cost sharing Notes & source The filed number of primary care visits before member charges begin. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Not supplied in selected filing
Primary care copays before other charges Notes & source The filed number of copay visits before a deductible or coinsurance rule begins. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Unknown

Office and routine care: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Primary Care Visit to Treat an Injury or Illness Notes & source A visit with a primary care clinician for an illness or injury. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Any differences in telehealth cost sharing from in-person services, applicable limitations, virtual provider referral requirements, or other virtual care (telehealth)-specific benefit characteristics can be found in the certificate and schedule of benefits. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Specialist Visit Notes & source A visit with a clinician who focuses on a particular condition or area of medicine. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $55.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Other Practitioner Office Visit (Nurse, Physician Assistant) Notes & source An office visit with a nurse practitioner, physician assistant, or another listed clinician. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Any differences in telehealth cost sharing from in-person services, applicable limitations, virtual provider referral requirements, or other virtual care (telehealth)-specific benefit characteristics can be found in the certificate and schedule of benefits. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Preventive Care/Screening/Immunization Notes & source Services intended to prevent illness or detect health problems early. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: No Charge In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Well Baby Visits and Care Notes & source Routine visits to check a baby’s health and development. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: No Charge In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Human donor milk must be covered as it is covered by the state base benchmark plan. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Tests and imaging: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Imaging (CT/PET Scans, MRIs) Notes & source Advanced scans used to examine the inside of the body. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Laboratory Outpatient and Professional Services Notes & source Laboratory testing without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
X-rays and Diagnostic Imaging Notes & source X-rays and other listed images used to help diagnose a health problem. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $40.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Urgent and emergency care: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Urgent Care Centers or Facilities Notes & source Care at an urgent care center for problems that need prompt attention. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $55.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Emergency Room Services Notes & source Evaluation and treatment of a medical emergency in an emergency department. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 25.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Emergency Transportation/Ambulance Notes & source Ambulance or other listed transportation for an emergency. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 25.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Hospital and surgery: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Notes & source The charge for using an outpatient facility, separate from a clinician’s professional fee. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Outpatient Surgery Physician/Surgical Services Notes & source The surgeon’s or other clinician’s services for surgery without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Inpatient Hospital Services (e.g., Hospital Stay) Notes & source Hospital facility services after admission as an inpatient. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Inpatient Physician and Surgical Services Notes & source Clinicians’ professional services during an inpatient hospital stay. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Cosmetic Surgery Notes & source Surgery mainly intended to change appearance. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Benefit details: Covers cosmetic surgery when medically necessary. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Transplant Notes & source Medical care involving transplantation of an organ or tissue. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Reconstructive Surgery Notes & source Surgery to restore function or repair a body part affected by injury, illness, or a birth condition. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Benefit details: Coverage for reconstructive breast surgery and treatment of congenital anomalies is required and is covered under the state-base benchmark plan. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Mental health and substance use: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Mental/Behavioral Health Outpatient Services Notes & source Mental or behavioral health care without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Other outpatient services (non-office visits) have a different cost share than office visits. For more information refer to your EOC. Any differences in telehealth cost sharing from in-person services, applicable limitations, virtual provider referral requirements, or other virtual care (telehealth)-specific benefit characteristics can be found in the certificate and schedule of benefits. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Mental/Behavioral Health Inpatient Services Notes & source Mental or behavioral health treatment during an inpatient stay. