How copayment plans work

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1 Idividuals ad Families Plas COPAymENT PLAN How copaymet plas work Copaymet plas are the simplest to use ad to uderstad. No services are subject to a deductible. With copaymet plas, you pay set charges (or copays) for certai covered services, so you kow your out-of-pocket costs for doctor s visits, prescriptios, etc., i advace. Usig a copaymet pla Let s say you ijure your akle ad visit your primary care physicia, who orders a X-ray. It s just a sprai, so the doctor prescribes a geeric pai medicatio. O the KP 0/25/Rx pla, you would pay a separate copaymet for each of the covered services you receive. I this case, you would pay a $25 copay for the doctor s office visit, a $25 copay for the X-ray, ad either a $15 copay or 50 percet coisurace (whichever is greater) for the geeric drug. Your copays (except for prescriptios) cotribute toward your out-of-pocket maximum. No surprises. No deductible. Call Visit buykp.org/apply Cotact your aget or producer today! Orego 6

2 Idividuals ad Families Plas COPAymENT PLAN Beefit highlights features Deductible (idividual/family) platium copaymet pla Kp 0/25/rx most copays cotribute to the out-of-pocket maximum. Noe Out-of-pocket maximum (idividual/family) $5,000/$15,000 Beefits prevetive care May prevetive care services, such as routie physical exams ad mammogram screeigs, are o charge. outpatiet services (per visit or procedure) Primary care office visit $25 copay Specialty care office visit $35 copay Outpatiet surgery 1 $250 copay Lab tests ad X-rays 1 $25 copay MRI, PET, CT $100 copay Chiropractic care (up to 12 visits) $25 copay ipatiet hospital care Ipatiet care (icludig materity) $500 copay per day Maximum per admittace $2,500 materity coverage (outpatiet) Preatal care (applies to preatal office visits, oe postatal visit, ad lactatio cosultatios) No charge emergecy ad UrGet care Emergecy Departmet visit (waived if admitted) Urget care visit Ambulace service $250 copay $45 copay $250 per trip prescriptio drugs 2 (up to a 30-day supply) other Visio exams Visio hardware allowace (applies to leses, frames, ad/or cotacts every 24 moths) Detal plas $15 or 50% (whichever is greater) $25 copay $150 allowace Optioal coverage available. See the "Detal Plas" sectio. This brochure provides summaries of various plas ad is ot a cotract. Pla details are provided i the Evidece of Coverage. To obtai a Evidece of Coverage for a particular pla, cotact Membership Services. The beefits that you select may chage o Jauary 1, At that time, i order to meet the ew beefit stadards uder the Affordable Care Act, we may chage the beefits ad the rate you pay uder your pla, or ask you to select a ew pla. 1 Prevetive tests ad procedures are o charge. 2 Prescribed cotraceptives are o charge. Call Visit buykp.org/apply Cotact your aget or producer today! Orego 7

3 Idividuals ad Families Plas DEDUCTIbLE PLANS How deductible plas work Deductible plas geerally offer lower mothly premiums i exchage for your payig more out of your ow pocket for services covered by your health pla. With these plas, you pay full charge for most covered services util your expeses meet a aual deductible. The, for covered services, you pay coisurace. Deductibles Uder a deductible pla, may covered services are subject to the deductible the set amout for which you pay full charge i a caledar year. This meas you ll pay full charge for certai medical services util you reach your aual deductible. I our traditioal deductible plas, some services are available for a copay or coisurace before you meet your deductible. For example, primary care, specialty care, ad urget care visits are ot subject to the deductible. Ad to ecourage you to receive prevetive care, may of these services are available for o charge before you meet your deductible. Family deductibles I a family pla, there are two ways for erolled family members to meet their deductible: Each family member ca separately meet the idividual deductible. Out-of-pocket maximum Your out-of-pocket maximum puts a cap o how much you ll sped o most covered services each caledar year. This helps protect you fiacially if you have a serious illess or ijury. I our traditioal deductible plas, the deductible does ot apply toward the out-of-pocket maximum. You must first meet your deductible before your coisurace starts to apply toward your out-of-pocket maximum. For example, if you are a sigle subscriber o KP 500/25/ Rx, you would pay full charge for most covered services util your out-of-pocket costs reach $500. To reach your $5,000 out-of-pocket maximum, you would have to pay $5,000 i coisurace i additio to the $500 you paid toward your deductible. Coisurace ad copays that are ot subject to the deductible, such as copaymets for prevetive care services, do ot apply to your out-of-pocket maximum. The family s combied expeses ca meet the family deductible. Call Visit buykp.org/apply Cotact your aget or producer today! Orego 8

