SAMPLE - Kaiser Permanenteinfo.kaiserpermanente.org/healthplans/plandocuments/hawaii/pdfs/2016... · KP Gold - $17 Plan (formerly called KP Gold - $12 Plan) Medical deductible will

January 5, 2016

Dear Kaiser Permanente member:

Thank you for choosing Kaiser Permanente for your health care needs.

Please find enclosed your Kaiser Permanente health plan and benefit information. We haveincluded your member handbook including our physicians and locations directory and yourbenefit summary in this packet. Please keep these materials on hand as a reference to yourbenefits and services as a valued Kaiser Permanente member.

If you have any questions regarding your eligibility or health plan benefits, please contact youremployer or our Customer Service Center, Monday through Friday, 8 a.m. to 5 p.m., at432-5955 from Oahu, toll free at 1-800-966-5955 from the Neighbor Islands or1-877-447-5990 by TTY (toll free direct by special telephone equipment for people who havedifficulties with hearing or speech).

We look forward to serving you now and in the future.

Sincerely,

Kaiser Foundation Health Plan, Inc.

Kaiser Foundation Health Plan, Inc.711 Kapiolani BoulevardHonolulu, Hawaii 96813

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kpgroup_importchg_16r.doc 1 rev. 09/2015

Kaiser Foundation Health Plan, Inc. A NONPROFIT HEALTH PLAN - HAWAII REGION

2016 Summary of Important Changes for Contract Renewals for the

Kaiser Permanente Group Plan (These changes are subject to regulatory approval)

This summary does not apply to Added Choice out-of-network coverage, Kaiser Permanente for Individuals and Families, Federal, State, Medicaid members or Medicare members. This summary does not fully describe your coverage. For details on your coverage, please refer to your employer’s applicable Face Sheet, Group Medical and Hospital Service Agreement, Benefit Schedule, and Riders if any (collectively known as “Service Agreement”). The Service Agreement is the legally binding document between Health Plan and its members. In the event of ambiguity, or a conflict between this summary and the Service Agreement, the Service Agreement shall control. For specific questions about benefits, you may call our Customer Service Center at 1-800-966-5955. Your employer may have purchased benefits (referred to as “riders”) that override some of these changes. However, riders are not available for some of the changes described below. Under the Patient Protection and Affordable Care Act (PPACA), your coverage may be considered a “grandfathered plan.” Some of the benefit changes below may not be applicable to a grandfathered plan. CONTRACT CHANGES (that apply to all group plans) These changes become effective on your employer’s contract renewal date, unless specified otherwise below. 1. Benefits covered with a single copay or coinsurance. Services provided as part of the hospital,

observation, outpatient surgery or procedure (performed in an ambulatory surgery center or outpatient hospital setting), skilled nursing facility, dialysis, radiation therapy, and emergency room benefit categories will be covered under a single copay or coinsurance. (However, the complex imaging copay or coinsurance will continue to apply if such services are received during an emergency room visit.)

2. In vitro fertilization. In vitro fertilization will be covered for unmarried women and for women using a

non-spousal sperm donor. Current benefit copays, coinsurance, limitations and exclusions still apply. 3. State mandates. Coverage will be added for orthodontic services for treatment of orofacial

anomalies due to birth defects. Coverage is also being added for diagnosis and treatment of autism. (For both benefits, age and dollar limits in accord with state law apply.)

CONTRACT LANGUAGE CLARIFICATIONS (that apply to all group plans) These clarifications are effective immediately, unless otherwise specified below. 1. Language clarifications. Language clarifications have been made to the Service Agreement to

comply with the PPACA. PLAN SPECIFIC COST SHARE CHANGES These changes become effective on your employer’s contract renewal date, unless specified otherwise below. 1. KP Group $25/$150 (50% Lab Imaging and Testing) Plan

Supplemental charges maximum will be $3,000 per member/$9,000 for family of 3 or more members (was $2,500/$7,500).

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kpgroup_importchg_16r.doc 2 rev. 09/2015

2. KP Group $20/20% Plan (formerly called KP Group $12/20% Plan)

Primary office visit will be $20 per visit (was $12 per visit). Specialist office visit will be $30 per visit (was $20 per visit).

3. KP Platinum - $20 Plan

Specialty drug will be $75 per prescription (was $45 per prescription). 4. KP Platinum I - $15 Plan

Outpatient specialty laboratory/imaging will be 10% (was $20 per day). Brand drug will be $45 per prescription (was $35 per prescription) and specialty drug will be $75

per prescription (was $35 per prescription). 5. KP Gold - $15 Plan

There will be a separate limit on supplemental charges for pharmacy-dispensed drugs in the amount of $4,650 per member/$9,300 for family of 2 or more members. (Previously, pharmacy-dispensed drugs were counted toward the medical supplemental charges maximum.)

Prescription drug deductible for specialty drug prescriptions will be $400 per member/$800 for family of 2 or more members (was $250/$500).