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Substance Abuse Disorder Outpatient Services Notes & source Treatment for substance use disorders without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Other outpatient services (non-office visits) have a different cost share than office visits. For more information refer to your EOC. Any differences in telehealth cost sharing from in-person services, applicable limitations, virtual provider referral requirements, or other virtual care (telehealth)-specific benefit characteristics can be found in the certificate and schedule of benefits. Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-05-13): Substance Use Disorder Outpatient Services: Office visits: Member pays $30 Copayment for primary care provider and specialty care provider office visits The crosswalk explains that office visits and other outpatient services have different cost sharing. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Substance Abuse Disorder Inpatient Services Notes & source Treatment for substance use disorders during an inpatient stay. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Prescription drugs: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Generic Drugs Notes & source Medicines classified by the plan as generic drugs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $20.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Month Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. For prescription contraceptive drugs coverage includes a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. For HIOS ID 25768WA1230001 (KP Silver Access PPO 3500 LX), both WAF014 and WAF015 apply. For HIOS ID 25768WA1230005 (KP Silver Access PPO 2500 LX), both WAF012 and WAF013 apply. For HIOS ID 25768WA1230002 (KP Gold Access PPO 600 LX), both WAF018 and WAF019 apply. For HIOS ID 25768WA1230004 (KP Gold Access PPO 1500 LX), both WAF020 and WAF021 apply. For HIOS ID 25768WA1230003 (KP Platinum Access PPO 350 LX), both WAF026 and WAF027 apply. For HIOS ID 25768WA1230006 (KP Platinum Access PPO 500 LX), both WAF024 and WAF025 apply. For HIOS ID 25768WA1230007 (KP Silver Access PPO 5000), both WAF010 and WAF011 apply. For HIOS ID 25768WA1230015 (KP Bronze Access PPO 8000), both WAF006 and WAF007 apply. For HIOS ID 25768WA1230016 (KP Gold Access PPO 2000 LX), both WAF022 and WAF023 apply. Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-05-13): Enhanced Benefit: Preferred generic drugs (Tier 1): Member pays $10 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): Member pays $25 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Deductible, Member pays 30% coinsurance up to a 90-day supply Specialty drugs (Tier 4): After Deductible, Member pays 40% coinsurance up to a 30- day supply Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Preferred Brand Drugs Notes & source Brand-name medicines placed in the plan’s preferred drug category. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $50.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Month Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. For prescription contraceptive drugs coverage includes a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. For HIOS ID 25768WA1230001 (KP Silver Access PPO 3500 LX), both WAF014 and WAF015 apply. For HIOS ID 25768WA1230005 (KP Silver Access PPO 2500 LX), both WAF012 and WAF013 apply. For HIOS ID 25768WA1230002 (KP Gold Access PPO 600 LX), both WAF018 and WAF019 apply. For HIOS ID 25768WA1230004 (KP Gold Access PPO 1500 LX), both WAF020 and WAF021 apply. For HIOS ID 25768WA1230003 (KP Platinum Access PPO 350 LX), both WAF026 and WAF027 apply. For HIOS ID 25768WA1230006 (KP Platinum Access PPO 500 LX), both WAF024 and WAF025 apply. For HIOS ID 25768WA1230007 (KP Silver Access PPO 5000), both WAF010 and WAF011 apply. For HIOS ID 25768WA1230015 (KP Bronze Access PPO 8000), both WAF006 and WAF007 apply. For HIOS ID 25768WA1230016 (KP Gold Access PPO 2000 LX), both WAF022 and WAF023 apply. Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-05-13): Enhanced Benefit: Preferred generic drugs (Tier 1): Member pays $10 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): Member pays $25 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Deductible, Member pays 30% coinsurance up to a 90-day supply Specialty drugs (Tier 4): After Deductible, Member pays 40% coinsurance up to a 30- day supply Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Non-Preferred Brand Drugs Notes & source Brand-name medicines outside the plan’s preferred drug category. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 40.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Month Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. For prescription contraceptive drugs coverage includes a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. For HIOS ID 25768WA1230001 (KP Silver Access PPO 3500 LX), both WAF014 and WAF015 apply. For HIOS ID 25768WA1230005 (KP Silver Access PPO 2500 LX), both WAF012 and WAF013 apply. For HIOS ID 25768WA1230002 (KP Gold Access PPO 600 LX), both WAF018 and WAF019 apply. For HIOS ID 25768WA1230004 (KP Gold Access PPO 1500 LX), both WAF020 and WAF021 apply. For HIOS ID 25768WA1230003 (KP Platinum Access PPO 350 LX), both WAF026 and WAF027 apply. For HIOS ID 25768WA1230006 (KP Platinum Access PPO 500 LX), both WAF024 and WAF025 apply. For HIOS ID 25768WA1230007 (KP Silver Access PPO 5000), both WAF010 and WAF011 apply. For HIOS ID 25768WA1230015 (KP Bronze Access PPO 8000), both WAF006 and WAF007 apply. For HIOS ID 25768WA1230016 (KP Gold Access PPO 2000 LX), both WAF022 and WAF023 apply. Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-05-13): Enhanced Benefit: Preferred generic drugs (Tier 1): Member pays $10 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): Member pays $25 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Deductible, Member pays 30% coinsurance up to a 90-day supply Specialty drugs (Tier 4): After Deductible, Member pays 40% coinsurance up to a 30- day supply Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Specialty Drugs Notes & source Medicines placed in the plan’s specialty category, often requiring special handling or monitoring. