In-network Kaiser Permanente. In-network Kaiser Permanente

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1 2016 Features of your Added Choice Kaiser Permanente group plan In-network Kaiser Permanente Lowe s kp.org Out-of-network Kaiser Permanente Insurance Company Benefit Calendar year deductible (individual / family unit of 3 or more members) Out-of-pocket maximum (individual / family unit of 3 or more members) Annual supplemental charges maximum (individual / family unit of 3 or more members) None $100/$300 $2,000/$6,000 $2,000/$6,000 $2,000/$6,000 N/A In-network Kaiser Permanente Contracted Non-contracted Precertification is required for certain services Benefit Preventive services Well-child office visits (birth through age 5) No charge 20% of MAC 20% of MAC Routine Immunizations (birth through age 5) No charge Covered at 100% of MAC Covered at 100% of MAC Routine Immunizations (age 6 and up) No charge 20% of MAC 20% of MAC One preventive office visit per calendar year No charge 20% of MAC 20% of MAC (age 6 and older) One gynecological office visit per calendar year No charge 20% of MAC 20% of MAC (for female members) Outpatient services Office visits $20 per visit 20% of MAC 20% of MAC Routine obstetrical care No charge 20% of MAC 20% of MAC FDA-approved contraceptives drugs and devices PPACA-Mandated 20% of MAC 20% of MAC Drugs/Devices On KP Formulary - No charge All Other Drugs & Devices - 50% of applicable charges 20% of MAC 20% of MAC Inpatient services Hospital room and board 10% per day - including observation & maternity stay 20% of MAC 20% of MAC Physician s medical and surgical services Anesthesia services Administered drugs No charge 20% of MAC 20% of MAC Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. This is only a summary. This document is meant to be reviewed in conjunction with the attached, detailed benefit summary. It does not fully describe your benefit coverage. For complete details on your benefit coverage, including exclusions, limitations, and plan terms, please refer to your employer s applicable Face Sheet, Group Medical and Hospital Service Agreement, benefit schedule, and riders (collectively known as Service Agreement ), and the Kaiser Permanente Insurance Company (KPIC) Group Policy and Certificate of Insurance. The Service Agreement and KPIC Group Policy are the legal binding documents between Health Plan, KPIC, and your employer. In the event of ambiguity, or a conflict between this summary and the Service Agreement and KPIC Group Policy, the Service Agreement and KPIC Group Policy shall control. Page 1 of 29

2 In-network Kaiser Permanente Contracted Non-contracted Benefit Inpatient lab, imaging, and testing Outpatient lab, imaging, and testing See Inpatient Services Copay $10 per day OR 20% of applicable charges for: specialty lab tests, specialty imaging, specialty testing 20% of MAC 20% of MAC 20% of MAC 20% of MAC Mental health services (non-serious mental illness) Outpatient office visits $20 per visit 20% of MAC 20% of MAC Hospital inpatient care 10% per day 20% of MAC 20% of MAC Day treatment or partial hospitalization services $20 per visit 20% of MAC 20% of MAC Non-hospital residential services 10% per day 20% of MAC 20% of MAC Chemical dependency services / Substance abuse Outpatient office visits $20 per visit 20% of MAC 20% of MAC Hospital inpatient care 10% per day 20% of MAC 20% of MAC Day treatment or partial hospitalization services $20 per visit 20% of MAC 20% of MAC Non-hospital residential services 10% per day 20% of MAC 20% of MAC Emergency services (for initial treatment only). Copay waived if admitted Emergency services Emergency medical services are covered by Kaiser Foundation Health Plan, Inc. (KFHP). Nonemergency medical services received in an emergency care setting that are not covered by KFHP may be eligible for coverage by Kaiser Permanente Insurance Company (KPIC). Emergency Department surcharge fees are not covered by KPIC. Within the Hawaii service area $100 copay N/A N/A Outside the Hawaii service area $100 copay N/A N/A Ambulance services Ambulance services Diabetes equipment Internal prosthetics, devices, and aids Additional services External Prosthetics / durable medical equipment (with additional hearing aid coverage; see rider for details) 20% of applicable charges 50% of applicable charges 20% of MAC 20% of MAC 20% of MAC 20% of MAC No charge 20% of MAC 20% of MAC 20% of applicable charges 20% of MAC 20% of MAC Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. This is only a summary. This document is meant to be reviewed in conjunction with the attached, detailed benefit summary. It does not fully describe your benefit coverage. For complete details on your benefit coverage, including exclusions, limitations, and plan terms, please refer to your employer s applicable Face Sheet, Group Medical and Hospital Service Agreement, benefit schedule, and riders (collectively known as Service Agreement ), and the Kaiser Permanente Insurance Company (KPIC) Group Policy and Certificate of Insurance. The Service Agreement and KPIC Group Policy are the legal binding documents between Health Plan, KPIC, and your employer. In the event of ambiguity, or a conflict between this summary and the Service Agreement and KPIC Group Policy, the Service Agreement and KPIC Group Policy shall control. Page 2 of 29

3 In-network Kaiser Permanente Contracted Benefit 4-Tier Prescription drug 5/15/50/75 **Applies to annual supplement charges maximum per accumulation period Prescription drug mail-order incentive Active & Fit Generic Maintenance Drugs: $5 per prescription Other Generic Drugs: $15 per prescription Brand-Name Drugs: $50 per prescription Specialty Drugs: $75 per prescription Two drug copayments for a 90-consecutive day supply $100 per contract period gym membership or $10 per contract period home fitness program 20% of charge but not less than stated copay value per prescription of each given category. (Limited to a 30-day supply per prescription) Not covered N/A Non-contracted Not covered Not covered N/A Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. This is only a summary. This document is meant to be reviewed in conjunction with the attached, detailed benefit summary. It does not fully describe your benefit coverage. For complete details on your benefit coverage, including exclusions, limitations, and plan terms, please refer to your employer s applicable Face Sheet, Group Medical and Hospital Service Agreement, benefit schedule, and riders (collectively known as Service Agreement ), and the Kaiser Permanente Insurance Company (KPIC) Group Policy and Certificate of Insurance. The Service Agreement and KPIC Group Policy are the legal binding documents between Health Plan, KPIC, and your employer. In the event of ambiguity, or a conflict between this summary and the Service Agreement and KPIC Group Policy, the Service Agreement and KPIC Group Policy shall control. Page 3 of 29

4 Kaiser Permanente Added Choice with 80%/20% Out-of-network plan 2016 benefits summary This is only a summary, and is not the legally binding document between the Health Plan and its members. It does not fully describe your benefit coverage. For complete details on your benefit coverage, including exclusions, limitations, and plan terms, please refer to your employer s applicable Face Sheet, Group Medical and Hospital Service Agreement, benefit schedule, and Riders (collectively known as Service Agreement ), and the Kaiser Permanente Insurance Company (KPIC) Group Policy and Certificate of Insurance. The Service Agreement and KPIC Group Policy are the legal binding documents between Health Plan, KPIC, and your employer. In event of ambiguity, or a conflict between this summary and the Service Agreement and KPIC Group Policy, the Service Agreement and KPIC Group Policy shall control. You are covered for Medically Necessary covered services as defined under Service Agreement and KPIC Certificate of Insurance. Unless explicitly described in a particular benefit section (e.g. physical therapy is explicitly described under the hospice benefit section), each medical service or item is covered in accord with its relevant benefit section. For example, drugs or laboratory services related to in vitro fertilization are not covered under the in vitro fertilization benefit. Drugs related to in vitro fertilization are covered under the prescribed drugs benefit section. Laboratory services related to in vitro fertilization are covered under the laboratory services benefit section. Coverage limits In-network Kaiser Permanente Out-of-network Kaiser Permanente Insurance Company General Provisions Calendar year deductible must be satisfied before benefits are payable. None $100 per member $300 per family unit Lifetime maximum benefit while insured No dollar lifetime maximum No dollar lifetime maximum Utilization management/precertification All care and services must be prescribed, or performed by a Kaiser Permanente physician, medically necessary, and received from Kaiser Permanente facilities within the Hawaii service area. Note: all references to physician refer to a Kaiser Permanente physician. Precertification is required three days prior to receiving select services as listed in the KPIC Certificate of Insurance. If precertification is not obtained, benefits otherwise payable will be reduced by $300 each time precertification is required and not obtained, up to a maximum penalty of $1,000 per calendar year. Please consult your Certificate of Insurance for the current list of services requiring preauthorization. Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Page 4 of 29