6. KP Gold - $17 Plan (formerly called KP Gold - $12 Plan)

Medical deductible will be $50 per member/$100 for family of 2 or more members (was $0/$0). Primary office visit will be $17 per visit (was $12 per visit). Specialist office visit will be $25 per visit (was $20 per visit). Hospital inpatient will be 20% after deductible. (Previously this benefit was not subject to the

deductible) Observation will be 20% after deductible. (Previously this benefit was not subject to the

deductible) Outpatient specialty laboratory/imaging will be 20% after deductible. (Previously this benefit was

not subject to the deductible) Outpatient surgery/procedures in an ambulatory surgery center or outpatient hospital based

setting will be 20% after deductible. (Previously this benefit was not subject to the deductible) Generic maintenance drug will be $10 per prescription (was $5 per prescription) and other

generic drug will be $20 per prescription (was $15 per prescription). Emergency services (in/out of area) will be 20% after deductible. (Previously this benefit was not

subject to the deductible) Skilled nursing care (up to 120 days per accumulation period) will be 20% after deductible.

(Previously this benefit was not subject to the deductible)

7. KP Silver - $30 Plan Medical deductible will be $1,200 per member/$2,400 for family of 2 or more members (was

$1,000/$2,000). Hospital inpatient will be $750/day (was $500/day). Observation will be $750/day (was $500/day). Generic maintenance drug will be $10 per prescription (was $5 per prescription), and other

generic drug will be $20 (was $15 per prescription).

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kp.org

Important Benefit Information Enclosed Benefit Summary

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KP Gold $15 – Optical – Dent.2016 Benefits summary

This is only a summary. It does not fully describe your benefit coverage. For details on your benefit coverage, exclusions, andplan 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”). The Service Agreement is the legally binding document between HealthPlan and its members. In event of ambiguity, or a conflict between this summary and the Service Agreement, the ServiceAgreement shall control. Senior Advantage members must refer to their Kaiser Permanente Senior Advantage Evidence ofCoverage for a description of their benefits.

You are covered for Medically Necessary services at Kaiser Permanente facilities within the Hawaii service area, and which areprovided, prescribed or directed by a Kaiser Permanente physician and consistent with reasonable medical management techniquesspecified under this plan with respect to the frequency, method, treatment or licensing or certification, to the extent the provider isacting within the scope of the provider’s license or certification under applicable state law. All care and services need to becoordinated by a Kaiser Permanente physician except for emergency services, urgent care or services authorized by a writtenreferral.

Riders, if any, are described after the Exclusions and Limitations sections.

If you receive covered services and items in one of these seven care settings, you only pay a single copay or coinsurance: hospital, observation,outpatient surgery and procedures in an ambulatory surgery center or outpatient hospital-based setting, skilled nursing facility, dialysis,radiation therapy and emergency room services. However, services and items received during an emergency room visit are included in the copayor coinsurance for emergency services, except complex imaging services (including interpretation of imaging) are covered under the compleximaging benefit.

For settings that are not mentioned above, 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 vitrofertilization are covered under the prescribed drugs benefit section. Laboratory services related to in vitro fertilization are covered under thelaboratory services benefit section.

Section Benefits You paySupplementalchargesmaximum **

Your copays and coinsurance for covered Basic Health Services are cappedby a supplemental charges maximum

$2,200 per member; $4,400per family unit (2 or moremembers) per calendar year

Your copays and coinsurance for covered pharmacy dispensed drugs arecapped by a prescription drug supplemental charges maximum

$4,650 per member;$9,300 per family unit (2 ormore members) peraccumulation period

Deductible Deductible ** $200 per member, $400 perfamily unit (family unit of 2 ormore members) per calendaryear

Outpatientservices

Office visits **· For primary care $15 per visit

· With a Specialist $15 per visit

Outpatient surgery and procedures

· Provided in medical office during a primary care visit $15 per visit

· Provided in medical office with a Specialist $15 per visit

· Provided in an ambulatory surgery center (ASC) or hospital-basedsetting

10% of applicable chargesafter deductible

· Routine pre- and post-surgical office visits in connection with acovered surgery

No Charge

Telehealth Applicable cost shares apply.See applicable benefitsections†

Allergy testing $15 per visitAllergy treatment materials that are on Kaiser Permanente’sformulary and require skilled administration by medical personnel

$20 per dose

▼ Members must pay their office visit copay for the office visit.† For example, office visits are subject to office visit copay, inpatient care are subject to hospital inpatient care cost share, lab, imaging and testing are subject

to lab, imaging and testing cost share, etc.).* See Coverage Exclusions Section** See Coverage Limitations Section

- 1 - GP_chart_ODS_16.docx 1/2016

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Section Benefits You payChemotherapy, includes the treatment of infections or malignantdiseases· Office visits $15 per visit

· Chemotherapy infusions or injections that require skilledadministration by medical personnel

$20 per dose

· Self-administered chemotherapy (e.g. oral chemotherapy)Note: In accordance with state law, oral chemotherapy will be administered at the sameor lower cost share as intravenous chemotherapy.