4 Idividuals ad Families Plas DEDUCTIbLE PLANS Usig a deductible pla Let s say you ijure your akle ad visit your primary care physicia, who orders a X-ray. It s just a sprai, so the doctor prescribes a geeric pai medicatio. O the KP 500/25/Rx pla, you have to pay $500 out of pocket before you are eligible to pay a copaymet or coisurace for most covered services. I this example, eve if you have ot met your deductible, you would oly pay a $25 copaymet for the doctor s office visit ad a $25 copay for the X-ray, because these services are ot subject to the deductible uder this pla. For the geeric drug, you would pay either a $15 copay or a 50 percet coisurace (whichever is greater). This service is also ot subject to a deductible. Visit the treatmet fee tool at kp.org/treatmetestimates to estimate the cost of your ext appoitmet or your potetial out-of-pocket medical costs for the year. The HSA differece Some of our deductible plas are HSA-qualified deductible plas, which ca be paired with a optioal health savigs accout, or HSA. HSA-qualified plas work similarly to traditioal deductible plas with just a few differeces. If you re eligible, you ca ope a HSA with a HSA-qualified pla. Moey you deposit ito your HSA is deductible from your icome o your federal icome tax form. You ca use fuds from your HSA to pay for qualified medical expeses. With a HSA-qualified deductible pla, the deductible cotributes to the out-of-pocket maximum. With traditioal deductible plas, the deductible does ot cotribute to the out-of-pocket maximum. I traditioal deductible plas with family coverage, each family member eeds to meet his or her idividual deductible ad out-of-pocket maximum. I HSA-qualified plas with family coverage, there are o idividual deductibles or out-of-pocket maximums. The family must meet family deductibles or out-ofpocket maximums. Tax savigs relate to federal icome tax oly. For more iformatio, please cosult your fiacial or tax adviser. To lear more about health savigs accouts, visit or call Call Visit buykp.org/apply Cotact your aget or producer today! Orego 9

5 Idividuals ad Families Plas DEDUCTIbLE PLANS Beefit highlights features Kp 500/25/rx Gold deductible plas Kp 1000/25/rx Deductible does ot cotribute to the out-of-pocket maximum. most coisurace cotributes to the out-of-pocket maximum. Deductible (idividual/family) $500/$1,500 $1,000/$3,000 Out-of-pocket maximum (idividual/family) $5,000/$15,000 Beefits prevetive care outpatiet services (per visit or procedure) Primary care office visit Specialty care office visit Outpatiet surgery 1 Lab tests ad X-rays 1 MRI, PET, CT Chiropractic care (up to 12 visits) ipatiet hospital care Ipatiet care (icludig materity) Maximum per admittace materity coverage (outpatiet) Services ot subject to deductible uless otherwise idicated May prevetive care services, such as routie physical exams ad mammogram screeigs, are o charge. $25 copay $35 copay $150 copay (after deductible) $25 copay 20% coisurace (after deductible) $25 copay 20% coisurace (after deductible) Noe Preatal care (applies to preatal office visits, oe postatal visit, ad lactatio cosultatios) No charge emergecy ad UrGet care Emergecy Departmet visit Urget care visit Ambulace service 20% coisurace (after deductible) $45 copay 20% coisurace (after deductible) prescriptio drugs 2 (up to a 30-day supply) other Visio exams Visio hardware allowace (applies to leses, frames, ad/or cotacts every 24 moths) Detal plas $15 or 50% (whichever is greater) $25 copay $100 allowace Optioal coverage available. See the "Detal Plas" sectio. This brochure provides summaries of various plas ad is ot a cotract. Pla details are provided i the Evidece of Coverage. To obtai a Evidece of Coverage for a particular pla, cotact Membership Services. The beefits that you select may chage o Jauary 1, At that time, i order to meet the ew beefit stadards uder the Affordable Care Act, we may chage the beefits ad the rate you pay uder your pla, or ask you to select a ew pla. 1 Prevetive procedures ad tests are o charge ad ot subject to deductible. 2 Prescribed cotraceptives are o charge. Call Visit buykp.org/apply Cotact your aget or producer today! Orego 10