5 Coverage limits In-network Kaiser Permanente Out-of-network Kaiser Permanente Insurance Company General Provisions (continued) Calendar year Supplemental Charges Maximum and calendar year Out-of-Pocket Maximum Kaiser Permanente Supplemental Charges Maximum Out-of-Pocket maximum $2,000 per member, $2,000 per member $6,000 per family unit (3 or more members) $6,000 per family unit Your out-of-pocket expenses for covered Basic Health Services are capped each calendar year by a supplemental charges maximum. YOU MUST RETAIN YOUR RECEIPTS for these supplemental charges and when that maximum amount has been PAID, present these receipts to our Business Office at Moanalua Medical Center, Honolulu, Waipio, or Wailuku Clinics, or to the cashier at other clinics. After verification that the supplemental charges maximum has been PAID, you will be given a card which indicates that no additional supplemental charges for covered Basic Health Services will be collected for the remainder of the calendar year. You need to show this card at your visits to ensure no additional supplemental charges are billed or collected for the remainder of the calendar year in which the medical services were received. All payments are credited toward the calendar year in which the medical services were received. You will be provided an updated status about which of your payments may be applied to the supplemental charges maximum. Please allow a minimum of 10 working days to verify that your supplemental charge maximum has been met. Note: Once you have met the supplemental charges maximum, please submit your proof of payment as soon as reasonably possible. All receipts must be submitted no later than February 28 of the year following the one in which the medical services were received. Supplemental charges for the following covered Basic Health Services can be applied toward the supplemental charges maximum: ambulance service, artificial insemination, chemical dependency services (including residential services), dialysis, drugs requiring skilled administration, emergency service, family planning office visits, health evaluation office visits for adults, home health, imaging (including X-rays), immunizations (excluding travel immunizations), in vitro fertilization procedure (excluding drugs), infertility office visits, inpatient room (semi-private), interrupted pregnancy/abortion, laboratory, mental health services, obstetrical (maternity) care, covered office visits for services listed in this Basic Health Services section, outpatient surgery and procedures, radiation and respiratory therapy, reconstructive surgery, short-term physical therapy, short-term speech therapy, short-term occupational therapy, testing services, transplants (the procedure), and urgent care. These are not Basic Health Services and charges for these services/items are not applicable towards the supplemental charges maximum: all services for which coverage has been exhausted, all excluded or non-covered benefits, all other services not specifically listed above as a Basic Health Service, allergy test materials, blood or blood processing, braces, complementary alternative medicine (chiropractic, acupuncture, or massage therapy), contraceptive drugs and devices, dental services, diabetes supplies and equipment, dressings and casts, durable medical equipment, external prosthetics, handling fee or taxes, health education services, classes or support groups, hospice, internal prosthetics, internal devices and aids, medical foods, medical social services, office visits for services which are not Basic Health Services, orthopedic devices, radioactive materials, self-administered/outpatient prescription drugs, skilled nursing care, take-home supplies, and travel immunizations. For a Member: When a Member s share of Covered Charges incurred equals the Out-of-Pocket Maximum (shown in the Schedule of Coverage) during a calendar year, the Percentage Payable will increase to 100 percent of further Covered Charges incurred by that same Member during the remainder of that calendar year. For a Family: When the amount of Covered Charges incurred by all covered family members equals the Out-of-Pocket Maximum (shown in the Schedule of Coverage) during a calendar year, the Percentage Payable will increase to 100 percent of further Covered Charges incurred by covered family members during the remainder of that calendar year. Any part of a charge that does not qualify as a Covered Charge, will not be applied toward satisfaction of the Out-of-Pocket Maximum. * Out-of-network benefit payments are based on the Maximum Allowable Charge (MAC). The MAC is the lesser of (1) the usual and customary charge; (2) the negotiated rate; or (3) the actual billed charges. In addition to any coinsurance amounts, a member is responsible for charges which exceed the MAC. ** Members must pay their office visit copay for the office visit Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Page 5 of 29

6 Out-of-network Benefits In-network Kaiser Permanente Insurance Company See also benefit exclusions and limitations lists. Kaiser Permanente Contracted Non-contracted Provider Outpatient Services Primary care and specialty care office visits (office visits are limited to one or more of the following services: exam, history, medical decision making) Choice of primary care s and access to specialty care: Member may choose any primary care physician available to accept Member. Parents may choose a pediatrician as the primary care physician for their child. Members do not need a referral or prior authorization for certain specialty care, such as Obstetrical or Gynecological care. The physician may have to get prior authorization for certain services. $20 per visit 20% of MAC * 20% of MAC * Outpatient surgery and procedures Provided in medical office $20 per visit 20% of MAC * 20% of MAC * Provided in ambulatory surgery center (ASC) or hospital-based setting Routine immunizations For children 5 years of age and under on the date the immunization is administered For members 6 years of age and over on the date the immunization is administered 10% of applicable charges 20% of MAC * 20% of MAC * No charge Covered at 100% of MAC *, deductible waived No charge Covered at 80% of MAC * Covered at 100% of MAC *, deductible waived Covered at 80% of MAC * Unexpected mass immunizations 50% of applicable charges 20% of MAC * 20% of MAC * Out-of-network Benefits In-network Kaiser Permanente Insurance Company See also benefit exclusions and limitations lists. Kaiser Permanente Contracted Non-contracted Provider Short-term physical, occupational, and speech therapy 2 $20 per visit; combined inpatient and outpatient therapy only if the condition is subject to significant, measurable improvement in physical function; Kaiser Permanente clinical guidelines apply 20% of MAC * limited to a combined maximum of 60 outpatient visits per calendar year. Therapy must be for a condition that is subject to significant improvement within two months. Dialysis Physician and facility services for dialysis 10% of applicable charges 20% of MAC * 20% of MAC * Equipment, training, medical supplies for home dialysis No charge 20% of MAC * 20% of MAC * Materials for dressings and casts No charge ** Ω 20% of MAC * 20% of MAC * 1 See Coverage Exclusions Section ** Members must pay their office visit copay for the office visit 2 See Coverage Limitations Section Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Ω When provided in an outpatient office visit, copay is as indicated. When service or items are received in any other setting (e.g., hospital inpatient, skilled nursing facility, or outpatient surgery or procedure in an ASC), the copay is in accord with the relevant benefit section. * Out-of-network benefit payments are based on the Maximum Allowable Charge (MAC). The MAC is the lesser of (1) the usual and customary charge; (2) the negotiated rate; or (3) the actual billed charges. In addition to any coinsurance amounts, Page 6 of 29 a member is responsible for charges which exceed the MAC.

7 Out-of-network Benefits In-network Kaiser Permanente Insurance Company See also benefit exclusions and limitations lists. Kaiser Permanente Contracted Non-contracted Provider Hospital inpatient care (for acute care registered bed patients) Hospital inpatient care includes services such as: Room and board General nursing care and special duty nursing Physicians services Surgical procedures Respiratory therapy and radiation therapy Anesthesia Medical supplies Use of operating and recovery rooms Intensive care room Laboratory Services Imaging Services Testing Services Radiation Therapy Chemotherapy Physical therapy Occupational therapy Speech therapy Administered drugs Internal Prosthetics and devices Blood Durable Medical equipment (inpatient setting) External Prosthetic devices and braces 10% per day - including observation & maternity stay 20% of MAC * 20% of MAC * Short-term physical, occupational and speech therapy 2 Materials for dressings and casts Included in the above hospital inpatient care copay; combined inpatient and outpatient therapy only if the condition is subject to significant, measurable improvement in physical function; Kaiser Permanente clinical guidelines apply Included in the above hospital inpatient copay 20% of MAC * 20% of MAC * 20% of MAC * 20% of MAC * 1 See Coverage Exclusions Section ** Members must pay their office visit copay for the office visit 2 See Coverage Limitations Section Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Ω When provided in an outpatient office visit, copay is as indicated. When service or items are received in any other setting (e.g., hospital inpatient, skilled nursing facility, or outpatient surgery or procedure in an ASC), the copay is in accord with the relevant benefit section. * Out-of-network benefit payments are based on the Maximum Allowable Charge (MAC). The MAC is the lesser of (1) the usual and customary charge; (2) the negotiated rate; or (3) the actual billed charges. In addition to any coinsurance amounts, Page 7 of 29 a member is responsible for charges which exceed the MAC.

8 Out-of-network Benefits In-network Kaiser Permanente Insurance Company See also benefit exclusions and limitations lists. Kaiser Permanente Contracted Non-contracted Provider Laboratory services, imaging services, and testing services / X-rays and laboratory exams Inpatient laboratory services, imaging services, and testing services / X-rays and laboratory exams Outpatient laboratory services, imaging services, and testing services / X-rays and laboratory exams Included in hospital inpatient care copay $10 per day OR 20% of applicable charges for: specialty lab tests, specialty imaging, specialty testing & radiation therapy 20% of MAC * 20% of MAC * 20% of MAC * 20% of MAC * Transplants Transplants, including kidney, heart, heart-lung, liver, lung, simultaneous kidney-pancreas, bone marrow, cornea, small bowel, and small bowel-liver transplants 1 See applicable benefit sections (e.g. - office visits subject to office visit copay, inpatient care subject to hospital inpatient care copay, etc.) Not covered Not covered Preventive care services In-network only: Preventive care services (which protect against disease, promote health, and/or detect disease in its earliest stages before noticeable symptoms develop) A list of preventive care services provided at no charge is available through the Customer Service Center. This list is subject to change at any time. If you receive any other covered services during a preventive care visit, you will pay the applicable charges for those services. FDA approved contraceptive drugs and devices 2 that are available on the Health Plan formulary, as required by the federal Patient Protection and Affordable Care Act (PPACA). Coverage of all other FDA approved contraceptive drugs and devices are described in the Obstetrical care section. Female sterilizations 2 Rental or purchase of breast feeding pump, including any equipment that is required for pump functionality No charge (non-preventive care services according to member s regular plan benefits) 20% of MAC * (limited to select services - see your KPIC Certificate of Insurance for complete details) 20% of MAC * (limited to select services - see your KPIC Certificate of Insurance for complete details) Preventive care office visits Well child visits (at birth, ages 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, 3 years, 4 years, and 5 years) One preventive office visit per calendar year for members 6 years of age and over One gynecological office visit per calendar year for female members No charge 20% of MAC *, deductible waived 20% of MAC *, deductible waived No charge 20% of MAC * 20% of MAC * No charge 20% of MAC * 20% of MAC * 1 See Coverage Exclusions Section ** Members must pay their office visit copay for the office visit 2 See Coverage Limitations Section Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Ω When provided in an outpatient office visit, copay is as indicated. When service or items are received in any other setting (e.g., hospital inpatient, skilled nursing facility, or outpatient surgery or procedure in an ASC), the copay is in accord with the relevant benefit section. * Out-of-network benefit payments are based on the Maximum Allowable Charge (MAC). The MAC is the lesser of (1) the usual and customary charge; (2) the negotiated rate; or (3) the actual billed charges. In addition to any coinsurance amounts, Page 8 of 29 a member is responsible for charges which exceed the MAC.