Self-administered/take homedrug copay (if you have a drugrider) or $20 per dose (if youdo not have a drug rider)

* Physical, occupational and speech therapy **includes treatment for autismNote: includes short-term therapy and habilitative services

$15 per visit

Dialysis· Kaiser Permanente physician and facility services for dialysis· Equipment, training and medical supplies for home dialysis

10% of applicable chargesNo charge

Materials for dressings and casts Applicable cost shares apply.See applicable benefitsections†

Outpatientlaboratory,imaging, andtesting services

Laboratory services ** $20 per day for basic labservices and 20% of applicablecharges after deductible forspecialty lab services

Imaging services **· General radiology· Specialty imaging services

$20 per day for generalradiology and 20% ofapplicable charges afterdeductible for specialimaging


Testing services** 20% of applicable charges

Outpatientradiationtherapy

Radiation therapy **· Provided in a hospital based setting, ambulatory surgery center, or

skilled nursing facility· Provided in other outpatient settings

Applicable cost shares apply.See applicable benefit sections†20% of applicable charges

Observation Observation 10% of applicable chargesafter deductible

Hospitalinpatient care

Hospital inpatient care ** 10% of applicable chargesafter deductible

* Physical, occupational and speech therapy **Note: includes short-term therapy and habilitative services

Included in the above hospitalinpatient care cost share

Transplants * Transplants ** Applicable cost shares apply.See applicable benefitsections†




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Section Benefits You payPreventive careservices

Preventive care services (which protect against disease, promotehealth, and/or detect disease in its earliest stages before noticeablesymptoms develop), including:

No charge(non-preventive care servicesaccording to member’s regularplan benefits)

· Screening services for Grade A and B recommendations of the U.S.Preventive Services Task Force (USPSTF), such as:· Preventive counseling services· Screening laboratory services· Screening radiology services

· FDA approved contraceptive drugs and devices** that are available onthe Health Plan formulary, as required by the federal PatientProtection and Affordable Care Act (PPACA). Coverage of all otherFDA approved contraceptive drugs and devices are described in theObstetrical care section.

· Female sterilizations**· Purchase of breast feeding pump, including any equipment that is

required for pump functionalityA complete list of preventive care services provided at no charge is available throughthe Customer Service Center. This list is subject to change at any time. If youreceive any other covered services during a preventive care visit, you will pay theapplicable charges for those services.

Preventive care office visits for:· Well child office 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 care office visit per calendar year for members 6 yearsof age and over

· One gynecological office visit per calendar year for female membersPrescribeddrugs

Prescribed drugs that require skilled administration bymedical personnel, such as injections and infusions(e.g. cannot be self-administered) **· Provided in a medical office· Provided during other settings, such as hospital stay, outpatient

surgery, skilled nursing care· Prescribed Self-administered drugs (such as drugs taken orally)

$20 per dose ▼

Applicable cost shares apply.See applicable benefit sections†See attached Drug summary

Diabetes supplies ** 50% of applicable charges(a minimum price asdetermined by PharmacyAdministration may apply)

Tobacco cessation drugs and products ** No charge

FDA approved contraceptive drugs and devices ** 50% of applicable charges(a minimum price asdetermined by PharmacyAdministration may apply) ▼

Other drug therapy services· Home IV/Infusion therapy ** No charge

· Medically necessary growth hormone therapy· Prescribed inhalation therapy

Applicable cost shares apply.See applicable benefitsections†

Routine immunizations No charge




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Section Benefits You payObstetrical care,interruptedpregnancy,family planning,infertilityservices, andartificialconceptionservices

Routine obstetrical (maternity) care ** No charge for routineprenatal visits and onepostpartum visit, 10% ofapplicable charges afterdeductible fordelivery/hospital stay

· Routine prenatal visits· Routine postpartum visit· Delivery/hospital stay (uncomplicated)

Non-routine obstetrical (maternity) care, including complicationsof pregnancy and false labor


Inpatient stay and inpatient care for newborn, includingcircumcision and nursery care, during or after mother's hospital stay(assuming newborn is timely enrolled on Kaiser Permanente subscriber’splan)

Hospital inpatient care costshare apply (see hospitalinpatient care section)

Interrupted pregnancy ** $15 per visit

Family planning office visits for female members that are provided inaccordance with the Patient Protection and Affordable Care Act

No charge

All other family planning office visits $15 per visit

Involuntary infertility office visits Primary care and Specialistoffice visit copay applies, 20%of applicable charges for IVF

* In vitro fertilization **

* Artificial insemination

Sterilization services· Vasectomy services· Female sterilizations **, such as tubal ligation


Reconstructivesurgery

Surgery to improve physical function, such as bariatric surgery andsurgery to correct congenital anomalies

Surgery following injury or medically necessary surgery

Surgery following mastectomy, including treatment for complicationsresulting from a covered mastectomy and reconstruction, such aslymphedema


Home healthcare andhospice care

Home health care, nurse and home health aide visits to homeboundmembers, when prescribed by a Kaiser Permanente physician

No charge(office visit copays apply tophysician visits)

Hospice care ** No charge(office visit copays apply tophysician visits)

Skilled nursingcare *

Skilled nursing care ** 10% of applicable chargesafter deductible for up to 120days per calendar year

Emergencyservices

Emergency services ** within and outside the Hawaii service area

Note: The copayment for emergency services is waived if you are directly admitted as ahospital inpatient from the emergency department (the hospital copay will apply).

20% of applicable charges and20% of applicable chargesafter deductible for specialtyimaging

Urgent careservices

Urgent care services **

· At a Kaiser Permanente (or Kaiser Permanente-designated) urgent carecenter within the Hawaii service area, for primary care services

$15 per visit

· At a Kaiser Permanente(or Kaiser Permanente-designated) urgent carecenter within the Hawaii service area, with a Specialist

$15 per visit

· At a non-Kaiser Permanente facility outside the Hawaii service area 20% of applicable charges

Ambulanceservices

Ambulance services ** 20% of applicable charges




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Section Benefits You payBlood Blood and blood processing ** Applicable cost shares apply.