6 Idividuals ad Families Plas DEDUCTIBLE PLANS Beefit highlights FEATURES SILVER DEDUCTIBLE PLANS BRONZE DEDUCTIBLE PLANS KP 1500/30/Rx KP 2500/30/Rx KP 3500/30/Rx KP 5000/35 KP 7500/35 Deductible does ot cotribute to the out-of-pocket maximum. Most coisurace cotributes to the out-of-pocket maximum. Deductible (idividual/family) $1,500/$4,500 $2,500/$7,500 $3,500/$10,500 $5,000/$15,000 $7,500/$22,500 Out-of-pocket maximum (idividual/family) $10,000/$30,000 $15,000/$45,000 BENEFITS PREVENTIVE CARE OUTPATIENT SERVICES (per visit or procedure) Services ot subject to deductible uless otherwise idicated May prevetive care services, such as routie physical exams ad mammogram screeigs, are o charge. Primary care office visit $30 copay $35 copay Specialty care office visit Outpatiet surgery 1 Lab tests ad X-rays 1 30% coisurace (after deductible) 50% coisurace (after deductible) MRI, PET, CT Chiropractic care (up to 12 visits) $30 copay $35 copay INPATIENT HOSPITAL CARE Ipatiet care (icludig materity) 30% coisurace (after deductible) 50% coisurace (after deductible) Maximum per admittace Noe Noe MATERNITY COVERAGE (outpatiet) Preatal care (applies to preatal office visits, oe postatal visit, ad lactatio cosultatios) EMERGENCY AND URGENT CARE No charge No charge Emergecy Departmet visit 30% coisurace (after deductible) 50% coisurace (after deductible) Urget care visit $50 copay $55 copay Ambulace service 30% coisurace (after deductible) 50% coisurace (after deductible) PRESCRIPTION DRUGS 2 (up to a 30-day supply) $15 or 50% (whichever is greater) Not covered OTHER Visio exams 30% coisurace 50% coisurace Visio hardware allowace (applies to leses, frames, ad/or cotacts every 24 moths) Not covered Not covered Detal plas Optioal coverage available. See the "Detal Plas" sectio. This brochure provides summaries of various plas ad is ot a cotract. Pla details are provided i the Evidece of Coverage. To obtai a Evidece of Coverage for a particular pla, cotact Membership Services. The beefits that you select may chage o Jauary 1, At that time, i order to meet the ew beefit stadards uder the Affordable Care Act, we may chage the beefits ad the rate you pay uder your pla, or ask you to select a ew pla. 1 Prevetive procedures ad tests are o charge ad ot subject to deductible. 2 Prescribed cotraceptives are o charge. Call Visit buykp.org/apply Cotact your aget or producer today! Orego 11

7 Idividuals ad Families Plas HSA-QUALIfIED DEDUCTIbLE PLANS How HSA-qualified deductible plas work A HSA-qualified pla is a deductible pla that is eligible to be paired with a optioal health savigs accout, or HSA. If you sig up for a HSA-qualified deductible pla ad ope a HSA, you ca pay for qualified medical expeses with tax-deductible dollars. 1 A HSA-qualified pla works much like a traditioal deductible pla i that you pay full charge for most services out of pocket util you meet your deductible. I our HSA-qualified plas, however, oce you meet your deductible, you ca receive most covered services for a 20 percet coisurace. You ca also save moey with HSA-qualified plas because you ca pay for qualified medical expeses eve those ot covered by your health pla with tax-deductible dollars. However, qualified expeses ot covered by your health pla will ot cotribute to your deductible or out-of-pocket maximum. All you have to do is: Sig up for a HSA-qualified health pla. If you are eligible, ope a health savigs accout. Cotribute tax-deductible dollars to this accout. 2 Advatages of opeig a HSA Portability The moey belogs to you, so if you chage health plas, you ca take your HSA with you. Rollover of uused fuds There is o use it or lose it restrictio each year. What you do t use stays i your accout util you are ready to use it. 3 Cotrol You decide whe to put the moey i ad whe to take it out. Retiremet savigs The moey i your accout ca be ivested through the istitutio where you ope it. Ad after age 65, you ca use the fuds, taxed at your ordiary icome rate, for ay reaso without pealties flexibility You ca use the moey i your HSA to pay for qualified medical expeses, eve those your deductible pla does ot cover. Use those tax-free fuds to pay for qualified health care expeses. What you do t use rolls over to the ext year ad cotiues earig iterest. 3 1 Tax refereces relate to federal icome tax oly. The tax treatmet of health savigs accout cotributios ad distributios uder state icome tax laws differs from the federal tax treatmet. Cosult with your fiacial or tax adviser for more iformatio. 2 For 2013, the federally established maximum cotributio for a eligible idividual with self-oly coverage is $3,250. The aual maximum cotributio for a eligible idividual with family coverage is $6,450. This aual maximum is idexed aually for iflatio. Tax savigs refer to federal icome tax oly. For more iformatio, please cosult your fiacial or tax adviser. 3 Earigs vary depedig o the type of ivestmet pla you opt for ad/or the HSA provider you choose. Amout eared is based o the ivestmet pla ad market value, ad i some istaces, the accout may actually lose moey. Call Visit buykp.org/apply Cotact your aget or producer today! Orego 12