9 Out-of-network Benefits In-network Kaiser Permanente Insurance Company See also benefit exclusions and limitations lists. Kaiser Permanente Contracted Non-contracted Provider Prescribed drugs Prescribed drugs that require skilled administration by medical personnel (e.g. cannot be self-administered) which meet all of the following: Prescribed by a physician/licensed prescriber, and The drug is one for which a prescription is required by law Diabetes 2 $20 per dose ** Ω per prescription on the Health Plan formulary and used in accordance with formulary criteria, guidelines, or restrictions Drugs also may be prescribed by a prescriber we designate 50% of applicable charges ** (a minimum price as determined by Pharmacy Administration may apply) 20% of MAC * 20% of MAC * 20% of MAC * 20% of MAC * Tobacco cessation drugs and products 2 50% of applicable charges ** (a minimum price as determined by Pharmacy Administration may apply) Exclusions: Self-administered drugs (such as drugs taken orally) Drugs that are necessary or associated with services that are excluded or not covered 20% of MAC * 20% of MAC * Limitation: Diabetic drugs and insulin are covered by Kaiser Permanente Insurance Company (KPIC). 20% of MAC *. Covered charges for diabetic drugs and insulin are limited to a 30-day consecutive supply per prescription or refill. Your group may have purchased drug coverage for self-administered drugs under a separate rider. If so, it will be listed on the attached pages. Obstetrical care, interrupted pregnancy, family planning, involuntary infertility services, and artificial conception services Routine obstetrical (maternity) care Prenatal visits at the routine scheduled intervals, uncomplicated delivery/hospital stay and routine post-partum visit Note: If member is discharged within 48 hours after delivery (or within 96 hours if delivery is by cesarean section), the member s Kaiser Permanente physician may order a follow-up visit for the member and newborn to take place within 48 hours after discharge. No charge for routine prenatal visit and one postpartum visit, 10% of applicable charges for delivery/hospital stay 20% of MAC * 20% of MAC * 1 See Coverage Exclusions Section ** Members must pay their office visit copay for the office visit 2 See Coverage Limitations Section Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Ω When provided in an outpatient office visit, copay is as indicated. When service or items are received in any other setting (e.g., hospital inpatient, skilled nursing facility, or outpatient surgery or procedure in an ASC), the copay is in accord with the relevant benefit section. * Out-of-network benefit payments are based on the Maximum Allowable Charge (MAC). The MAC is the lesser of (1) the usual and customary charge; (2) the negotiated rate; or (3) the actual billed charges. In addition to any coinsurance amounts, Page 9 of 29 a member is responsible for charges which exceed the MAC.

10 Out-of-network Benefits In-network Kaiser Permanente Insurance Company See also benefit exclusions and limitations lists. Kaiser Permanente Contracted Non-contracted Provider Inpatient stay and inpatient care for newborn during or after mother s hospital stay (assuming newborn is timely enrolled on Kaiser Permanente subscriber s plan) Hospital inpatient care benefits apply (see hospital inpatient care section) 20% of MAC * 20% of MAC * Interrupted pregnancy Medically indicated abortions $20 per visit Ω 20% of MAC * 20% of MAC * Elective abortions (including abortion drugs such $20 per visit Ω 20% of MAC * 20% of MAC * as RU-486) limited to two per member per lifetime Family planning office visits $20 per visit Not applicable - Not applicable - see the Preventive Care section in the KPIC Certificate of Insurance see the Preventive Care section in the KPIC Certificate of Insurance FDA approved contraceptive drugs and devices (to prevent unwanted pregnancies) 2 50% of applicable charges ** (a minimum price as determined by Pharmacy Administration may apply) 20% of MAC * 20% of MAC * Involuntary infertility office visits (for diagnosis only) $20 per visit 20% of MAC * 20% of MAC * Treatment of involuntary infertility limited to the following: Artificial insemination 1 $20 per visit 20% of MAC * 20% of MAC * In vitro fertilization 1 - Limited to one-time only benefit while a Kaiser Permanente/KPIC member 20% of applicable charges 20% of MAC *. Excluded for members or member s spouse who have had voluntary surgically-induced sterility (with or without reversal). Home health care and hospice care Home health care, nurse and home health aide visits to homebound members, when prescribed by a physician Hospice care. Supportive and palliative care for a terminally ill member, as directed by a physician. The member must be certified by a physician as terminally ill at the beginning of each period. (Hospice benefits apply in lieu of any other plan benefits for treatment of terminal illness.) Hospice care includes services such as: Nursing care (excluding private duty nursing) Medical social services Home health aide services Medical supplies Physician services Counseling and coordination of bereavement services Physical therapy, occupational therapy or speech language pathology No charge (office visit copay applies for physician house calls) No charge. Hospice coverage includes two 90-day periods, followed by an unlimited number of 60-day periods. 20% of MAC * limited to a combined maximum of 150 days per calendar year. 20% of MAC * limited to a combined maximum of 210 days while insured. 1 See Coverage Exclusions Section ** Members must pay their office visit copay for the office visit 2 See Coverage Limitations Section Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Ω When provided in an outpatient office visit, copay is as indicated. When service or items are received in any other setting (e.g., hospital inpatient, skilled nursing facility, or outpatient surgery or procedure in an ASC), the copay is in accord with the relevant benefit section. * Out-of-network benefit payments are based on the Maximum Allowable Charge (MAC). The MAC is the lesser of (1) the usual and customary charge; (2) the negotiated rate; or (3) the actual billed charges. In addition to any coinsurance amounts, Page 10 of 29 a member is responsible for charges which exceed the MAC.

11 Out-of-network Benefits In-network Kaiser Permanente Insurance Company See also benefit exclusions and limitations lists. Kaiser Permanente Contracted Non-contracted Provider Skilled nursing care Prescribed skilled nursing care services in an approved facility (such as a hospital or skilled nursing facility). Covered services include nursing care, room and board, medical social services, medical supplies, and durable medical equipment ordinarily provided by a skilled nursing facility. For in-network coverage only: In determining eligibility Health Plan also consults Medicare guidelines to determine when skilled nursing services are covered, except that a prior three-day stay in an acute care hospital is not required. Exclusions: Personal comfort items such as telephone, television, and take-home medical supplies. 10% of applicable charges up to 120 days per accumulation period 20% of MAC * limited to a combined maximum of 120 days per accumulation period Emergency services (covered for initial emergency treatment only) Copay waived if admitted Emergency medical services are covered by Kaiser Foundation Health Plan, Inc. (KFHP). Non-emergency medical services received in an emergency care setting that are not covered by KFHP may be eligible for coverage by Kaiser Permanente Insurance Company (KPIC). Emergency department surcharge fees are not covered by KPIC. At a facility within the Hawaii service area for covered Emergency Services At a facility outside the Hawaii service area for covered Emergency Services Covered as an in-network benefit - $100 copayment per visit Covered as an in-network benefit - $100 copayment per visit Emergency Services" are those medically necessary services available through the emergency department to medically screen, examine and Stabilize the patient for Emergency Medical Conditions. An Emergency Medical Condition is a medical condition manifesting itself by acute symptoms of sufficient severity that meet the prudent layperson standard and the absence of immediate medical attention will result in serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or place the health of the individual in serious jeopardy. Continuing or follow-up treatment from non-kaiser Permanente practitioners is not covered in-network. Note: Member (or member s family) must notify Health Plan within 48 hours if admitted to a non-kaiser Permanente facility. Out-of-area urgent care (while temporarily outside the Hawaii service area) Out-of-area urgent care at a non-kaiser Permanente facility for covered urgent care services while temporarily outside of the Hawaii service area Covered as an in-network benefit - 20% of applicable charges Out-of-area urgent care is covered by Kaiser Foundation Health Plan, Inc. (KFHP). "Urgent Care Services" means medically necessary services for a condition that requires prompt medical attention but is not an Emergency Medical Condition. Continuing or follow-up treatment from non-kaiser Permanente practitioners is not covered (in-network) by KFHP. 1 See Coverage Exclusions Section ** Members must pay their office visit copay for the office visit 2 See Coverage Limitations Section Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Ω When provided in an outpatient office visit, copay is as indicated. When service or items are received in any other setting (e.g., hospital inpatient, skilled nursing facility, or outpatient surgery or procedure in an ASC), the copay is in accord with the relevant benefit section. * Out-of-network benefit payments are based on the Maximum Allowable Charge (MAC). The MAC is the lesser of (1) the usual and customary charge; (2) the negotiated rate; or (3) the actual billed charges. In addition to any coinsurance amounts, Page 11 of 29 a member is responsible for charges which exceed the MAC.