See applicable benefitsections†

Mental healthservices **

Mental health outpatient services, including office visits, day treatmentand partial hospitalization services

$15 per visit

Mental health hospital inpatient care, including non-hospital residentialservices


Chemicaldependencyservices **

Chemical dependency outpatient services, including office visits, daytreatment and partial hospitalization services

$15 per visit

Chemical dependency hospital inpatient care, including non-hospitalresidential services and detoxification services


Health education General health education services **, including diabetesself-management training and education

$15 per visit

Student coverageoutside theservice area **

While attending a college in the United States and outside of the KaiserPermanente’s service areas on a full-time basis, members up to age 26 arecovered per calendar year for the following services:· Up to 10 office visits for routine primary care $20 per visit

· Up to 10 combined outpatient basic laboratory services, basic imagingservices, and testing services· Basic laboratory services· Basic imaging services· Testing services

$10 per day$10 per day20% of applicable charges

· Up to 10 prescriptions of self-administered drugs 20% of applicable chargesInternalprosthetics,devices,and aids **

Implanted internal prosthetics, including fitting and adjustment ofthese devices, including repairs and replacement other than those due tomisuse or loss:


Durablemedicalequipment **

Diabetes equipment 50% of applicable chargesHome phototherapy equipment for newborns No chargeBreast feeding pump, including any equipment that is required forpump functionality

No Charge

All other durable medical equipment 10% of applicable chargesExternalprostheticdevices andbraces **

External prosthetic devices and braces 10% of applicable charges

A prosthetic device following mastectomy, if all or part of a breast issurgically removed for medically necessary reasons

Note: Replacement will be made when a prosthesis is no longer functional. Custom-madeprostheses will be provided when necessary.

Applicable internalprosthetics, devices, and aidscost shares apply

Hearing aids ** Hearing aids, provided once every three years for each hearing impairedear

10% of applicable charges

Other medicalservices andsupplies

Anesthesia and hospital services for dental procedures forchildren with serious mental, physical, or behavioralproblems

Pulmonary rehabilitation

Hyperbaric oxygen therapy

Treatment of erectile dysfunction due to an organic cause

Temporomandibular Joint Dysfunction (TMJ)

Vision appliances, including eyeglasses and contact lenses, and visionprocedures for certain medical conditions

Anesthesia services, including general anesthesia, regional anesthesia,and monitored anesthesia for high-risk members

Applicable cost shares apply.See applicable benefit sections(e.g. – office visits subject tooffice visit copay, inpatientcare subject to hospitalinpatient care copay, etc.)

Dependentcoverage

Dependent (biological, step or adopted) children of the Subscriber (or the Subscriber’s spouse) are eligibleup to the child’s 26th birthday. Other dependents may include: 1) the Subscriber's (or Subscriber’s spouse’s)dependent (biological, step or adopted) children (over age 26) who are incapable of self-sustaining




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Section Benefits You payemployment because of a physically- or mentally-disabling injury, illness, or condition that occurred prior toreaching age 26, and receive 50 percent or more of their support and maintenance from the Subscriber (orSubscriber’s Spouse) (proof of incapacity and dependency may be required), or 2) a person who is under age26, for whom the Subscriber (or Subscriber’s spouse), is (or was before the person’s 18th birthday) the courtappointed legal guardian.

* 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 alsoexcluded. "Service" means any treatment, diagnosis, care, procedure, test, drug, injectable, facility, equipment, item, device, or supply.The following Services are excluded:· Acupuncture. (This exclusion may not apply if you have the applicable Complementary Alternative Medicine Rider.)· 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 thisexclusion 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. Ifyour plan is required to cover all essential health benefits, then part of this exclusion does not apply (for example, external prostheticdevices, braces, and hearing aids may be covered benefits). Corrective lenses and eyeglasses may be covered for certain medicalconditions, if all essential health benefits are required to be covered. Pediatric vision care services and devices may also be coveredas 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 andregardless of the means of administration, except as stated under the “Blood” section. Donor directed units are not covered.

· Cardiac rehabilitation.· Chiropractic Services. (This exclusion may not apply if you have the applicable Complementary Alternative Medicine Rider.)· 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, KaiserPermanente physician services to correct significant disfigurement resulting from an injury or medically necessary surgery, incident toa 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 thisexclusion does not apply (for example, Services relating to temporomandibular joint dysfunction (TMJ) may be covered). (Part ofthis exclusion may not apply if you have a Dental Rider.)

· Employer or government responsibility: Services that an employer is required by law to provide or that are covered byWorker's Compensation or employer liability law; Services for any military service-connected illness, injury or condition when suchServices are reasonably available to the member at a Veterans Affairs facility; Services required by law to be provided only by, orreceived only from, a government agency.

· Experimental or investigational Services.· 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 andpediatric 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), andPhoto-refractive keratectomy (PRK). If your plan is required to cover all essential health benefits, then part of this exclusion doesnot 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 weight management and 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 or 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 tosuch Services and donor sperm and donor eggs used for such Services.




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- Services to reverse voluntary, surgically-induced infertility.- Stand-alone ovulation induction Services.

· 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 forparole or probation. Physical examinations that are authorized and deemed medically necessary by a Kaiser Permanente physicianand 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; routine vision services ;services provided by family or household members; duplicate services provided by another therapy or available through schoolsand/or government programs.