8 Idividuals ad Families Plas HSA-QUALIfIED DEDUCTIbLE PLANS Usig a health savigs accout What are qualified medical expeses? You ca use a HSA to pay for copays, coisuraces, ad deductibles, ad may supplies ad services ot covered by your health pla. Geerally, these are expeses that would qualify for the medical ad detal expese deductio o your icome tax. Here are just a few examples of HSA-qualified expeses: Eyeglasses ad laser eye surgery Detal care Acupucture Chiropractic services Hearig aids For a complete list, see Publicatio 502, Medical ad Detal Expeses at Who s eligible for a HSA? To be eligible for a HSA, you eed to meet the followig requiremets: You ca t be erolled i Medicare. You ca t be eligible to be claimed as a depedet o someoe else s tax retur. You ca t have additioal health coverage that is ot a qualified deductible pla (with certai exceptios). You ca t have received beefits from the Departmet of Veteras Affairs i the past three moths. A HSA offers triple tax advatages Tax-deductible cotributios to your accout Tax-free ivestmet earigs Tax-free withdrawals whe fuds are used for qualified medical expeses Usig a HSA-qualified deductible pla Let s say you ijure your akle ad visit your primary care physicia, who orders a X-ray. It s just a sprai, so the doctor prescribes a geeric pai medicatio. With our HSA-qualified deductible plas, you pay full charge for all covered services util you meet your deductible. O KP/2000/20%/HSA/Rx, the deductible for a idividual is $2,000, so you would eed to pay $2,000 out of your ow pocket util you reach the deductible. The you would be eligible to pay a 20 percet coisurace for most covered services. The good ews is that the deductible cotributes toward the out-of-pocket maximums i our HSA-qualified plas. So the $2,000 you paid toward your deductible applies to your $5,000 out-of-pocket maximum. Ad, if you opeed a HSA, you would be able to pay for these services with tax-free dollars. (Tax savigs relate to federal icome tax oly. For more iformatio, please cosult your fiacial or tax adviser. For more iformatio o health savigs accouts, please visit You may set up your HSA through ay fiacial istitutio that offers these accouts. 1 1 Kaiser Permaete does ot provide or admiister fiacial products, icludig HSAs, ad does ot offer fiacial, tax, or ivestmet advice. Members are resposible for their ow ivestmet decisios. If a member uses his or her HSA debit card to pay for somethig other tha a qualified medical expese, the expediture is subject to tax ad, for idividuals who are ot disabled or over 65, a 20 percet tax pealty. Call Visit buykp.org/apply Cotact your aget or producer today! Orego 13

9 Idividuals ad Families Plas HSA-QUALIfIED DEDUCTIbLE PLANS Beefit highlights hsa-qualified plas Kp 2000/20%/hsa/rx Kp 3000/20%/hsa features The deductible cotributes to the out-of-pocket maximum. most copays ad coisurace cotribute to the out-of-pocket maximum. Deductible (idividual/family) $2,000/$4,000 $3,000/$6,000 Out-of-pocket maximum (idividual/family) $5,000/$10,000 Beefits Services ot subject to deductible uless otherwise idicated prevetive care May prevetive care services, such as routie physical exams ad mammogram screeigs, are o charge. outpatiet services (per visit or procedure) Primary care office visit Specialty care office visit Outpatiet surgery 1 Lab tests ad X-rays 1 MRI, PET, CT Chiropractic care (up to 12 visits) ipatiet hospital care Ipatiet care (icludig materity) Maximum per admittace materity coverage (outpatiet) Preatal care (applies to preatal office visits, oe postatal visit, ad lactatio cosultatios) 20% coisurace (after deductible) $25 copay (after deductible) 20% coisurace (after deductible) Noe No charge emergecy ad UrGet care Emergecy Departmet visit Urget care visit Ambulace service 20% coisurace (after deductible) prescriptio drugs 2 (up to a 30-day supply) $15 or 50% (whichever is greater) (after deductible) Not covered other Visio exams 20% coisurace (after deductible) Visio hardware allowace (applies to leses, frames, ad/or cotacts every 24 moths) Not covered Detal plas Optioal coverage available. See the "Detal Plas" sectio. This brochure provides summaries of various plas ad is ot a cotract. Pla details are provided i the Evidece of Coverage. To obtai a Evidece of Coverage for a particular pla, cotact Membership Services. The beefits that you select may chage o Jauary 1, At that time, i order to meet the ew beefit stadards uder the Affordable Care Act, we may chage the beefits ad the rate you pay uder your pla, or ask you to select a ew pla. 1 Prevetive procedures ad tests are o charge ad ot subject to deductible. 2 Prescribed cotraceptives are o charge. Call Visit buykp.org/apply Cotact your aget or producer today! Orego 14