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 40.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Month Benefit details: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill. For HIOS ID 25768WA1230001 (KP Silver Access PPO 3500 LX), both WAF014 and WAF015 apply. For HIOS ID 25768WA1230005 (KP Silver Access PPO 2500 LX), both WAF012 and WAF013 apply. For HIOS ID 25768WA1230002 (KP Gold Access PPO 600 LX), both WAF018 and WAF019 apply. For HIOS ID 25768WA1230004 (KP Gold Access PPO 1500 LX), both WAF020 and WAF021 apply. For HIOS ID 25768WA1230003 (KP Platinum Access PPO 350 LX), both WAF026 and WAF027 apply. For HIOS ID 25768WA1230006 (KP Platinum Access PPO 500 LX), both WAF024 and WAF025 apply. For HIOS ID 25768WA1230007 (KP Silver Access PPO 5000), both WAF010 and WAF011 apply. For HIOS ID 25768WA1230015 (KP Bronze Access PPO 8000), both WAF006 and WAF007 apply. For HIOS ID 25768WA1230016 (KP Gold Access PPO 2000 LX), both WAF022 and WAF023 apply. Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-05-13): Enhanced Benefit: Preferred generic drugs (Tier 1): Member pays $10 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): Member pays $25 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Deductible, Member pays 30% coinsurance up to a 90-day supply Specialty drugs (Tier 4): After Deductible, Member pays 40% coinsurance up to a 30- day supply Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Supply limits and coverage conditions Notes & source Retail, mail-order and specialty prescription terms, with the source drug tiers and exceptions retained. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Generic Drugs; Preferred Brand Drugs; Non-Preferred Brand Drugs · Benefit details: Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. For prescription contraceptive drugs coverage includes a twelve-month refill of contraceptive drugs obtained at one time by the enrollee, unless the enrollee requests a smaller supply or the prescribing provider instructs that the enrollee must receive a smaller supply. For HIOS ID 25768WA1230001 (KP Silver Access PPO 3500 LX), both WAF014 and WAF015 apply. For HIOS ID 25768WA1230005 (KP Silver Access PPO 2500 LX), both WAF012 and WAF013 apply. For HIOS ID 25768WA1230002 (KP Gold Access PPO 600 LX), both WAF018 and WAF019 apply. For HIOS ID 25768WA1230004 (KP Gold Access PPO 1500 LX), both WAF020 and WAF021 apply. For HIOS ID 25768WA1230003 (KP Platinum Access PPO 350 LX), both WAF026 and WAF027 apply. For HIOS ID 25768WA1230006 (KP Platinum Access PPO 500 LX), both WAF024 and WAF025 apply. For HIOS ID 25768WA1230007 (KP Silver Access PPO 5000), both WAF010 and WAF011 apply. For HIOS ID 25768WA1230015 (KP Bronze Access PPO 8000), both WAF006 and WAF007 apply. For HIOS ID 25768WA1230016 (KP Gold Access PPO 2000 LX), both WAF022 and WAF023 apply. Generic Drugs; Preferred Brand Drugs; Non-Preferred Brand Drugs; Specialty Drugs · Benefit details: Supporting benefit crosswalk (SERFF submitted 2026-05-13): Enhanced Benefit: Preferred generic drugs (Tier 1): Member pays $10 Copayment per 30-days up to a 90-day supply Preferred brand name drugs (Tier 2): Member pays $25 Copayment per 30- days up to a 90-day supply Non-Preferred generic and brand name drugs (Tier 3): After Deductible, Member pays 30% coinsurance up to a 90-day supply Specialty drugs (Tier 4): After Deductible, Member pays 40% coinsurance up to a 30- day supply Specialty Drugs · Benefit details: First fill allowed at a retail pharmacy. Additional fills must be provided at a specialty pharmacy. Coverage is limited to a 30-day supply for specialty and self-administrable cancer chemotherapy medications from a specialty pharmacy per fill or refill. For HIOS ID 25768WA1230001 (KP Silver Access PPO 3500 LX), both WAF014 and WAF015 apply. For HIOS ID 25768WA1230005 (KP Silver Access PPO 2500 LX), both WAF012 and WAF013 apply. For HIOS ID 25768WA1230002 (KP Gold Access PPO 600 LX), both WAF018 and WAF019 apply. For HIOS ID 25768WA1230004 (KP Gold Access PPO 1500 LX), both WAF020 and WAF021 apply. For HIOS ID 25768WA1230003 (KP Platinum Access PPO 350 LX), both WAF026 and WAF027 apply. For HIOS ID 25768WA1230006 (KP Platinum Access PPO 500 LX), both WAF024 and WAF025 apply. For HIOS ID 25768WA1230007 (KP Silver Access PPO 5000), both WAF010 and WAF011 apply. For HIOS ID 25768WA1230015 (KP Bronze Access PPO 8000), both WAF006 and WAF007 apply. For HIOS ID 25768WA1230016 (KP Gold Access PPO 2000 LX), both WAF022 and WAF023 apply.
Formulary tier 1 Notes & source Filed formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Drug category: Zero Cost Share Preventive Drugs Three-month in-network mail order: Yes
Formulary tier 2 Notes & source Filed formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Drug category: Preferred Generic Three-month in-network mail order: Yes
Formulary tier 3 Notes & source Filed formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Drug category: Preferred Brand Three-month in-network mail order: Yes
Formulary tier 4 Notes & source Filed formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Drug category: Non-Preferred Generic, Non-Preferred Brand Three-month in-network mail order: Yes
Formulary tier 5 Notes & source Filed formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Drug category: Generic, Brand Three-month in-network mail order: Yes
Formulary tier 6 Notes & source Filed formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Drug category: Specialty Drugs Three-month in-network mail order: No
Formulary tier 7 Notes & source Filed formulary tier. Mail-order availability refers to three-month in-network supply; coverage, supply limits and medication requirements still apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Drug category: Medical Service Drugs Three-month in-network mail order: No