· 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 KaiserPermanente licensed health care practitioner, 2) is approved by Kaiser Permanente’s medical director or designee, and 3) is for thepurpose of treating a medical condition, is the most appropriate delivery or level of service (considering potential benefits and harms to thepatient), and known to be effective in improving health outcomes. Effectiveness is determined first by scientific evidence, then byprofessional standards of care, then by expert opinion. Coverage is limited to the services which are cost effective and adequately meet themedical needs of the member.

· All Services, drugs, injections, equipment, supplies and prosthetics related to treatment of sexual dysfunction, except evaluations and

health care practitioners’ services for treatment of sexual dysfunction.· Personal comfort items, such as telephone, television, and take-home medical supplies, during covered skilled nursing care.· Services, procedures, treatments and supplies 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.




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** 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 alabor dispute or a natural disaster.

· Coverage is not provided for treatment of conditions for which a member has refused recommended treatment for personal reasonswhen Kaiser Permanente physicians believe no professionally acceptable alternative treatment exists. Coverage will cease at the pointthe 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 othermeans, would result in death or serious impairment of the member’s health, and 2) is for the purpose of transporting the member toreceive medically necessary acute care. In addition, air ambulance must be for the purpose of transporting the member to the nearestmedical facility designated by Health Plan for receipt of medically necessary acute care, and the member’s condition must require theservices of an air ambulance for safe transport.

· Coverage of blood and blood processing includes (regardless of replacement, units and processing of units) whole blood, redcell products, cryoprecipitates, platelets, plasma, and fresh frozen plasma. Rh immune globulin is provided subject to the cost sharefor skilled-administered prescription drugs. Coverage of blood and blood processing also includes collection, processing, and storageof 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 facilityapproved by Kaiser Permanente Medical Group. Specialized alcohol or chemical dependence treatment services include daytreatment or partial hospitalization services and non-hospital residential services. All covered chemical dependency services will beprovided under an approved individualized treatment plan. Your coverage includes treatment for conditions listed in the currentDiagnostic and Statistical Manual of the American Psychiatric Association that meet the standards of medical necessity.

· Members are covered for contraceptive drugs and devices (to prevent unwanted pregnancies) only when all of the followingcriteria are met: 1) prescribed by a licensed Prescriber, 2) the drug is one for which a prescription is required by law, and 3) obtainedat 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 thoseservices. 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 deductiblebefore the noted copayment will be effective). This deductible is separate from any other benefit-specific deductible that may bedescribed herein. For example if prescription drugs are subject to a drug deductible, payments toward that drug deductible do notcount toward this medical deductible. Payments toward this medical deductible do not count toward any other benefit-specificdeductible (such as a drug deductible). Services that are subject to this medical deductible are: 1) outpatient surgery or proceduresprovided in an ambulatory surgery center (ASC) or other hospital-based setting, 2) hospital inpatient care, 3) specialty laboratoryservices, 4) specialty imaging services, 5) skilled nursing care, and 6) emergency services (when noted).

· Up to a 30-consecutive-day supply of diabetes supplies is provided (as described under the prescribed drugs section) if all ofthe following criteria are met: 1) prescribed by a licensed Prescriber, 2) on the Health Plan formulary and used in accordance withformulary criteria, guidelines, or restrictions, and 3) obtained at pharmacies in the Service Area that are operated by KaiserFoundation Hospital, Kaiser Foundation Health Plan, Inc. or a pharmacy we designate.

· 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 formularyguidelines or restrictions, and 3) prescription is required by law.

· Durable medical equipment (such as oxygen dispensing equipment and oxygen, diabetes equipment, home phototherapyequipment for newborns, and breast feeding pump) must be prescribed by a Kaiser Permanente or Kaiser Permanente-designatedphysician, preauthorized in writing by Kaiser Permanente, and obtained from sources designated by Kaiser Permanente on either apurchase or rental basis, as determined by Kaiser Permanente. Durable medical equipment is that equipment and supplies necessaryto operate the equipment which: 1) is intended for repeated use, 2) is primarily and customarily used to serve a medical purpose, 3)is appropriate for use in the home, 4) is generally not useful to a person in the absence of illness or injury, 5) was in general use onMarch 1 of the year immediately preceding the year in which this Service Agreement became effective or was last renewed, 6) is notexcluded from coverage from Medicare, and if covered by Medicare, meets the coverage definitions, criteria and guidelinesestablished by Medicare at the time the diabetes equipment is prescribed, and 7) is on Kaiser Permanente’s formulary and used inaccordance with formulary criteria, guidelines, or restrictions. Repair, replacement and adjustment of durable medical equipment,other than due to misuse or loss, is included in coverage. Diabetes equipment is limited to glucose meters and external insulinpumps, and the supplies necessary to operate them. Coverage of breast feeding pump includes any equipment that is requiredfor pump functionality. If rented or loaned from Kaiser Permanente, the member must return any durable medical equipment itemsto Kaiser Permanente or its designee or pay Kaiser Permanente or its designee the fair market price for the equipment when it is nolonger prescribed by a Kaiser Permanente physician or used by the member. Coverage is limited to the standard item of durablemedical equipment in accord with Medicare guidelines that adequately meets the medical needs of the member. Convenience andluxury items and features are not covered. The following are excluded from coverage: 1) comfort and convenience equipment, anddevices not medical in nature such as sauna baths and elevators, 2) disposable supplies for home use such as bandages, gauze, tape,




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antiseptics, and ace type bandages, 3) exercise and hygiene equipment, 4) electronic monitors of the function of the heart or lungs, 5)devices to perform medical tests on blood or other body substances or excretions, 6) dental appliances or devices, 7) repair,adjustment or replacement due to misuse or loss, 8) experimental or research equipment, 9) durable medical equipment related tosexual dysfunction, and 10) modifications to a home or car.