10 Idividuals ad Families Plas ImPORTANT DETAILS AND NOTICES Importat details ad otices Choosig a health care provider is oe of the most importat decisios you ll ever make, so you ll wat to make sure you re well-iformed. This sectio features detailed iformatio o our Idividuals ad Families plas so you ca be cofidet you re choosig the best pla. The followig is a summary of the Kaiser Permaete Idividuals ad Families Plas geeral exclusios ad limitatios. (See your cotract for a detailed list of beefit specific exclusios ad limitatios.) medical exclusios ad limitatios The followig are ot covered or have limited coverage: Services related to ocovered services, except services otherwise covered if they are to treat complicatios which arise from the ocovered services. Services provided by ulicesed people, uless licesig is ot required by the state ad the medical coditio does ot require the services of a licesed provider. Acupucture, chiropractic services, massage therapy, ad aturopathy services are limited to whe a participatig provider makes a referral i accord with medical group criteria, or uless you have a Chiropractic Services Rider. Physical exams ad other services required to obtai or maitai employmet or to participate i employee programs; isurace or govermetal licesig; o a court order or required for parole or probatio; or while icarcerated. Services provided or arraged by crimial justice officials or istitutios for detaied or cofied idividuals is limited to services which meet the requiremets of emergecy care uder the Evidece of Coverage. Cosmetic care services that are iteded primarily to chage or maitai your appearace ad that will ot result i sigificat improvemet i physical fuctio. This exclusio does ot apply to recostructive surgery services. Custodial care services for assistace with activities of daily livig or care that ca be performed safely ad effectively by persos who, i order to provide the care, do ot require licesure or certificatio or the presece of a supervisig licesed urse. Detal services, except medically ecessary for members who have a medical coditio that a participatig provider determies would place the member at udue risk if the detal procedure were performed i a detal office. The procedure must be approved by a participatig physicia. Services are subject to Utilizatio Review by Compay usig criteria developed by Medical Group ad approved by Compay. Collectio, processig, ad storage of blood doated by doors whom the member desigates, ad procuremet ad storage of cord blood are covered oly whe medically ecessary for the immiet use at the time of collectio for a desigated recipiet. Durable medical equipmet, orthopedic shoes or appliaces, ad medical supplies, except for the followig: diabetic supplies; equipmet furished ad billed as part of covered ipatiet hospital, home health, or hospice services; certai maxillofacial prosthetic devices; breast pumps; medically ecessary prosthetics ad orthotics; ad post-mastectomy prostheses ad bras. We do ot reimburse the employer for ay services that the law requires a employer to provide. Experimetal or ivestigatioal services, uless erolled ad (cotiues) Call Visit buykp.org/apply Cotact your aget or producer today! Orego 26

11 Idividuals ad Families Plas ImPORTANT DETAILS AND NOTICES Importat details ad otices (cotiued) participatig i qualifyig cliical trials for medically ecessary services typically covered abset a cliical trial. Radial keratotomy, photorefractive keratectomy, ad refractive surgery, icludig evaluatios for the procedures. Services provided by a member of your immediate family. Geetic testig ad related services are limited to geetic couselig ad medically appropriate geetic testig for the purpose of diagostic testig to determie disease ad/or predispositio of disease ad to develop treatmet plas. Covered services are limited to precoceptio ad preatal testig for detectio of cogeital ad heritable disorders, ad testig for the predictio of high-risk occurrece or reoccurrece of disease whe medically ecessary as determied by a participatig physicia, i accordace with applicable law. However, testig for family members who are ot members is always excluded. We do ot reimburse the govermet agecy for services that the law requires be provided oly by or received from a govermet agecy. This exclusio does ot apply to Medicaid. Hearig aids, tests to determie their efficacy, ad hearig tests to determie a appropriate hearig aid are excluded for members 18 ad older uless the member is uder the limitig age. Hypotherapy ad all related services. Services for diagosis ad treatmet of ifertility, icludig reversal of volutary, surgically iduced ifertility; the cost of door seme, door eggs, ad services related to their procuremet ad storage. All services for coceptio by artificial meas icludig, but ot limited, to prescriptio drugs, door seme, ad door eggs related to these services. This exclusio icludes, but is ot limited to, artificial isemiatio, i vitro fertilizatio, ovum trasplats, ad gamete (GIFT) ad zygote (ZIFT) itrafallopia trasfers. Services that are ot medically ecessary. Noreusable medical supplies are limited to those supplied ad applied by a licesed health care provider while providig a covered service. Services that are ot health care services, supplies or items, such as: educatioal testig; teachig ad support services to icrease itelligece; ad teachig readig, eve for dyslexia. Temporomadibular joit disorders (TMJ) services. Supportive care primarily to maitai the level of correctio already achieved; care primarily for the coveiece of the member; ad care o a o-acute, symptomatic basis. Corrective leses, eyeglasses, ad cotact leses, icludig cotact leses fittig ad follow-up care, uless a Visio Hardware Optical Services Rider is attached to the Evidece of Coverage. Visio therapy, orthoptics, or eye exercises. Low-visio aids. Bariatric surgery, gastric staplig, gastric bypass, gastric bads, switch duodeal, biliopacreatic divisio, weight loss programs, ad ay other services for weight cotrol, eve if the purpose of the services is to treat other medical coditios related to, caused by, or complicated by obesity. disclosure statemet Nogroup disclosure statemet for members without medicare beefits This brochure provides summaries of various plas ad is ot a cotract. For specific pla iformatio about the plas referred to i this brochure, see the followig forms: for traditioal copaymet: EOIDTRAD0113, RORXGU0113, ROIDVHY0113, ROIDVHI0113, FSOID0113, BOIDTRAD0113; for deductible plas: EOIDDED0113, BOIDDED0113, RORXGU0113, (cotiues) Call Visit buykp.org/apply Cotact your aget or producer today! Orego 27