Pregnancy and childbirth: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Prenatal and Postnatal Care Notes & source Care during pregnancy and after childbirth. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: No Charge In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Delivery and All Inpatient Services for Maternity Care Notes & source Care for childbirth and related inpatient services. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Abortion for Which Public Funding is Prohibited Notes & source The filing’s category for abortion services that cannot receive public funding. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: No Charge In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Coverage includes termination of pregnancy for all female members. Out-of-network copay: No Charge Out-of-network coinsurance: Not Applicable Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Therapy and recovery: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Hospice Services Notes & source Care focused on comfort and support near the end of life. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: No Charge In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 14 Limit unit: Days per Lifetime Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Home Health Care Services Notes & source Medical care delivered at home under a care plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 130 Limit unit: Visit(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Skilled Nursing Facility Notes & source Care in a facility providing skilled nursing or rehabilitation. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Service limit: Yes Limit amount: 60 Limit unit: Days per Year Benefit details: Coverage is limited to 60-inpatient days/year. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Outpatient Rehabilitation Services Notes & source Therapy to help restore abilities after illness or injury without inpatient admission. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $55.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 25 Limit unit: Visit(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Habilitation Services Notes & source Therapy to help develop or maintain skills needed for daily activities. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $55.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Year Benefit details: Coverage for habilitative services is limited to 30-inpatient days/year. Coverage for habilitative services is limited to 25-outpatient visits/year. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Rehabilitative Speech Therapy Notes & source Therapy to restore speech, communication, or swallowing abilities. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $55.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Year Benefit details: Coverage is limited to 30-inpatient days/year and 25- outpatient visits/year. Rehabilitative Speech Therapy and Rehabilitative Occupational and Rehabilitative Physical Therapy combine for 25 visits for Rehabilitative Services. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Rehabilitative Occupational and Rehabilitative Physical Therapy Notes & source Therapy to restore movement or the ability to carry out everyday tasks. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $55.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 30 Limit unit: Days per Year Benefit details: Coverage is limited to 30-inpatient days/year and 25- outpatient visits/year. Rehabilitative Speech Therapy and Rehabilitative Occupational and Rehabilitative Physical Therapy combine for 25 visits for Rehabilitative Services. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Infusion Therapy Notes & source Treatment that delivers medicine or fluids through a needle or catheter. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Covered under applicable benefit (such as office visit). Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Durable Medical Equipment Notes & source Medical equipment for repeated use, such as a wheelchair or home oxygen equipment. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Other services: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Infertility Treatment Notes & source Medical services to evaluate or treat difficulty becoming pregnant. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Chiropractic Care Notes & source Care provided by a chiropractor, including listed spinal or joint treatments. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 10 Limit unit: Visit(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Hearing Aids Notes & source Devices that help improve hearing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Item(s) per 3 Years Benefit details: Coverage is limited to an annual hearing exam and one hearing aid per ear every 3 years. Cochlear Implants for children are also covered. Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Routine Foot Care Notes & source Regular foot care, such as listed nail or callus services. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $55.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Acupuncture Notes & source Treatment using thin needles placed at specific points on the body. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Dialysis Notes & source Treatment that filters the blood when the kidneys cannot do so adequately. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Chemotherapy Notes & source Drug treatment used for cancer and certain other conditions. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $55.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Covered under the base benchmark plan. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Radiation Notes & source Treatment using targeted radiation, commonly for cancer. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $55.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Covered under the base benchmark plan; covered under applicable benefit (such as office visit). Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Diabetes Education Notes & source Instruction to help a person manage diabetes. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Prosthetic Devices Notes & source Devices that replace a missing body part. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Temporomandibular joint (TMJ) treatment Notes & source Treatment for problems affecting the jaw joint and nearby muscles. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Nutritional Counseling Notes & source Professional guidance on food choices and nutrition. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 100.00% Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Gender Affirming Care Notes & source Health services that support a person’s gender identity. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Benefit details: Gender Affirming Care includes health care services prescribed to treat any condition related to the individual's gender identity and may include primary care visits, specialty care, outpatient mental health services, prescription drug benefits, and surgical services. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Other Law/Regulation Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Diabetes Care Management Notes & source Coordinated support for managing diabetes and its treatment. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Inherited Metabolic Disorder - PKU Notes & source Care for phenylketonuria, an inherited condition affecting how the body processes part of dietary protein. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Hearing exams Notes & source Assessments of hearing; consult the filed benefit for limits and member costs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Benefit details: Coverage is limited to an initial assessment and one annual hearing exam. Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Bariatric Surgery Notes & source Listed in the source exclusion summary. Check its exceptions and the issued contract for the exact terms. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Source statement: Bariatric Surgery is listed in the source exclusions; review the qualifications. Source exclusion context: 2027 SBC exclusions (not exhaustive): bariatric surgery; cosmetic surgery; adult and child dental care; infertility treatment (except artificial insemination); long-term care; non-emergency care when traveling outside the U.S.; private-duty nursing; routine foot care; weight loss programs. Check the coverage agreement for the complete exclusions and limitations.