12 Out-of-network Benefits In-network Kaiser Permanente Insurance Company See also benefit exclusions and limitations lists. Kaiser Permanente Contracted Non-contracted Provider Ambulance services For in-network coverage only: Ambulance services are those services which: Use of any other means of transport, regardless of availability of such other means, would result in death or serious impairment of the member s health, and Is for the purpose of transporting the member to receive medically necessary acute care. In addition, air ambulance must be for the purpose of transporting the member to the nearest medical facility designated by Health Plan for receipt of medically necessary acute care, and the member s condition must require the services of an air ambulance for safe transport. Blood Regardless of replacement, units, and processing of units of whole blood, red cell products, cryoprecipitates, platelets, plasma, fresh frozen plasma, and Rh immune globulin Collection, processing, and storage of autologous blood when prescribed by a physician for a scheduled surgery whether or not the units are used 20% of applicable charges 20% of MAC * for transportation to or from an acute care hospital or skilled nursing facility where treatment is being rendered. Air ambulance will only be covered when medically necessary for the purpose of transporting the Member for receipt of acute care, and the Member s condition requires the services of an air ambulance for safe transport. No charge Ω 20% of MAC * 20% of MAC * No charge Ω 20% of MAC * 20% of MAC * Mental health services Outpatient office visits $20 per visit 20% of MAC * 20% of MAC * Hospital inpatient care Applicable hospital 20% of MAC * 20% of MAC * inpatient care copay Day treatment or partial hospitalization services $20 per visit 20% of MAC * 20% of MAC * In-network only: Treatment unit or facility providing services must be approved by Kaiser Permanente Medical Group. Non-hospital residential services In-network only: Treatment unit or facility providing services must be approved by Kaiser Permanente Medical Group. Applicable hospital inpatient care copay 20% of MAC * 20% of MAC * Chemical dependency services / Substance abuse Outpatient office visits $20 per visit 20% of MAC * 20% of MAC * Hospital inpatient care Applicable hospital 20% of MAC * 20% of MAC * inpatient care copay Day treatment or partial hospitalization services $20 per visit 20% of MAC * 20% of MAC * In-network only: Treatment unit or facility providing services must be approved by Kaiser Permanente Medical Group. Non-hospital residential services In-network only: Treatment unit or facility providing services must be approved by Kaiser Permanente Medical Group. Applicable hospital inpatient care copay 20% of MAC * 20% of MAC * 1 See Coverage Exclusions Section ** Members must pay their office visit copay for the office visit 2 See Coverage Limitations Section Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Ω When provided in an outpatient office visit, copay is as indicated. When service or items are received in any other setting (e.g., hospital inpatient, skilled nursing facility, or outpatient surgery or procedure in an ASC), the copay is in accord with the relevant benefit section. * Out-of-network benefit payments are based on the Maximum Allowable Charge (MAC). The MAC is the lesser of (1) the usual and customary charge; (2) the negotiated rate; or (3) the actual billed charges. In addition to any coinsurance amounts, Page 12 of 29 a member is responsible for charges which exceed the MAC.

13 Out-of-network Benefits In-network Kaiser Permanente Insurance Company See also benefit exclusions and limitations lists. Kaiser Permanente Contracted Non-contracted Provider Implanted internal prosthetics and devices Implanted internal prosthetics (such as pacemakers and hip joints), and internally implanted devices (such as surgical mesh, stents, bone cement, implanted nuts, bolts, screws, and rods) which are prescribed by a Physician Fitting and adjustment of these devices, including repairs and replacement other than those due to misuse or loss No charge Ω 20% of MAC * 20% of MAC * No charge Ω 20% of MAC * 20% of MAC * Diabetes equipment Blood glucose monitors and external insulin pumps 2 (and the supplies necessary to operate them) when prescribed by a physician and meets Medicare coverage guidelines and limitations 50% of applicable charges when On the Health Plan formulary, Preauthorized in writing by Kaiser Permanente Obtained from sources designated by Health Plan 20% of MAC * 20% of MAC * Diabetic drugs and insulin Not covered Not applicable 20% of MAC * (Limited to a 30- day supply per prescription.) Out-of-network Benefits In-network Kaiser Permanente Insurance Company See also benefit exclusions and limitations lists. Kaiser Permanente Contracted Non-contracted Provider Dependent coverage Dependent (biological, step or adopted) children of the Subscriber (or the Subscriber s spouse) are eligible up to the child s 26 th birthday. Other dependents may include: The Subscriber s (or Subscriber s spouse s) dependent (biological, step or adopted) children (over age 26) who are incapable of self-sustaining employment because of a physically- or mentally-disabling injury, illness, or condition that occurred prior to reaching age 26 and receive 50 percent or more of their support and maintenance from the Subscriber (or Subscriber s Spouse) (proof of incapacity and dependency may be required). A person who is under age 26, for whom the Subscriber (or Subscriber s spouse), is (or was before the person s 18 th birthday) the court appointed legal guardian. 1 See Coverage Exclusions Section ** Members must pay their office visit copay for the office visit 2 See Coverage Limitations Section Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Ω When provided in an outpatient office visit, copay is as indicated. When service or items are received in any other setting (e.g., hospital inpatient, skilled nursing facility, or outpatient surgery or procedure in an ASC), the copay is in accord with the relevant benefit section. * Out-of-network benefit payments are based on the Maximum Allowable Charge (MAC). The MAC is the lesser of (1) the usual and customary charge; (2) the negotiated rate; or (3) the actual billed charges. In addition to any coinsurance amounts, Page 13 of 29 a member is responsible for charges which exceed the MAC.

14 Out of Area Student Coverage While attending an accredited educational institution in the United States and outside of the Kaiser Permanente s service areas on a full-time basis, members up to age 26 are covered for the following routine and primary care services: Up to 10 office visits per annual contract effective year for routine primary care $20 per visit Up to 10 combined outpatient basic laboratory services, basic imaging services, and testing services per annual contract effective year Basic laboratory services $10 per day Basic imaging services $10 per day Testing services 20% of applicable charges Up to 10 prescriptions per annual contract effective year of self-administered drugs 20% of applicable charges 1 See Coverage Exclusions Section ** Members must pay their office visit copay for the office visit 2 See Coverage Limitations Section Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Ω When provided in an outpatient office visit, copay is as indicated. When service or items are received in any other setting (e.g., hospital inpatient, skilled nursing facility, or outpatient surgery or procedure in an ASC), the copay is in accord with the relevant benefit section. * Out-of-network benefit payments are based on the Maximum Allowable Charge (MAC). The MAC is the lesser of (1) the usual and customary charge; (2) the negotiated rate; or (3) the actual billed charges. In addition to any coinsurance amounts, Page 14 of 29 a member is responsible for charges which exceed the MAC.

15 Coverage exclusions When a Service is excluded or non-covered, all Services that are necessary or related to the excluded or non-covered Service are also excluded. "Service" means any treatment, diagnosis, care, procedure, test, drug, injectable, facility, equipment, item, device, or supply. The following Services are excluded: Acupuncture. Rider.) (This exclusion may not apply if you have the applicable Complementary Alternative Medicine Alternative medical Services not accepted by standard allopathic medical practices such as: hypnotherapy, behavior testing, sleep therapy, biofeedback, massage therapy, naturopathy, rest cure and aroma therapy. (The massage therapy portion of this exclusion may not apply if you have the applicable Complementary Alternative Medicine Rider.) Artificial aids, corrective aids, and corrective appliances such as orthopedic aids, corrective lenses and eyeglasses. If your plan is required to cover all essential health benefits, then part of this exclusion does not apply (for example, external prosthetic devices, braces, and hearing aids may be covered benefits). Corrective lenses and eyeglasses may be covered for certain medical conditions, if all essential health benefits are required to be covered. Pediatric vision care services and devices may also be covered as an essential health benefit. (The eyeglasses and contact lens portion of this exclusion may not apply if you have an Optical Rider). All blood, blood products, blood derivatives, and blood components whether of human or manufactured origin and regardless of the means of administration, except as stated under the "Blood" section. Donor directed units are not covered. Cardiac rehabilitation. Chiropractic Services. Medicine Rider.) (This exclusion may not apply if you have the applicable Complementary Alternative Services for confined members (confined in criminal institutions, or quarantined). Contraceptive foams and creams, condoms or other non-prescription substances used individually or in conjunction with any other prescribed drug or device. Cosmetic Services, such as plastic surgery to change or maintain physical appearance, which is not likely to result in significant improvement in physical function, including treatment for complications resulting from cosmetic services. However, Kaiser Permanente physician services to correct significant disfigurement resulting from an injury or medically necessary surgery, incident to a covered mastectomy, or cosmetic service provided by a Physician in a Health Plan facility are covered. Custodial Services or Services in an intermediate level care facility. Dental care Services, including pediatric oral care, such as dental x-rays, dental implants, dental appliances, or orthodontia and Services relating to Craniomandibular Pain Syndrome. If your plan is required to cover all essential health benefits, then part of this exclusion does not apply (for example, Services relating to temporomandibular joint dysfunction (TMJ) may be covered). (Part of this exclusion may not apply if you have a Dental Rider.) Durable medical equipment, such as crutches, canes, oxygen-dispensing equipment, hospital beds and wheelchairs used in the member s home (including an institution used as his or her home), except as described in the above benefit sections (e.g., diabetes blood glucose monitors and external insulin pumps are covered). If your plan is required to cover all essential health benefits, then this exclusion does not apply (for example, durable medical equipment may be a covered benefit). (This exclusion does not apply if you have a Durable Medical Equipment Rider.) Employer or government responsibility: Services that an employer is required by law to provide or that are covered by Worker s Compensation or employer liability law; Services for any military service-connected illness, injury or condition when such Services are reasonably available to the member at a Veterans Affairs facility; Services required by law to be provided only by, or received only from, a government agency. Experimental or investigational Services. Page 15 of 29