12 Idividuals ad Families Plas ImPORTANT DETAILS AND NOTICES Importat details ad otices (cotiued) ROIDVH10113, FSOID0113; for HSAqualified deductible plas (HDHP): EOIDHDHP0113, BOIDHDHP0113, FSOID0113, RORXHDH Pla details are provided i the Evidece of Coverage. To obtai a Evidece of Coverage for a particular pla, cotact Membership Services. otice This disclosure statemet addresses health pla coverage ad deductibles, copaymets, ad coisurace. It is iteded for your use if you are purchasig a health pla for the first time or replacig or addig to existig coverage. Please ote that this statemet is ot iteded to be part of the Evidece of Coverage ad that oly the laguage of the Evidece of Coverage issued by Kaiser Foudatio Health Pla of the Northwest (KFHPNW) is fial ad bidig. read your EvidEcE of coverage If you purchase the offered pla, read the Evidece of Coverage carefully as soo as you receive it. As a purchaser of a idividual pla, you have the opportuity to recosider your decisio ad may request a premium refud. Fill out your applicatio completely ad truthfully. If misstatemets are made or iformatio about your health is omitted from the applicatio, KFHPNW may void the Evidece of Coverage or dey your claims. If your age is misstated, the cotract may be rescided or the premium will be adjusted to reflect the correct premium for your age. are you cosiderig replacig your curret coverage? Before you replace your curret pla, you should review the Evidece of Coverage for each to determie if replacemet is i your best iterest. The ew coverage may be differet i importat respects. You should be aware of these differeces ad whether they are temporary or permaet. If you obtaied your curret pla from aother producer or a represetative of aother compay, be sure to ask that producer or represetative ay questios you may have about that pla. are you cosiderig addig to your curret coverage? Before you add ew coverage to your curret coverage, you should review both agreemets to make sure you are ot buyig uecessary coverage. If you obtaied your curret pla from aother producer or a represetative of aother compay, be sure to ask that producer or represetative ay questios you may have about that pla ad the eed for additioal coverage. If you have questios that are ot aswered by this disclosure statemet, be sure to ask your producer or isurace represetative. who to call For more iformatio about beefits, please refer to your Evidece of Coverage, Beefit Summary, visio rider, chiropractic rider, ad prescriptio drug rider (if icluded). If you have questios, you may visit our Membership Services desk at the facility earest you or call Membership Services from 8 a.m. to 6 p.m., Moday through Friday. From Portlad, call ; from all other areas, call The toll-free TTY lie for the hearig ad speech impaired, from all areas, is ; for laguage iterpretive services, from all areas, call outlie of coverage Read the Evidece of coverage carefully This outlie of coverage provides a very brief descriptio of the importat features of the pla. Please ote that this outlie is ot iteded to be a part of the Evidece of Coverage. Oly the actual Evidece of Coverage provisios are fial ad bidig. The Evidece of Coverage itself sets forth, i detail, your rights ad obligatios as well as those of KFHPNW. Kaiser Permaete Idividuals ad families Plas coverage Our plas are desiged to provide a broad rage of ipatiet ad outpatiet coverage (care) ipatiet hospital, medical, ad surgical services (care); X-ray ad laboratory; prescriptio drugs (some plas); routie physical exams; ad rehabilitatio therapies subject to ay deductible, copaymet, ad/ or coisurace provisios or other limitatios that may be set forth i the Evidece of Coverage. (cotiues) Call Visit buykp.org/apply Cotact your aget or producer today! Orego 28

13 Idividuals ad Families Plas ImPORTANT DETAILS AND NOTICES Importat details ad otices (cotiued) beefits A brief descriptio of the beefits icludig copaymets, coisurace, ad deductible; dollar amouts; ad exclusios ad limitatios is outlied i this kit. Waitig periods for pre-existig coditios This medical coverage has a sixmoth waitig period for preexistig coditios. This meas that we do ot provide covered services to applicats age 19 ad older for pre-existig coditios durig the six moths followig the effective date of coverage. A pre-existig coditio is ay medical coditio, illess, or ijury withi the six moths prior to the effective date of coverage for which medical advice was give, for which a health care provider recommeded or provided treatmet, or for which a prudet perso would have sought advice or treatmet. I certai circumstaces, we will waive or reduce this waitig period based o curret or prior creditable coverage. Emergecy beefits I a emergecy, call 911 or go to the earest emergecy facility. Emergecy care is for emergecy medical coditios. Emergecy medical coditios are coditios i which the immediate oset of acute symptoms are of sufficiet severity, icludig severe pai, that a prudet layperso possessig a average kowledge of health ad medicie would reasoably expect that failure to receive immediate medical attetio would place the health of a perso, or fetus i the case of a pregat woma, i serious jeopardy. Prescriptio drug coverage (applies oly to plas with prescriptio optio) If your pla icludes coverage for outpatiet prescriptio drugs, you must use our pharmacies to fill prescriptios writte by participatig providers or licesed detists. For most refills, try our mail-delivery pharmacy service. It s fast ad coveiet. For details, check the Medical Directory or ask at your pharmacy. What you pay Please refer to your pla s beefit descriptio for copaymet ad coisurace for covered prescriptios. If you do ot use our pharmacy or if your prescriptio is ot writte by a participatig provider or licesed detist, you will pay 100 percet of the full charge. The formulary process Our drug formulary icludes the list of drugs reviewed ad approved by the Regioal Formulary ad Therapeutics Committee. To fid out if a particular drug is icluded o the formulary, call our Formulary Applicatio Services Team (FAST) at or toll free at The Regioal Formulary ad Therapeutics Committee chooses drugs for the formulary based o a umber of factors, icludig safety ad effectiveess as determied from a review of scietific literature. For most members, formulary drugs are appropriate treatmet. However, whe a participatig provider feels that a oformulary drug is medically ecessary to meet a patiet s idividual medical eeds, the provider may request a exceptio. Criteria for exceptios iclude the followig: The oformulary drug is required by law to bear the leged Rx oly. We determie the drug meets all other coverage requiremets except that our formulary does ot list it for your coditio. A participatig or desigated physicia has determied the patiet has experieced treatmet failure with or is allergic to or itolerat of the alteratives listed i the formulary. Your coditio meets ay additioal requiremets that the Regioal Formulary ad Therapeutics Committee has approved for the drug, supply, or supplemet. If the exceptio is approved, you pay the same charge as for a formulary drug. (cotiues) Call Visit buykp.org/apply Cotact your aget or producer today! Orego 29