· Emergency services are covered for initial emergency treatment only. Member (or member’s family) must notify Health Planwithin 48 hours if admitted to a non-Kaiser Permanente facility. Emergency Services are those medically necessary services availablethrough the emergency department to medically screen, examine and Stabilize the patient for Emergency Medical Conditions. AnEmergency Medical Condition is a medical condition manifesting itself by acute symptoms of sufficient severity that meet theprudent 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. Examples of an EmergencyMedical Condition include chest pain or other heart attack signs, poisoning, loss of consciousness, convulsions or seizures, brokenback or neck, heavy bleeding, sudden weakness on one side, severe pain, breathing problems, drug overdose, severe allergic reaction,severe burns, and broken bones. Examples on non-emergencies are colds, flu, earaches, sore throats, and using the emergency roomfor convenience or during normal office hours for medical conditions that can be treated in a medical office. Continuing orfollow-up treatment for Emergency Medical Conditions 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 (includingbehavioral health treatment), prescription drugs, rehabilitative and habilitative services and devices, laboratory services, preventiveand wellness services and chronic disease management, and pediatric services to the extent required by HHS and EHB-benchmarkplan. Pediatric oral care services are covered under this Service Agreement only if a separate Dental Rider is attached (coveredservices are described within any applicable Dental Rider). A complete list of essential health benefits is available through thecustomer service center. Essential health benefits are provided upon payment of the copayments listed under the appropriate benefitsections (e.g. – office visits subject to office visit copay, inpatient care subject to hospital inpatient care copay, etc.).

· External prosthetic devices and braces (including speech generating devices and voice synthesizers) must be prescribed by aKaiser Permanente physician, preauthorized in writing by Kaiser Permanente, and obtained from sources designated by KaiserPermanente. External prosthetic devices must meet all of the following criteria: 1) are affixed to the body externally, 2) are requiredto replace all or part of any body organ or replace all or part of the function of a permanently inoperative or malfunctioning bodyorgan, 3) were in general use on March 1 of the year immediately preceding the year in which this Service Agreement becameeffective or was last renewed, and 4) are not excluded from coverage from Medicare, and if covered by Medicare, meet the coveragedefinitions criteria and guidelines established by Medicare at the time the prosthetic is prescribed. Fitting and adjustment of thesedevices, including repairs and replacement other than due to misuse or loss, is included in coverage. Covered braces are those rigidand semi-rigid devices which: 1) are required to support a weak or deformed body member, or 2) are required to restrict or eliminatemotion in a diseased or injured part of the body, and 3) 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. The following itemsare not covered as external prosthetics, but may be covered under another benefit category: 1) pacemakers and other surgicallyimplanted internal prosthetic devices (these are covered under implanted internal prosthetic devices and aids), 2) hearing aids (theseare covered under the hearing aid benefit), and 3) corrective lenses and eyeglasses (these are covered under any applicable pediatric visioncare service and may also be covered if an Optical Rider is attached). The following items are excluded from coverage: 1) dentalprostheses, devices and appliances, 2) non-rigid appliances such as elastic stockings, garter belts, arch supports, non-rigid corsets and similardevices, 3) orthopedic aids such as corrective shoes and shoe inserts, 4) replacement of lost prosthetic devices, 5) repairs, adjustments orreplacements due to misuse or loss, 6) experimental or research devices and appliances, 7) external prosthetic devices related to sexualdysfunction, 8) supplies, whether or not related to external prosthetic devices or braces, 9) external prosthetics for comfort and/orconvenience, or which are not medical in nature, and 10) disposable supplies for home use such as bandages, gauze, tape, antiseptics, andace type bandages. Coverage is limited to the standard model of external prosthetic device or brace in accord with Medicare guidelines thatadequately meets the medical needs of the member. Convenience and luxury items and features are not covered.

· When covered as a preventive care service (under the Patient Protection and Affordable Care Act), the following types of femalesterilizations and related items and services are provided: 1) sterilization surgery for women: Trans-abdominal SurgicalSterilization/Surgical Implant; 2) sterilization implant for women: Trans-cervical Surgical Sterilization Implant; 3) pre and postoperative visits associated with female sterilization procedures; and 4) Hysterosalpingogram test following sterilization implantprocedure.

· General health education services include patient education classes which are educational programs directed toward memberswho have specific diagnosed medical conditions whereby members are taught self-care skills to understand, monitor, manage and/orimprove their condition. Examples of conditions include asthma, diabetes, cardiovascular disease, chronic obstructive pulmonarydisease (COPD), and behavioral health conditions.