16 Eye examinations for contact lenses and vision therapy, including orthoptics, visual training and eye exercises. If your plan is required to cover all essential health benefits, then part of this exclusion does not apply (for example, habilitative services and pediatric vision care services may be covered). (Eye exams for contact lens may be partially covered if you have an Optical Rider.) Eye surgery solely for the purpose of correcting refractive defects of the eye, such as Radial keratotomy (RK), and Photo-refractive keratectomy (PRK). If your plan is required to cover all essential health benefits, then part of this exclusion does not apply (for example, vision procedures for certain medical conditions may be covered). Routine foot care, unless medically necessary. Health education: specialized health promotion classes and support groups (such as the bariatric surgery program). Homemaker Services. The following costs and Services for infertility services, in vitro fertilization or artificial insemination: The cost of equipment and of collection, storage and processing of sperm. In vitro fertilization using either donor sperm or donor eggs. In vitro fertilization that does not meet state law requirements. Services related to conception by artificial means other than artificial insemination or in vitro fertilization, such as ovum transplants, gamete intrafallopian transfer (GIFT) and zygote intrafallopian transfer (ZIFT), including prescription drugs related to such Services and donor sperm and donor eggs used for such Services. Services to reverse voluntary, surgically-induced infertility. Non FDA-approved drugs and devices. Certain exams and Services. Certain Services and related reports/paperwork, in connection with third party requests, such as those for: employment, participation in employee programs, sports, camp, insurance, disability, licensing, or on court-order or for parole or probation. Physical examinations that are authorized and deemed medically necessary by a Kaiser Permanente physician and are coincidentally needed by a third party are covered according to the member s benefits. Long term physical therapy, occupational therapy, speech therapy; maintenance therapies; applied behavioral analysis services; routine vision services. Services not generally and customarily available in the Hawaii service area. Services and supplies not medically necessary.a service or item is medically necessary (in accord with medically necessary state law definitions and criteria) only if, 1) recommended by the treating Kaiser Permanente physician or treating Kaiser Permanente licensed health care practitioner, 2) is approved by Kaiser Permanente s medical director or designee, and 3) is for the purpose of treating a medical condition, is the most appropriate delivery or level of service (considering potential benefits and harms to the patient), and known to be effective in improving health outcomes. Effectiveness is determined first by scientific evidence, then by professional standards of care, then by expert opinion. Coverage is limited to the services which are cost effective and adequately meet the medical needs of the member. All Services, drugs, injections, equipment, supplies and prosthetics related to treatment of sexual dysfunction, except evaluations and health care practitioner s services for treatment of sexual dysfunction. Personal comfort items, such as telephone, television, and take-home medical supplies, for covered skilled nursing care. Services, drugs, prosthetics, devices or surgery related to gender re-assignment surgery, including surgery and prosthetics. Take home supplies for home use, such as bandages, gauze, tape, antiseptics, ace type bandages, drug and ostomy supplies, catheters and tubing. The following costs and Services for transplants: Non-human and artificial organs and their transplantation. Bone marrow transplants associated with high-dose chemotherapy for the treatment of solid tissue tumors, except for germ cell tumors and neuroblastoma in children. Services for injuries or illness caused or alleged to be caused by third parties or in motor vehicle accidents. Transportation (other than covered ambulance services), lodging, and living expenses. Travel immunizations. Services for which coverage has been exhausted, Services not listed as covered, or excluded Services. Page 16 of 29

17 **Coverage limitations Benefits and Services are subject to the following limitations: Services may be curtailed because of major disaster, epidemic, or other circumstances beyond Kaiser Permanente s control such as a labor dispute or a natural disaster. Coverage is not provided for treatment of conditions for which a member has refused recommended treatment for personal reasons when physicians believe no professionally acceptable alternative to treatment exists. Coverage will cease at the point the member stops following the recommended treatment. Ambulance services are those services which: 1) use of any other means of transport, regardless of availability of such other means, would result in death or serious impairment of the member s health, and 2) is for the purpose of transporting the member to receive medically necessary acute care. In addition, air ambulance must be for the purpose of transporting the Member to the nearest medical facility designated by Health Plan for receipt of medically necessary acute care, and the member s condition must require the services of an air ambulance for safe transport. Coverage of blood and blood processing includes (regardless of replacement, units and processing of units) whole blood, red cell products, cryoprecipitates, platelets, plasma, fresh frozen plasma, and Rh immune globulin. Coverage also includes collection, processing, and storage of autologous blood when prescribed by a Kaiser Permanente physician for a scheduled surgery whether or not the units are used. Chemical dependency services include coverage in a specialized alcohol or chemical dependence treatment unit or facility approved by Kaiser Permanente Medical Group. Specialized alcohol or chemical dependence treatment services include day treatment or partial hospitalization services and non-hospital residential services. Members are covered for contraceptive drugs and devices (to prevent unwanted pregnancies) only when all of the following criteria are met: 1) prescribed by a licensed Prescriber, 2) the drug is one for which a prescription is required by law, and 3) obtained at pharmacies in the Service Area that are operated by Kaiser Foundation Hospital or Kaiser Foundation Health Plan, Inc. When applicable, the deductible is the amount that members must pay for certain services before Health Plan will cover those services. Services that are subject to the deductible are noted in the You Pay column of this benefit summary (for example, if after deductible is noted in the You Pay column after the copayment, then members or family units must meet the deductible before the noted copayment will be effective). This deductible is separate from any other benefit-specific deductible that may be described herein. For example if prescription drugs are subject to a drug deductible, payments toward that drug deductible do not count toward this deductible. Consequently, payments toward this deductible do not count toward any other benefit-specific deductible (such as a drug deductible). Services that are subject to this deductible are: 1) outpatient surgery or procedures provided in an ambulatory surgery center (ASC) or other hospital-based setting, 2) hospital inpatient care, 3) specialty laboratory services, 4) specialty imaging services, 5) skilled nursing care, and 6) emergency services. Up to a 30-consecutive-day supply of diabetes supplies is provided (as described under the prescribed drugs section) if all of the following criteria are met: 1) prescribed by a licensed Prescriber, 2) on the Health Plan formulary and used in accordance with formulary criteria, guidelines, or restrictions, and 3) obtained at pharmacies in the Service Area that are operated by Kaiser Foundation Hospital, Kaiser Foundation Health Plan, Inc. or a pharmacy we designate. Emergency services are covered for initial emergency treatment only. Member (or Member s family) must notify Health Plan within 48 hours if admitted to a non-kaiser Permanente facility. Emergency Services are those medically necessary services available through the emergency department to medically screen, examine and Stabilize the patient for Emergency Medical Conditions. An Emergency Medical Condition is a medical condition manifesting itself by acute symptoms of sufficient severity that meet the prudent layperson standard and the absence of immediate medical attention will result in serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or place the health of the individual in serious jeopardy. Continuing or follow-up treatment at a non-kaiser Permanente facility is not covered. When applicable, essential health benefits are provided to the extent required by law and include ambulatory services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services (including behavioral health treatment), prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventive and wellness services and chronic disease management, and pediatric services to the extent required by HHS and EHB-benchmark plan. Pediatric oral care services are covered under this Service Agreement only if a separate Dental Rider is attached (covered services are described within any applicable Dental Rider). A complete list of essential health benefits is available through the customer service center. Essential health Page 17 of 29

18 benefits are provided upon payment of the copayments listed under the appropriate benefit sections (e.g.. office visits subject to office visit copay, inpatient care subject to hospital inpatient care copay, etc.). When covered under the preventive care services section, the following types of female sterilizations and related items and services are provided: 1) sterilization surgery for women: Trans-abdominal Surgical Sterilization/Surgical Implant; 2) sterilization implant for women: Trans-cervical Surgical Sterilization Implant; 3) pre and post operative visits associated with female sterilization procedures; and 4) Hysterosalpingogram test following sterilization implant procedure. Coverage of hospice care is supportive and palliative care for a terminally ill member, as directed by a Kaiser Permanente physician. Hospice coverage includes two 90-day periods, followed by an unlimited number of 60-day periods. The member must be certified by a Kaiser Permanente physician as terminally ill at the beginning of each period. (Hospice benefits apply in lieu of any other plan benefits for treatment of terminal illness.) Hospice includes services such as: 1) nursing care (excluding private duty nursing), 2) medical social services, 3) home health aide services, 4) medical supplies, 5) physician services, 6) counseling and coordination of bereavement services, 7) services of volunteers, and 8) physical therapy, occupational therapy, or speech language pathology. Hospital inpatient care (for acute care registered bed patients) includes services such as: 1) room and board, 2) general nursing care and special duty nursing, 3) physicians. services, 4) surgical procedures, 5) respiratory therapy and radiation therapy, 6) anesthesia, 7) medical supplies, 8) use of operating and recovery rooms, 9) intensive care room, 10) laboratory services, 11) imaging services, 12) testing services, 13) radiation therapy, 14) physical therapy, 15) occupational therapy, 16) speech therapy, 17) administered drugs, 18) internal prosthetics and devices, 19) blood, 20) durable medical equipment ordinarily furnished by a Hospital, and 21) external prosthetic devices and braces. Specialty imaging services are services such as CT, interventional radiology, MRI, nuclear medicine, and ultrasound. General radiology includes services such as x-rays and diagnostic mammography. Coverage of in vitro fertilization is limited to a one-time only benefit at Kaiser Permanente. Please see Coverage Exclusions above for services and items not covered. Internal prosthetics, devices, and aids (such as pacemakers, hip joints, surgical mesh, stents, bone cement, bolts, screws, and rods) must be prescribed by a Physician, preauthorized in writing by Kaiser Permanente, and obtained from sources designated by Health Plan. Internal prosthetics, devices, and aids are those which meet all of the following: 1) are required to replace all or part of an internal body organ or replace all or part of the function of a permanently inoperative or malfunctioning body organ, 2) are used consistently with accepted medical practice and approved for general use by the Federal Food and Drug Administration (FDA), 3) were in general use on March 1 of the year immediately preceding the year in which this Service Agreement became effective or was last renewed, and 4) are not excluded from coverage from Medicare, and if covered by Medicare, meet the coverage definitions, criteria and guidelines established by Medicare at the time the device is prescribed. Fitting and adjustment of these devices, including repairs and replacement other than due to misuse or loss, is included in coverage. The following are excluded from coverage: a) all implanted internal prosthetics and devices and internally implanted aids related to an excluded or non covered service/benefit, and b) Prosthetics, devices, and aids related to sexual dysfunction. Coverage is limited to the standard prosthetic model that adequately meets the medical needs of the Member. Convenience and luxury items and features are not covered. The following interrupted pregnancies are included: 1) medically indicated abortions, and 2) elective abortions (including abortion drugs such as RU-486). Elective abortions are limited to two per member per lifetime. Specialty laboratory services include tissue samples, cell studies, chromosome studies, and testing for genetic diseases. All other laboratory services are considered basic lab services. Mental health services include coverage in a specialized mental health treatment unit or facility approved by Kaiser Permanente Medical Group. Specialized mental health treatment services include day treatment or partial hospitalization services and non-hospital residential services. Office visits are limited to one or more of the following services: exam, history, and/or medical decision making. Office visits also include: 1) eye examinations for eyeglasses (see also Coverage Exclusions for more information on eye examinations), and 2) ear examinations to determine the need for hearing correction. Members. choice of primary care s and access to specialty care allow for the following: 1) Member may choose any primary care physician available to accept Member, 2) parents may choose a pediatrician as the primary care physician for their child, 3) Members do not need a referral or prior authorization for certain specialty care, such as obstetrical or gynecological care, and 4) the physician may have to get prior authorization for certain services. Short-term physical, occupational and speech therapy (only if the condition is subject to significant, measurable improvement in physical function; Kaiser Permanente clinical guidelines apply) services means medical services provided for those conditions which meet all of the following criteria: 1) the therapy is ordered by a Physician under Page 18 of 29