Dental and vision: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Routine Eye Exam (Adult) Notes & source A regular adult vision exam, separate from treatment for an eye disease or injury. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: $30.00 In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Visit(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Not an essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Routine Eye Exam for Children Notes & source Regular vision exams for children. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: No Charge In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Exam(s) per Year Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Eye Glasses for Children Notes & source Prescription eyeglasses for children. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: No Charge In-network tier 1 coinsurance: Not Applicable Coverage: Covered Service limit: Yes Limit amount: 1 Limit unit: Item(s) per Year Benefit details: Coverage is limited to one frame and one pair (two lenses)/ calendar year or contacts (in lieu of glasses). Out-of-network copay: No Charge Out-of-network coinsurance: Not Applicable Essential health benefit: Yes Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes
Dental Anesthesia Notes & source Anesthesia used during dental treatment. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	In-network tier 1 copay: Not Applicable In-network tier 1 coinsurance: 25.00% Coinsurance after deductible Coverage: Covered Out-of-network copay: Not Applicable Out-of-network coinsurance: 50.00% Coinsurance after deductible Essential benefit variation: Additional essential health benefit Excluded from in-network spending limit: No Excluded from out-of-network spending limit: Yes

Network and access: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Provider network Notes & source The insurer’s name for the network linked to this plan. Check the current provider directory to confirm a doctor or hospital participates. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Access PPO
Specialist referral Notes & source Whether the plan generally requires a referral before seeing a specialist. Check the listed exceptions. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	No
Referral details Notes & source The insurer’s explanation of when specialist referrals are needed. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Possible source conflict: the selected filing and Access PPO FAQ say no referrals for medically necessary in-network specialist care; the 2027 SBC says referrals are required, with some self-referral. Certain services still require preauthorization. Confirm with Kaiser.
Provider tiers Notes & source Whether in-network providers are grouped into tiers with different member costs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	No
National network Notes & source Whether the filing lists a national provider network; this does not confirm any particular provider participates. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	No
Care outside the country Notes & source Whether the filing lists coverage outside the country; restrictions may apply. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	No
International care details Notes & source The insurer’s explanation of coverage and restrictions outside the country. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	The 2027 benefit summary lists worldwide emergency and urgent care. This does not establish routine international coverage; applicable copays, coinsurance, deductibles and contract limits still apply.
Care outside the service area Notes & source Whether the filing lists coverage away from the plan’s normal service area. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	No
Outside-area care details Notes & source The insurer’s explanation of care covered away from the normal service area. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	The 2027 guide describes in-network care through Kaiser Permanente and Aetna PPO providers outside Washington and Idaho Kootenai/Latah counties. Nonparticipating providers use the out-of-network benefit level; balance billing may apply.