14 Idividuals ad Families Plas ImPORTANT DETAILS AND NOTICES Importat details ad otices (cotiued) Utilizatio review Utilizatio review is the formal method we use to moitor the use of or evaluate the medical ecessity, appropriateess, efficacy, or efficiecy of specific health care services, procedures, or settigs. Certai treatmets ad services are subject to utilizatio review based o criteria developed by Northwest Permaete, P.C., Physicias ad Surgeos (KFHPNW s medical group), ad/or other orgaizatios utilized by the medical group ad approved by KFHPNW. For more iformatio about utilizatio review or a writte explaatio of our utilizatio review criteria for a particular coditio, cotact Membership Services. Prior authorizatio Most care at participatig facilities does ot require prior authorizatio (advace approval) if it s received from a participatig provider. However, certai services do require prior or cocurret authorizatio i order to be covered. A service must also be covered by your health pla i order for you to receive the beefit. Services that require prior or cocurret authorizatio iclude, but are ot limited to: Breast reductio surgery Ipatiet hospital services Hospice ad home health care services No-emergecy medical trasportatio Ope MRI Drug formulary exceptios Plastic or recostructive surgery Referrals for oparticipatig providers services Rehabilitative therapy services Routie foot care Skilled ursig facility services Trasplats Your participatig provider will request prior or cocurret authorizatio whe ecessary. If a treatmet or service you believe you eed is ot authorized, you ll receive a writte explaatio of the reaso, your right to appeal the decisio, ad the appeal process. Keepig your records private Kaiser Permaete will protect the privacy of your protected health iformatio (PHI). We also require cotractig providers to protect your PHI. Your PHI is idividually idetifiable iformatio about your health, health care services you receive, or paymet for your health care. You may geerally see ad receive copies of your PHI, correct or update your PHI, ad ask us for a accoutig of certai disclosures of your PHI. We may use or disclose your PHI for treatmet, health research, paymet, ad health care operatios purposes, such as measurig the quality of services. We are sometimes required by law to give PHI to others, such as govermet agecies or i judicial actios. I additio, member idetifiable health iformatio is shared with your employers oly with your authorizatio or as otherwise permitted by law. We will ot use or disclose your PHI for ay other purpose without your (or your represetative s) writte authorizatio, except as described i our Notice of Privacy Practices. Givig us this authorizatio is at your discretio. This is oly a brief summary of some of our key privacy practices. Our Notice of Privacy Practices explais our privacy practices i detail. To request a copy, please call Membership Services. Our Notice of Privacy Practices is also available at kp.org. Access to your PHI To review your medical record, cotact: Health Iformatio Maagemet Regioal Process Ceter SE Suyside Road Clackamas, OR For completio of medical/isurace reports or for copies of medical records, call , 7:30 a.m. to 4:30 p.m., Moday through Friday. To obtai emergecy medical record iformatio, call , 24 hours a day. Call Visit buykp.org/apply Cotact your aget or producer today! Orego 30