19 an individual treatment plan; 2) in the judgment of a Physician, the condition is subject to significant, measurable improvement in physical function with short-term therapy; 3) the therapy is provided by or under the supervision of a Physician-designated licensed physical, speech, or occupational therapist, as appropriate.; and 4) as determined by a Physician, the therapy must be necessary to sufficiently restore neurological and/or musculoskeletal function that was lost or impaired due to an illness or injury. Neurological and/or musculoskeletal function is sufficient when one of the following first occurs: a) neurological and/or musculoskeletal function is the level of the average healthy person of the same age, b) further significant functional gain is unlikely, or c) the frequency and duration of therapy for a specific medical condition as specified in Kaiser Permanente Hawaii s Clinical Practice Guidelines has been reached. Occupational therapy is limited to hand rehabilitation services, and medical services to achieve improved self care and other customary activities of daily living. Speech-language pathology is limited to deficits due to trauma, drug exposure, chronic ear infections, hearing loss, and impairments of specific organic origin. Prescribed drugs that require skilled administration by medical personnel must meet all of the following: 1) prescribed by a Kaiser Permanente licensed prescriber, 2) on the Health Plan formulary and used in accordance with formulary guidelines or restrictions, and 3) prescription is required by law. In accordance with routine obstetrical (maternity) care, if member is discharged within 48 hours after delivery (or within 96 hours if delivery is by cesarean section), the member s Kaiser Permanente physician may order a follow-up visit for the member and newborn to take place within 48 hours after discharge. Covered skilled nursing care in an approved facility (such as a hospital or skilled nursing facility) per Benefit Period, include the following services: 1) nursing care, 2) room and board, 3) medical social services, 4) medical supplies, and 5) durable medical equipment ordinarily provided by a skilled nursing facility. In addition to Health Plan criteria, Medicare guidelines are used to determine when skilled nursing services are covered, except that a prior three-day stay in an acute care hospital is not required. Your out-of-pocket expenses for covered Basic Health Services are capped each year by a supplemental charges maximum. Payments toward any applicable deductible count toward the limit on supplemental charges. You may retain your receipts for these Supplemental Charges and when that maximum amount has been incurred and/or paid, present these receipts to our Business Office at Moanalua Medical Center, Honolulu, Waipio, or Wailuku Clinics or to the cashier at other clinics. After verification that the Supplemental Charges Maximum has been incurred and/or paid, you will be given a card which indicates that no additional Supplemental Charges for covered Basic Health Services will be collected for the remainder of the calendar year. You need to show this card at your visits to ensure no additional Supplemental Charges are billed or collected for the remainder of the calendar year in which the medical services were received. All payments are credited toward the calendar year in which the medical services were received. Supplemental charges for the following Basic Health Services can be applied toward the Supplemental Charges Maximum, if the item or service is covered under this Service Agreement: Essential Health Benefits, covered office visits for medical services listed in this Basic Health Services section, ambulance service, artificial insemination, blood or blood processing, braces, chemical dependency services, contraceptive drugs and devices, diabetes supplies and equipment, dialysis, drugs requiring skilled administration, durable medical equipment, emergency service, external prosthetics, family planning office visits, hearing aids, health evaluation office visits for adults, home health, hospice, imaging (including X-rays), immunizations (excluding travel immunizations), internal prosthetics, devices, and aids, in vitro fertilization procedure, infertility office visits, inpatient room (semi-private), interrupted pregnancy/abortion, laboratory, medical foods, mental health services, obstetrical (maternity) care, outpatient surgery and procedures, radiation and respiratory therapy, reconstructive surgery, self-administered/outpatient prescription drugs (in some cases, payments for self-administered/outpatient prescription drugs may not count toward the Supplemental Charges Maximum; Members may contact Kaiser Permanente s Customer Service Center for more information), short-term physical therapy, short-term speech therapy, short-term occupational therapy, skilled nursing care, testing services, transplants (the procedure), and urgent care. The following services are not Basic Health Services and charges for these services/items are not applicable towards the Supplemental Charges Maximum: all services for which coverage has been exhausted, all excluded or non-covered benefits, all other services not specifically listed above as a Basic Health Service, allergy test materials, complementary alternative medicine (chiropractic, acupuncture, or massage therapy), dental services, dressings and casts, handling fee or taxes, health education services, classes or support groups, medical social services, office visits for services which are not Basic Health Services, radioactive materials, take-home supplies, and travel immunizations. Up to a 30-consecutive-day supply of tobacco cessation drugs and products is provided when all of the following criteria are met: 1) prescribed by a licensed Prescriber, 2) available on the Health Plan formulary s Tobacco Cessation list of approved drugs and products, including over-the-counter drugs and products, and in accordance with formulary criteria, guidelines, or restrictions, 3) obtained at pharmacies in the Service Area that are operated by Kaiser Foundation Hospital, Kaiser Foundation Health Plan, Inc. or a pharmacy we designate, and 4) Member meets Health Page 19 of 29

20 Plan-approved program-defined requirements for smoking cessation classes or counseling (tobacco cessation classes and counseling sessions are provided at no charge). Tuberculin skin test is limited to one per calendar year, unless medically necessary. Transplant services for transplant donors. Health Plan will pay for medical services for living organ and tissue donors and prospective donors if the medical services meet all of the requirements below. Health Plan pays for these medical services as a courtesy to donors and prospective donors, and this document does not give donors or prospective donors any of the rights of Kaiser Permanente members. Regardless whether the donor is a Kaiser Permanente member or not, the terms, conditions, and Supplemental Charges of the transplant-recipient Kaiser Permanente member will apply. Supplemental charges for medical services provided to transplant donors are the responsibility of the transplant-recipient Kaiser Permanente member to pay, and count toward the transplant-recipient Kaiser Permanente member s limit on supplemental charges. The medical services required are directly related to a covered transplant for a Kaiser Permanente member and required for a) screening of potential donors, b) harvesting the organ or tissue, or c) treatment of complications resulting from the donation. For medical services to treat complications, the donor receives the medical services from Kaiser Permanente practitioners inside a Health Plan Region or Group Health service area. Health Plan will pay for emergency services directly related to the covered transplant that a donor receives from non-kaiser Permanente practitioners to treat complications. The medical services are provided not later than three months after donation. The medical services are provided while the transplant-recipient is still a Kaiser Permanente member, except that this limitation will not apply if the Kaiser Permanente member s membership terminates because he or she dies. Health Plan will not pay for travel or lodging for donors or prospective donors. Health Plan will not pay for medical services if the donor or prospective donor is not a Kaiser Permanente member and is a member under another health insurance plan, or has access to other sources of payment. The above policy does not apply to blood donors. Urgent care services are covered for initial urgent care treatment only. "Urgent Care Services" means medically necessary services for a condition that requires prompt medical attention but is not an Emergency Medical Condition. Continuing or follow-up treatment at a non-kaiser Permanente facility is not covered. Third party liability, motor vehicle accidents, and surrogacy health services Kaiser Permanente has the right to recover the cost of care for a member s injury or illness caused by another person or in an auto accident from a judgment, settlement, or other payment paid to the member by an insurance company, individual or other third party. Kaiser Permanente has the right to recover the cost of care for Surrogacy Health Services. Surrogacy Health Services are Services the Member receives related to conception, pregnancy, or delivery in connection with a Surrogacy Arrangement. The Member must reimburse Kaiser Permanente for the costs of Surrogacy Health Services, out of the compensation the Member or the Member s payee are entitled to receive under the Surrogacy Arrangement. Page 20 of 29