Health accounts: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
HSA-compatible plan Notes & source Whether the filing identifies the plan as HSA-compatible; your personal ability to contribute also depends on other rules. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	No
Filed employer account contribution Notes & source Whether the plan filing includes an employer HSA or HRA contribution; it does not describe your employer’s actual contribution. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	No
Filed contribution amount Notes & source The employer account contribution amount included in the filing, if supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Not supplied in selected filing
HSA in source plan name Notes & source Source name evidence only; this does not establish personal HSA eligibility. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	No

Plan features and exclusions: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Wellness program Notes & source Whether the filing lists a program intended to support healthy habits. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	No
Condition support programs Notes & source Programs listed to help members manage ongoing health conditions. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	The Access PPO FAQ describes tobacco-cessation support and care management for complex health issues, plus a 24/7 advice line. Availability and individual participation require confirmation.
Plan design Notes & source The plan design description supplied by the insurer. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Unknown
Unique plan design Notes & source Whether the insurer marked the benefit design as distinct in its filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Yes
Plan exclusions Notes & source Services or situations the insurer lists as excluded from coverage. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	2027 SBC exclusions (not exhaustive): bariatric surgery; cosmetic surgery; adult and child dental care; infertility treatment (except artificial insemination); long-term care; non-emergency care when traveling outside the U.S.; private-duty nursing; routine foot care; weight loss programs. Check the coverage agreement for the complete exclusions and limitations.
Pregnancy notice Notes & source Whether the filing indicates a pregnancy-related notice requirement. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	No
Adult dental waiting period Notes & source Whether the filing lists a wait before adult dental benefits begin. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Not supplied in selected filing
Waiting period length Notes & source How long the filed waiting period lasts, if supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Not supplied in selected filing
Child-only coverage Notes & source How the filing describes coverage offered for children without an enrolled adult. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Allows Adult and Child-Only

Standardized coverage examples: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Having a baby example Notes & source 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Example deductible: $2,000 Example copays: $200 Example coinsurance: $2,300 Example uncovered costs: $20
Managing diabetes example Notes & source 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Example deductible: $0 Example copays: $900 Example coinsurance: $0 Example uncovered costs: $0
Simple fracture example Notes & source 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Example deductible: $2,000 Example copays: $300 Example coinsurance: $0 Example uncovered costs: $0