· Hearing aids must be prescribed by a Kaiser Permanente physician or Kaiser Permanente audiologist and obtained from sourcesdesignated by Kaiser Permanente. Coverage is limited to the standard hearing aid(s) in accord with Kaiser Permanente guidelinesthat adequately meets the medical needs of the member. Hearing aid(s) above the standard model will be provided upon payment ofthe copayment that member would have paid for a standard hearing aid(s) plus all additional charges for any amount above thestandard hearing aid(s). All other related costs are excluded from coverage, including but not limited to consultation, fitting,




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rechecks and adjustments for the hearing aid(s).· Prescription drugs that are self-administered intravenously under the home IV/infusion benefit include biological therapeutics,

biopharmaceuticals, or intravenous nutrient solutions needed for primary diet. Self-administered injections are covered uponpayment of the member cost share for take-home, self-administered prescription drugs.

· Coverage of hospice care is supportive and palliative care for a terminally ill member, as directed by a Kaiser Permanentephysician. Hospice coverage includes two 90-day periods, followed by an unlimited number of 60-day periods. The member mustbe certified by a Kaiser Permanente physician as terminally ill at the beginning of each period. (Hospice benefits apply in lieu of anyother plan benefits for treatment of terminal illness.) Hospice includes services such as: 1) nursing care (excluding private dutynursing), 2) medical social services, 3) home health aide services, 4) medical supplies, 5) physician services, 6) counseling andcoordination of bereavement services, 7) services of volunteers, and 8) physical therapy, occupational therapy, or speech languagepathology.

· Hospital inpatient care (for acute care registered bed patients) includes services such as: 1) room and board, 2) general nursingcare 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) isolation care room, 11) medicallynecessary services provided in an intermediate care unit at an acute care facility, 12) special diet, 13) laboratory services, 14) imagingservices, 15) testing services, 16) radiation therapy, 17) chemotherapy, 18) physical therapy, 19) occupational therapy, 20) speechtherapy, 21) administered drugs, 22) internal prosthetics and devices, 23) blood, 24) durable medical equipment ordinarily furnishedby a hospital, and 25) external prosthetic devices and braces ordinarily furnished by a hospital.

· Specialty imaging services are services such as CT, interventional radiology, MRI, nuclear medicine, and ultrasound. Generalradiology 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 Exclusionsabove for services and items not covered.

· Internal prosthetics, devices, and aids (such as pacemakers, hip joints, surgical mesh, stents, bone cement, bolts, screws, androds) must be prescribed by a Physician, preauthorized in writing by Kaiser Permanente, and obtained from sources designated byHealth Plan. Internal prosthetics, devices, and aids are those which meet all of the following: 1) are required to replace all or part ofan internal body organ or replace all or part of the function of a permanently inoperative or malfunctioning body organ, 2) are usedconsistently 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 waslast 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, includingrepairs and replacement other than due to misuse or loss, is included in coverage. The following are excluded from coverage: a) allimplanted internal prosthetics and devices and internally implanted aids related to an excluded or non-covered service/benefit, andb) Prosthetics, devices, and aids related to sexual dysfunction. Coverage is limited to the standard prosthetic model that adequatelymeets 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 (includingabortion 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, pathology, and testing for geneticdiseases. Basic laboratory services include services such as thyroid tests, throat cultures, urine analysis, fasting blood sugar andA1c for diabetes monitoring, electrolytes, drug screening, blood type and cross match, cholesterol tests, and hepatitis B.

· A service or item is Medically Necessary (subject to the applicable state law definitions and criteria) only if, 1) recommended bythe treating Physician or treating Kaiser Permanente licensed health care practitioner, 2) is approved by Kaiser Permanente’s medicaldirector 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 isdetermined first by scientific evidence. If no scientific evidence exists, then by professional standards of care. If no professionalstandards of care exist or if they exist but are outdated or contradictory, then by expert opinion.

· Mental health services include coverage in a specialized mental health treatment unit or facility approved by Kaiser PermanenteMedical Group. Specialized mental health treatment services include day treatment or partial hospitalization services andnon-hospital residential services. All covered mental health services will be provided under an approved individualized treatmentplan. Your coverage includes treatment for conditions listed in the current Diagnostic and Statistical Manual of the AmericanPsychiatric Association that meet the standards of medical necessity.

· Office visits are limited to one or more of the following services: examination, history, medical decision making and/orconsultation. Members’ choice of primary care providers and access to specialty care allow for the following: 1) member maychoose any primary care physician available to accept member, 2) parents may choose a pediatrician as the primary care physician fortheir child, 3) members do not need a referral or prior authorization for certain specialty care, such as obstetrical or gynecologicalcare, and 4) the physician may have to get prior authorization for certain services. A Specialist is a licensed medical practitioneridentified by Health Plan or Medical Group, including a Kaiser Permanente physician, except does not include (i) family practice, (ii)general practice, (iii) internal medicine, (iv) pediatrics, (v) obstetrics/gynecology (including certified nurse midwives), (vi) physicianassistants (PA), and (vii) Health Plan employed providers. Members must obtain a referral for most initial visits in order to receive




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covered services from certain Specialists.· Orthodontic services for treatment of orofacial anomalies resulting from birth defects or birth defect syndromes are

limited to Members under 26 years of age, and to a maximum benefit per treatment phase set annually by the insurancecommissioner for the applicable calendar year. For example, for 2016 contracts, Member will be responsible for all charges afterHealth Plan has paid the maximum benefit of $5,500 per treatment phase.