21 Durable medical equipment Out-of-network rider with 80%/20% Out-of-network plan with -20%/20% In-network Kaiser Permanente Insurance Company Benefits Kaiser Permanente Contracted Non-contracted Durable medical equipment, including oxygen dispensing equipment (and oxygen) used during a covered stay in a hospital or skilled nursing facility Medically necessary and appropriate durable medical equipment for use in the home, when prescribed by a physician Oxygen for use in conjunction with prescribed durable medical equipment Repair, replacement, and adjustment of durable medical equipment, other than those due to misuse or loss 20% of applicable charges 20% of MAC * 20% of MAC * 20% of applicable charges 20% of MAC * 20% of MAC * 20% of applicable charges 20% of MAC * 20% of MAC * 20% of applicable charges 20% of MAC * 20% of MAC * Durable medical equipment is that equipment and related supplies necessary to operate the equipment which meet all of the following criteria: Is intended for repeated use, Is primarily and customarily used to serve a medical purpose, Is appropriate for use in the home, Is generally not useful to a person in the absence of illness or injury, Was in general use on March 1 of the year immediately preceding the year in which this Agreement became effective or was last renewed, and Is not excluded from coverage from Medicare, and if covered by Medicare, meets the coverage definitions, criteria, and guidelines established by Medicare at the time the durable medical equipment is prescribed. Exclusions: All durable medical equipment related to an excluded or non-covered service/benefit Comfort and convenience equipment, disposable supplies, and devices not medical in nature such as sauna baths and elevators Exercise and hygiene equipment Electronic monitors of the function of the heart or lungs Devices to perform medical tests on blood or other body substances or excretions Dental appliances or devices Experimental or research equipment Durable medical equipment related to sexual dysfunctionadditional exclusions for in-network only: Disposable supplies for home use such as bandages, gauze, tape, antiseptics, and ace type bandages Repair, replacement, or adjustment due to misuse or loss Modifications to home or car Limitations: If rented or loaned from Health Plan, the Member must return any durable medical equipment to Kaiser Permanente or its designee or pay Kaiser Permanente or its designee the fair market price for the equipment when it is no longer prescribed by a Physician or used by the Member. Coverage is limited to the standard item or durable medical equipment in accord with Medicare guidelines that adequately meets the needs of the Member. Convenience and luxury items and features are not covered. For in-network services only: medically necessary and appropriate durable medical equipment for use in the home, when prescribed by a Kaiser Permanente physician, preauthorized in writing by Kaiser Permanente, must be obtained from sources designated by Kaiser Permanente on either a purchase or rental basis, as determined by Kaiser Permanente. Home glucose meters must be prescribed by a Kaiser Permanente physician and/or Health Plan diabetic nurse educator. * Out-of-network benefit payments are based on the Maximum Allowable Charge (MAC). The MAC is the lesser of (1) the usual and customary charge; (2) the negotiated rate; or (3) the actual billed charges. In addition to any coinsurance amounts, a member is responsible for charges which exceed the MAC. Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Page 21 of 29

22 External prosthetic Out-of-network devices and braces rider with 80%/20% Out-of-network plan - -20%/20% In-network Kaiser Permanente Insurance Company Benefits Kaiser Permanente Contracted Non-contracted External prosthetic devices and braces, when prescribed by a physician. Fitting and adjustment of these devices, including repairs and replacements other than those due to misuse or loss. A prosthetic device following mastectomy, if all or part of a breast is surgically removed for medically necessary reasons. Replacement will be made when a prosthesis is no longer functional. Custom-made prostheses will be provided when necessary. 20% of applicable charges 20% of MAC * 20% of MAC * 20% of applicable charges 20% of MAC * 20% of MAC * 20% of applicable charges 20% of MAC * 20% of MAC * External prosthetic devices are those which meet all of the following criteria: Are affixed to the body externally, Are required to replace all or part of any body organ or replace all or part of the function of a permanently inoperative or malfunctioning body organ, Were in general use on March 1 of the year immediately preceding the year in which this Agreement became effective or was last renewed, and Are not excluded from coverage from Medicare, and if covered by Medicare, meet the coverage definitions, criteria and guidelines established by Medicare at the time the prosthetic is prescribed. Braces are those rigid and semi-rigid devices which: Are required to support a weak or deformed body member, or Are required to restrict or eliminate motion in a diseased or injured part of the body, and Are not excluded from coverage from Medicare, and if covered by Medicare, meet the coverage definitions, criteria and guidelines established by Medicare at the time the brace is prescribed. Exclusions for in-network services: All external prosthetic devices and braces related to an excluded or non-covered service/benefit Supplies, whether or not related to external prosthetic devices or braces Prosthetic devices related to sexual dysfunction Dental prosthesis, devices and appliances Non-rigid appliances such as elastic stockings, garter belts, arch supports, non-rigid corsets, and similar devices Pacemakers and other surgically implanted internal prosthetic devices Hearing aids Corrective lenses and eyeglasses Orthopedic aids such as corrective shoes and shoe inserts Replacement of lost prosthetic devices Repairs, adjustments, or replacements due to misuse or loss Experimental or research devices and appliances External prosthetics for comfort and/or convenience, or which are not medical in nature Disposable supplies for home use such as bandages, gauze, tape, antiseptics, and ace type bandages Limitations: Coverage is limited to the standard model of external prosthetic device or brace in accord with Medicare guidelines that adequately meets the medical needs of the Member. Convenience and luxury items and features are not covered. For in-network coverage only: external prosthetic devices and braces must be preauthorized in writing by Kaiser Permanente and obtained from sources designated by Kaiser Permanente. * Out-of-network benefit payments are based on the Maximum Allowable Charge (MAC). The MAC is the lesser of (1) the usual and customary charge; (2) the negotiated rate; or (3) the actual billed charges. In addition to any coinsurance amounts, a member is responsible for charges which exceed the MAC. Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Page 22 of 29

23 Hearing Aids rider Out-of-network - 60% of applicable charges In-network Kaiser Permanente Insurance Company Benefits Kaiser Permanente Contracted Non-contracted Under this rider, medically necessary and appropriate hearing aids (applies to both ears) prescribed by a Physician or Kaiser Permanente audiologist, and obtained from sources designated by the Health Plan, are available upon payment of 60% of applicable charges per ear, once every 3 years. Thereafter, a hearing aid (s) will be provided on the same basis 3 years after the hearing aid(s) was last provided. Limitations for in-network services: 60% of applicable charges, per ear; additional charges may apply (see "Limitations" section below for details) Not covered Not covered Coverage is limited to the standard hearing aid(s) in accord with Health Plan guidelines that adequately meets the medical needs of the Member. Hearing aid(s) above the standard model will be provided upon payment of the Supplemental Charges that Member would have paid for a standard hearing aid(s), as described in section FF-1(a), plus all additional Applicable Charges for any amount above the standard hearing aid(s). Exclusions for in-network services: All other hearing aid related costs, including but not limited to: consultation, fitting, rechecks and adjustments for the hearing aid(s). * Out-of-network benefit payments are based on the Maximum Allowable Charge (MAC). The MAC is the lesser of (1) the usual and customary charge; (2) the negotiated rate; or (3) the actual billed charges. In addition to any coinsurance amounts, a member is responsible for charges which exceed the MAC. Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Page 23 of 29

24 Drug rider 5/15/50/75 with 80%/20% Out-of-network plan Benefits In-network Out-of-network Kaiser Permanente Insurance Company Kaiser Permanente or designated pharmacy Participating pharmacy Nonparticipating pharmacy For each prescription For in-network benefit only: Each prescription does not exceed: a 30-consecutive-day supply of a prescribed drug, or an amount as determined by the formulary. Self-administered drugs including drugs for the treatment of cancer, are provided in accordance with state and federal law and are covered only when all of the following criteria are met: prescribed by a physician/licensed prescriber, or a prescriber we designate, the drug is one for which a prescription is required by law, and drug does not require administration by nor observation by medical personnel. $5 per generic Maintenance drug prescription, $15 per prescription for all other generic drug prescriptions, $50 per brand-name drug prescription, and $75 per specialty drug prescription of a self-administered drug on the Health Plan formulary and used in accordance with formulary guidelines or restrictions 20% of charge but not less than not less than $5 per generic Maintenance drug prescription, $15 per prescription for all other generic drug prescriptions, $50 per brand-name drug prescription, and $75 per specialty drug prescription. (Limited to a 30-day supply per prescription.) Not covered Maintenance drugs are those which are used to treat chronic conditions, such as asthma, hypertension, diabetes, hyperlipidemia, cardiovascular disease, and mental health. Insulin $15 per generic drug prescription and $50 per brand-name drug prescription Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. 20% of charge but not less than $5 per generic Maintenance drug prescription, $15 per prescription for all other generic drug prescriptions, $50 per brand-name drug prescription, and $75 per specialty drug prescription. (Limited to a 30-day supply per prescription.) Not covered under this Rider Page 24 of 29

25 Exclusions for in-network services: Drugs which are obtained at pharmacies outside the Hawaii service area that are operated by Kaiser Foundation Hospital or Kaiser Foundation Health Plan, Inc. or pharmacies we designate. Drugs for which a prescription is not required by law (e.g. over-the-counter drugs) including condoms, contraceptive foams and creams or other non-prescription substances used individually or in conjunction with any other prescribed drug or device. This exclusion does not apply to tobacco cessation drugs and products as described in the prescribed drugs section. Drugs and their associated dosage strengths and forms in the same therapeutic category as a non-prescription drug that have the same indication as the non-prescription drug. Nonprescription vitamins. Drugs when used primarily for cosmetic purposes. Medical supplies such as dressings and antiseptics. Reusable devices such as blood glucose monitors and lancet cartridges. Diabetes supplies such as blood glucose test strips, lancets, syringes and needles. Non-formulary drugs unless specifically prescribed and authorized by a Kaiser Permanente physician/licensed prescriber, or prescriber we designate. Name-brand drugs requested by a member when there is a generic equivalent. Prescribed drugs that are necessary for or associated with excluded or non-covered services. Drugs related to sexual dysfunction. Drugs to shorten the duration of the common cold. Drugs related to enhancing athletic performance (such as weight training and body building). Any packaging other than the dispensing pharmacy s standard packaging. Immunizations, including travel immunizations. Contraceptive drugs and devices (to prevent unwanted pregnancies). Abortion drugs (such as RU-486). Replacement of lost, stolen or damaged drugs. Exclusions for out-of-network services: Prescriptions filled by pharmacies other than Added Choice Participating Pharmacies. Drugs and medicines for which a prescription is not required by law, except those listed in the Formulary. Drugs and medicines obtained from a non-participating pharmacy. Medical supplies such as dressings and antiseptics. Reusable devices such as blood sugar testing meters and finger stick lancet cartridges. Drugs and medicines that are necessary for services excluded under the Policy. Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Page 25 of 29