Filing assumptions: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Calculated actuarial value Notes & source An estimate of the share of covered costs the plan pays for a standard population, not your expected spending. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Unknown
Insurer actuarial value Notes & source The insurer’s estimate of the plan’s share of covered costs for a standard population. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	78.49%
Tier 1 filing assumption Notes & source The use of tier 1 providers assumed in the filing, not a prediction of your care. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	100%
Tier 2 filing assumption Notes & source The use of tier 2 providers assumed in the filing, not a prediction of your care. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Unknown
Essential benefit premium share Notes & source The filed portion of the premium allocated to essential health benefits. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Not supplied in selected filing
Children’s dental allocation Notes & source The filed allocation for children’s dental benefits. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Not supplied in selected filing
Composite premium available Notes & source Whether the filing offers a shared premium rate instead of separate age-based rates. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	No
Rate description Notes & source Whether the insurer labels its filed rate as guaranteed or estimated. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Not supplied in selected filing

Plan identifiers and filing context: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Plan ID Notes & source The identifier used to distinguish this plan in the filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	25768WA1230016
Plan variation ID Notes & source Identifies this plan’s specific version of benefits and cost sharing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	25768WA1230016-00
Plan variation name Notes & source The insurer’s name for this version of the plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	KP Gold Access PPO 2000 LX
Cost-sharing variation Notes & source The filed category for this version of the plan’s member costs. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Standard Gold Off Exchange Plan
Product ID Notes & source The identifier for the product family this plan belongs to. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	25768WA123
Network ID Notes & source Identifies this plan’s provider network within this insurer’s filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	WAN002
Service area ID Notes & source Identifies the area where the insurer offers this plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	WAS001
Drug list ID Notes & source Identifies the prescription drug list referenced by this plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	WAF022
Marketplace status Notes & source Whether the filing describes the plan as offered through the health insurance marketplace. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Off the Exchange
New or existing plan Notes & source Whether the insurer filed this as a new or continuing plan. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Existing
Child-only plan ID Notes & source Identifies a related child-only plan when one is supplied. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Not supplied in selected filing
Tribal cost-sharing variation Notes & source Identifies a special cost-sharing variation, if one is listed. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Not supplied in selected filing
Effective date Notes & source The start date listed for this plan in the filing. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	1/1/2027
Expiration date Notes & source The end date listed in the filing; a blank does not mean coverage continues indefinitely. 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	12/31/2027
Plan name Notes & source 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	KP Gold Access PPO 2000 LX
Legal issuer Notes & source 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Kaiser Foundation Health Plan of Washington Options, Inc
Plan type Notes & source 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	PPO

Carrier virtual care: KP Gold Access PPO 2000 LX
Benefit	KP Gold Access PPO 2000 LX
Virtual care options Notes & source 2027 public filing and reviewed supporting documents. Source qualifications are shown in each plan’s column. See Plan documents for available references.	Kaiser Permanente care includes e-visits, 24/7 online chat, and phone and video visits when appropriate and available. The linked FAQ does not specify this plan’s virtual-care cost sharing; confirm costs with Kaiser.

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Plan documents

2027 · Public plan ID 25768WA1230016 · Benefit variant 25768WA1230016-00

Summary of Benefits and Coverage (SBC)

Document notes

Original identity review: Original 2027 SBC retrieved and identity-reviewed October 28. Supplements fill only reviewed display gaps; the complete coverage agreement and current provider participation still require confirmation. SBC referral wording differs from the filed no-referral flag; see referral details. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.

Carrier document index

Document notes

Carrier source index; formats and available documents vary. Original 2027 SBC retrieved and identity-reviewed October 28. Supplements fill only reviewed display gaps; the complete coverage agreement and current provider participation still require confirmation. SBC referral wording differs from the filed no-referral flag; see referral details.

2027 Summary of Benefits (SOB)

Document notes

Original identity review: Brief 2027 benefit summary; other terms and limits apply. Use the coverage agreement and SBC for full terms. Publication copyright may predate the plan year. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.

Optional dental reference: Standard Family Dental Coverage (2027)

Document notes

Original identity review: Separate Delta Dental coverage reference. Adult coverage is optional; pediatric dental is paired separately. Dental premiums are billed separately and are not included in this medical estimate. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.

Optional dental reference: Basic Family Dental Coverage (2027)

Document notes

Access PPO network and travel reference (June 2026)

Document notes

Original identity review: Related reference from BHT’s 2027 Kaiser Washington small-group page; not the coverage contract. Confirm current terms and provider participation. Published June 2026; no 2027 cost share is inferred. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.