15 Idividuals ad Families Plas ImPORTANT DETAILS AND NOTICES Importat details ad otices (cotiued) If you thik part of your record is icorrect, you may ask to add a statemet amedig the record. For more iformatio, cotact Membership Services. If you thik your persoal health iformatio was shared without your prior permissio, cotact Member Relatios at (from Portlad) or (from all other areas). Participatig providers ad participatig facilities compesatio Participatig providers ad participatig facilities may be paid i various ways. These iclude salary, per diem rates, case rates, fee-forservice, icetive paymets, ad capitatio paymets. Capitatio paymets are based o the total umber of members (o a per-member per-moth basis), regardless of the amout of services provided. Compay may directly or idirectly make capitatio paymets to participatig providers ad participatig facilities oly for the professioal services they deliver, ad ot for services provided by other physicias, hospitals, or facilities. To lear more about the ways participatig providers ad participatig facilities are paid to provide or arrage medical ad hospital care for Kaiser Foudatio Health Pla of the Northwest members, please call Membership Services. Our cotracts with participatig providers ad participatig facilities provide that you are ot liable for ay amouts we owe. However, you will be liable for the cost of ocovered services that you receive from a participatig provider or participatig facility, as well as uauthorized services you obtai from oparticipatig providers ad oparticipatig facilities. Detal exclusios ad limitatios Cosmetic services that are iteded primarily to improve appearace, or to repair ad/ or replace cosmetic detal restoratios. Detal implats, icludig boe augmetatio ad fixed or removable prosthetic devices attached to or coverig the implats; all related services, icludig diagostic cosultatios, impressios, oral surgery, placemet, removal, ad cleaig whe provided i cojuctio with detal implats; ad services associated with postoperative coditios ad complicatios arisig from implats. Drugs obtaiable with or without a prescriptio. If you have separate medical coverage, these may be covered uder your medical coverage. Experimetal or ivestigatioal treatmets, procedures, ad other services that are ot commoly cosidered stadard detal practice or that require U.S. Food ad Drug Admiistratio (FDA) approval. A service is experimetal or ivestigatioal if: the service is ot recogized i accordace with geerally accepted detal stadards as safe ad effective for use i treatig the coditio i questio, whether or ot the service is authorized by law for use i testig or other studies o huma patiets; or the service requires approval by FDA authority prior to use ad such approval has ot bee grated whe the service is to be redered. Fees a provider may charge for a emergecy detal care or urget detal care visit. Full mouth recostructio ad occlusal rehabilitatio, icludig appliaces, restoratios, ad procedures eeded to alter vertical dimesio, occlusio, or correct attritio or abrasio. Geetic testig. Medical or hospital services. Myofuctioal therapy. Missed appoitmet fees a provider may charge for a missed appoitmet. Prosthetic devices followig extractio of a tooth (or teeth) for ocliical reasos or whe a tooth is restorable. Replacemet of prefabricated, ocast crows, icludig ocast stailess steel crows. (cotiues) Call Visit buykp.org/apply Cotact your aget or producer today! Orego 31

16 Idividuals ad Families Plas ImPORTANT DETAILS AND NOTICES Importat details ad otices (cotiued) Sedatio ad geeral aesthesia (such as itramuscular IV sedatio, o-iv sedatio, ad ihalatio sedatio) except for itrous oxide whe admiistered by a oral surgeo, periodotist, or pediatric detist pursuat to the itrous oxide beefit. Services for coditios that are covered by workers compesatio or that are the employer s resposibility. Services provided or arraged by crimial justice istitutios for members cofied therei, uless care would be covered as emergecy detal care. Services that the law requires be provided or reimbursed at or by a govermet agecy. Speech aid prosthetic devices ad follow-up modificatios. Surgery to correct malocclusio or temporomadibular joit disorders; treatmet for problems of the jaw joit, icludig temporomadibular joit sydrome ad craiomadibular disorders; ad treatmet of coditios of the joit likig the jawboe ad skull ad of the complex of muscles, erves, ad other tissues related to that joit. Treatmet of microgathia. Treatmet of macroglossia. Treatmet to restore tooth structure lost due to attritio, erosio, or abrasio. Limitatios Repair or replacemet eeded due to ormal wear ad tear of fixed ad removable prosthetics appliaces that are less tha five years old. Works-i-progress started prior to your effective date are ot covered ad are the liability of the member or a prior detal isurace carrier. The oly exceptio is a root caal i which the pulpal debridemet has bee completed. Detal services to complete the root caal followig pulpal debridemet will be covered. Orthodotic services exclusios We do ot cover services or supplies for ay of the followig: Replacemet of broke appliaces. Re-treatmet of orthodotic cases. Chages i treatmet ecessitated by a accidet. Maxillofacial surgery. Treatmet of primary/trasitioal detitio. This brochure provides summaries of various plas ad is ot a cotract. Detal pla details are provided i the Evidece of Coverage. For specific pla iformatio about the plas referred to i this flyer, see the followig forms: EOIDDNTDED0113 Evidece of Coverage; BOIDDNTDED0113 Beefit Summary for Detal Plas; FSOIDDNT0113 Face Sheet Idividuals ad Families Detal Plas. To obtai a Evidece of Coverage for a particular pla, cotact Membership Services. membership services If you have questios or eed help, call Membership Services. We re available by telephoe 8 a.m. to 6 p.m., Moday through Friday. Portlad All other areas TTY Laguage iterpretatio services Or log oto kp.org ad Membership Services. Call Visit buykp.org/apply Cotact your aget or producer today! Orego 32

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