26 Questions and answers about the drug rider 1. How does the drug rider work? When you visit a Kaiser Permanente or non-kaiser Permanente physician, licensed prescriber, or prescriber we designate, and he or she prescribes a drug for which a prescription is required by law, you can take the prescription to either a Kaiser Permanente pharmacy, Kaiser Permanente-designated pharmacy, or Added Choice Participating Pharmacy. If you go to a Kaiser Permanente or Kaiser Permanente-designated pharmacy, in most cases you will be charged only $5 per generic Maintenance drug prescription, $15 per prescription for all other generic drug prescriptions, $50 per brand-name drug prescription, and $75 per specialty drug prescription, which is on the Formulary, when it does not exceed a 30-consecutive-day supply of a prescribed drug (or an amount as determined by the Formulary). Each refill of the same prescription will also be provided at the same charge. If you fill a prescription at an Added Choice Participating Pharmacy, you will be charged coinsurance equal to 20% of the charge, but not less than $5 per generic Maintenance drug prescription, $15 per prescription for all other generic drug prescriptions, $50 per brand-name drug prescription, and $75 per specialty drug prescription. Each refill of the same prescription will also be provided at the same coinsurance. If you go to other pharmacies, you will be responsible for 100% of charge. 2. Where are Kaiser Permanente pharmacies, Kaiser Permanente-designated pharmacies and Added Choice Participating Pharmacies located?.most Kaiser Permanente Clinics have a pharmacy on premises. Please consult the Added Choice Member Handbook and Provider Locations for the Kaiser Permanente-designated pharmacy and Added Choice Participating Pharmacy nearest you and its hours of operation. 3. Can I get any drug prescribed by my Physician? Our drug formulary is considered a closed formulary, which means that medications on the list are usually covered under the prescription drug rider. However drugs on our formulary may not be automatically covered under your prescription drug rider because these benefits vary depending on which plan you.ve selected. Even though nonformulary drugs are generally not covered under your prescription drug rider, your physician may sometimes request a nonformulary drug for you, specifically when formulary alternatives have failed or use of nonformulary drug is medically necessary, provided the drug is not excluded under the prescription drug rider. Kaiser Permanente pharmacies, Kaiser Permanente-designated pharmacies, and Added Choice Participating Pharmacies may substitute a chemical or generic equivalent for a brand-name drug unless prohibited by your physician. Under the in-network benefit at a Kaiser Permanente or Kaiser Permanente-designated pharmacy, if you want a brand-name drug for which there is a generic equivalent, or if you request a non formulary drug, you will be charged Member Rates for these selections, since they are not covered under your prescription drug rider. If your Kaiser Permanente physician deems a higher priced drug to be medically necessary when a less expensive drug is available, you pay the usual drug copayment. If you request the higher priced drug and it has not been deemed medically necessary, you will be charged Member Rates. Under the out-of-network coverage, if a member requests a brand form of the prescribed drug or authorized drug, the member must pay any difference in price between the generic equivalent drug prescribed or authorized by the physician and the requested brand. You, your physician or your licensed prescriber can call the Kaiser Permanente Pharmacist at the Added Choice Pharmacy Hotline at , or any Added Choice Participating Pharmacy. 4. Do I need to present any identification when I receive drugs? Always present your Kaiser Permanente membership ID card, which has your medical record number, to the pharmacist. If you do not have a medical record number, please call the Customer Service Center at on Oahu or on Neighbor Islands. 5. What if I need more than a month s supply of medication?.your Kaiser Permanente membership contract entitles you to a maximum one-month supply per prescription (for each copayment, if applicable). However, as a convenience to you, our Kaiser Permanente pharmacies will dispense up to a three-month.s supply of certain prescriptions by request (you will be responsible for three copayment amounts). Kaiser Permanente-designated pharmacies and Added Choice Participating Pharmacies will dispense only up to one month s supply. Dispensing a three-month.s supply is done in good faith, presuming you will remain a Kaiser Permanente member for the next three months. If you terminate your membership with Kaiser Permanente before the end of the three-month period, we will bill you for the retail price for your remaining drugs. For example, if you end your membership after two months, we will bill you for the remaining one-month.s supply. Unless otherwise directed by Kaiser Permanente, refills may be allowed when 75% of the current prescription supply is taken/administered according to prescriber.s directions. Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Page 26 of 29

27 6. How do I receive prescriptions by mail? Save time and money on refills! If you have prescription drug coverage, you can get a 90-day supply of qualified prescription drugs covered under your drug rider for the price of 60 by using our convenient mail order service*. And we pay the postage! You can order your refills at your convenience, 24/7, using one of the methods below. For the quickest turnaround time, order online at kp.org. Order via our automated prescription refill service by calling (Oahu) or (Neighbor Islands). You ll have the following options: To check your order status, press 1. To order refills, press 2. You will be asked to enter your medical record number and prescription number. Then you.ll have the option of receiving your refills via mail order (by pressing 1) or picking up your refills at one of our locations (by pressing 2) To listen to detailed instructions, press 3. Order using our mail-order envelope, available at all Kaiser Permanente clinic locations...order via our Pharmacy Refill Center at (808) (Oahu), or toll free (Neighbor Islands), Monday to Friday, 8:30 a.m. to 5 p.m. TTY users may call So the next time you ve used two-thirds of your existing supply of prescription medications, try using one of these convenient options. If you must pick up your prescriptions at a clinic pharmacy, refillable prescriptions are usually ready for pickup at the designated pharmacy in one business day. Prescriptions requiring a physician.s approval are usually ready in two business days. Call the pharmacy or Kaiser Permanente Hawaii s automated prescription refill line in advance to make sure that your prescription is ready. Orders not picked up within one week are returned to stock. *We are not licensed to mail medications out of state. There are restrictions for delivery of certain medications and supplies, including but not limited to controlled medications, injections, medications affected by temperature, and medications excluded by Kaiser Permanente.s Pharmacy & Therapeutic Committee. Kaiser Permanente Insurance Company (KPIC) underwrites the Out-of-Network coverage. Page 27 of 29

28 Active&Fit R Program provides these extra services Active&Fit Services Basic Program fitness club and exercise center membership program$100 per Contract Period ^ Eligible Members may enroll with an American Specialty Health Networks, Inc. (ASH) contracted network fitness club Program enrollment includes standard fitness club services and features Eligible Members should verify services and features with the ASH contracted fitness club. Or Home Fitness Program $10 per Contract Period ^ Eligible Members may select up to two of the available ASH home fitness kits per calendar year. Active&Fit website All eligible Members have access to Active&Fit web-based services such as facility search, enrollment functions, educational content and fitness tools and trackers. The following are excluded from the Active&Fit Program: Personal trainers, classes, and club services, amenities, and products or supplies that are not routinely included in the general membership Access to fitness or exercise clubs that are not part of ASH s contracted network. Home fitness kits not provided through ASH s Active&Fit program. Enrollment for Members not specifically listed as eligible for this program, as defined by the Group. Enrollment for Members under the age of 16. Members must pay their $100 or $10 fee directly to ASH prior to using services. There will be no refunds, and fees are not prorated. Fees do not count toward the eligible Member s health benefit plan s Supplemental Charges Maximum. ^ Your Contract Period is the effective dates of coverage in your employer s contract with Health Plan. Questions and answers about the Active&Fit Program 1. How do I sign up for the Active&Fit Program? Members can enroll online at: kp.org/activeandfit or by calling the American Specialty Health Network Active&Fit toll-free member services hotline at , from 5 a.m. to 3 p.m. (Hawaii Time), Monday through Friday. Note: Payment will be taken at time of enrollment in the Active&Fit program. 2. If I sign up mid-year, is my fee prorated? No, the $100 or $10 fees will not be prorated, nor are refundable. Page 28 of 29

29 3. Does the $100 or $10 fee count toward my out-of-pocket maximum? The Active&Fit program is not a medical benefit, and therefore their $100 or $10 fee does not count towards your health plan out-of-pocket maximum. 4. Does an Active&Fit member get an ID card? If so, how is one obtained? Yes. Within five days of enrollment in the program, ASH Networks will mail the member ID card in the member.s Active&Fit enrollment kit. The member can take that ID card to the fitness facility that they chose. 5. If a member is participating in the Home Fitness Program and changes his/her mind and wants to join a fitness facility, how long must the member wait before he/she can join a facility? Members may call the toll-free member services hotline at any time to enroll with a fitness facility by paying the $100 fee. His/her effective date will be the first of the following month. The member will no longer receive the Active&Fit Home Fitness Kits. 6. If a member is participating in the Gym program and then changes his/her mind and wants the Active&Fit Home Fitness Program, does the member get reimbursed the $100 gym fee? No. The member will not get reimbursed the $100 gym fee. In addition, he/she will need to pay the $10 Home Fitness Program fee in order to receive their Home Fitness Kits. 7. If a member is participating in the Active&Fit Home Fitness Program and then changes his/her mind and joins a facility, does the member need to return the Home Fitness Kits? No. The member may keep the Active&Fit home fitness kits. However, the member will have to pay the $100 gym fee, and will not get reimbursed the $10 home fitness fee. 8. Does the member get a discount on the Gym Program since they already paid a fee for the Home Fitness Program? No, the member must pay the $100 fee in full. 9. Is this program available outside of the Hawaii service area? Yes, members may use their Active&Fit gym membership on the mainland when they travel. The member must call ASHN prior to traveling to register at another gym/facility. 10. If a member chooses the Active&Fit Home Fitness Program during the enrollment process, how long will it take for the home fitness kits to arrive? The kits will be mailed within 30 days of enrollment. Page 29 of 29