Access PPO FAQ (September 2026)

Document notes

Original identity review: Related reference from BHT’s 2027 Kaiser Washington small-group page; not the coverage contract. Confirm current terms and provider participation. The FAQ says no referrals for medically necessary in-network specialist care, while 2027 SBCs say referrals are required; confirm this conflict with Kaiser. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.

Compare Your Plan Options (2027)

Document notes

Original identity review: 2027 multi-plan overview, not the contract. Some overview figures differ from the selected filing and individual summaries; use the plan-specific SBC and coverage agreement for confirmation. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.

Cost Share Changes and Plan Mapping (2027)

Document notes

Original identity review: 2026-to-2027 benefit overview and suggested mapping; not a coverage contract or an automatic renewal assignment. Filed plan identity and costs remain separate. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.

Medicare Creditable Coverage — Small Group

Document notes

Original identity review: 2027 Medicare creditable-coverage reference; not a medical benefit or a personalized Medicare determination. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.

Small Group Rating Areas (2027)

Document notes

Original identity review: 2027 carrier service/rating-area reference. The calculator continues to use its filed per-plan service counties and approved statewide rating map. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.

Kaiser Washington Small Group Underwriting Guidelines (2027)

Document notes

Original identity review: 2027 carrier underwriting reference; the calculator does not determine group or individual eligibility from this document. Local copy retained; extracted text is review evidence, not a reconciled coverage contract.

Benton, Columbia, Franklin, Island, King, Kitsap, Lewis, Mason, Pierce, Skagit, Snohomish, Spokane, Thurston, Walla Walla, Whatcom, Whitman, Yakima. Availability still depends on the coverage start and employer eligibility.

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KP Gold Access PPO 2000 LX

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Plan benefits

▾Network overview

▾Annual deductibles (1)

Medical and prescription drug deductible

▾Annual out-of-pocket limits (1)

Maximum Out of Pocket for Medical and Drug Benefits (Total)

▾How costs are shared (6)

Combined medical and drug deductible

Combined medical and drug spending limit

Specialty drug coinsurance cap

Hospital copay day limit

Primary care visits before cost sharing

Primary care copays before other charges

▾Office and routine care (5)

Primary Care Visit to Treat an Injury or Illness

Specialist Visit

Other Practitioner Office Visit (Nurse, Physician Assistant)

Preventive Care/Screening/Immunization

Well Baby Visits and Care

▾Tests and imaging (3)

Imaging (CT/PET Scans, MRIs)

Laboratory Outpatient and Professional Services

X-rays and Diagnostic Imaging

▾Urgent and emergency care (3)

Urgent Care Centers or Facilities

Emergency Room Services

Emergency Transportation/Ambulance

▾Hospital and surgery (7)

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

Outpatient Surgery Physician/Surgical Services

Inpatient Hospital Services (e.g., Hospital Stay)

Inpatient Physician and Surgical Services

Cosmetic Surgery

Transplant

Reconstructive Surgery

▾Mental health and substance use (4)

Mental/Behavioral Health Outpatient Services

Mental/Behavioral Health Inpatient Services

Substance Abuse Disorder Outpatient Services

Substance Abuse Disorder Inpatient Services

▾Prescription drugs (12)

Generic Drugs

Preferred Brand Drugs

Non-Preferred Brand Drugs

Specialty Drugs

Supply limits and coverage conditions

Formulary tier 1

Formulary tier 2

Formulary tier 3

Formulary tier 4

Formulary tier 5

Formulary tier 6

Formulary tier 7

▾Pregnancy and childbirth (3)

Prenatal and Postnatal Care

Delivery and All Inpatient Services for Maternity Care

Abortion for Which Public Funding is Prohibited

▾Therapy and recovery (9)

Hospice Services

Home Health Care Services

Skilled Nursing Facility

Outpatient Rehabilitation Services

Habilitation Services

Rehabilitative Speech Therapy

Rehabilitative Occupational and Rehabilitative Physical Therapy

Infusion Therapy

Durable Medical Equipment

▾Other services (17)

Infertility Treatment

Chiropractic Care

Hearing Aids

Routine Foot Care

Acupuncture

Dialysis

Chemotherapy

Radiation

Diabetes Education

Prosthetic Devices