· Short-term physical, occupational and speech therapy (only if the condition is subject to significant, measurableimprovement in physical function; Kaiser Permanente clinical guidelines apply) services means medical services provided for thoseconditions which meet all of the following criteria: 1) the therapy is ordered by a Physician under an individual treatment plan; 2) inthe judgment of a Physician, the condition is subject to significant, measurable improvement in physical function with short-termtherapy; 3) the therapy is provided by or under the supervision of a Physician-designated licensed physical, speech, or occupationaltherapist, as appropriate.; and 4) as determined by a Physician, the therapy must be necessary to sufficiently restore neurological and/ormusculoskeletal function that was lost or impaired due to an illness or injury. Occupational therapy is limited to hand rehabilitationservices, and medical services to achieve improved self care and other customary activities of daily living, except when provided inaccordance with the coverage for habilitative services. Speech-language pathology is limited to deficits due to trauma, drugexposure, chronic ear infections, hearing loss, and impairments of specific organic origin, except when provided in accordance withthe coverage for habilitative services. Habilitative services and devices develop, improve, or maintain skills and functioning fordaily living that were never learned or acquired to a developmentally appropriate level. Skills and functioning for daily living, such asbasic activities of daily living, are typically learned or acquired during childhood development. Habilitative services and devicesinclude: 1) audiology services, 2) occupational therapy, 3) physical therapy, 4) speech-language therapy, 5) vision services, and 6)devices associated with these services including augmentative communication devices, reading devices, and visual aids. However,habilitative services do not include duplicate services provided by another therapy or available through schools and/or governmentprograms. Autism services are limited to: 1) diagnosis and treatment of autism for Members under 14 years of age, and 2) appliedbehavioral analysis services for Members under 14 years, up to a maximum benefit of $25,000 per calendar year. (Member will beresponsible for all charges after Health Plan has paid for $25,000 in services.) Treatment for autism will be provided in accord withan approved treatment plan.

· Radiation therapy services include radium therapy, radioactive isotope therapy, specialty imaging and skilled administered drugs.· 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 andnewborn 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 includes thefollowing services: 1) nursing care, 2) room and board (including semi-private rooms), 3) medical social services, 4) medical supplies,5) durable medical equipment ordinarily provided by a skilled nursing facility, 6) external prosthetic devises and braces ordinarilyfurnished by a skilled nursing facility, 7) radiation therapy, and 8) chemotherapy. In addition to Health Plan criteria, Medicareguidelines are used to determine when skilled nursing services are covered, except that a prior three-day stay in an acute care hospitalis not required.

· Services covered under the student coverage outside the service area benefit are subject to the following limitations: 1)services can only be obtained outside Kaiser Permanente Hawaii’s service area and outside all other Kaiser Permanente’s serviceareas, at non-Kaiser Permanente facilities and with non-Kaiser Permanente health care providers, 2) in order for Kaiser Permanenteto process the claim, at the time of filing the initial claim and thereafter, as requested by Kaiser Permanente, member shall submit awritten certification, on forms prescribed by Kaiser Permanente, certifying the member’s student status, 3) the student must pay forservices at the point in time the services are received then file a claim for reimbursement by submitting the claim to KaiserPermanente’s claims department, 4) this student coverage benefit cannot be combined with any other benefit, 5) Kaiser Permanentewill not pay under this student coverage benefit for a service Kaiser Permanente is covering under another section, such asemergency services, out of area urgent care, and referrals, and 6) this student coverage benefit does not apply to Senior Advantagemembers and Medicare members with Medicare as primary coverage. The following are excluded under the student coverageoutside the service area benefit: 1) transplant services and related care, 2) services received outside the United States, 3) servicesother than routine primary care, basic laboratory services, basic imaging services, testing services, and self-administered prescriptiondrugs, 4) outpatient surgery and procedures performed in an ambulatory surgery center or other hospital-based setting, 5) servicesreceived in other Kaiser Permanente regions’ service areas, 6) services received within Kaiser Permanente Hawaii’s service area, 7)dental, 8) mail order drugs, 9) chiropractic, acupuncture and massage therapy services, and 10) services not explicitly listed as coveredunder this student coverage benefit.

· Your incurred copays and coinsurance for covered medical Basic Health Services are capped each calendar year by a medicalsupplemental charges maximum.- Except dental services covered by Hawaii Dental Services, all incurred copays, coinsurance, and deductibles (if applicable) count

toward the limit on supplemental charges, and 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: office visits for services listed in this Basic Health Services section, allergytest materials, ambulance service, artificial insemination, blood or blood processing, braces, chemical dependency services,contraceptive drugs and devices, payments toward any applicable deductible, diabetes supplies and equipment, dialysis, drugs




SAMPLE

requiring skilled administration, durable medical equipment, emergency service, external prosthetics, family planning office visits,health evaluation office visits for adults, hearing aids, home health, hospice, imaging (including X-rays), immunizations (excludingtravel immunizations), internal prosthetics, internal devices and aids, in vitro fertilization procedure, infertility office visits, inpatientroom (semi-private), interrupted pregnancy/abortion, laboratory, medical foods, mental health services, obstetrical (maternity) care,outpatient surgery and procedures, radiation and respiratory therapy, radioactive materials, reconstructive surgery, coveredself-administered/outpatient prescription drugs (including payments toward any applicable prescription drug deductible),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 theSupplemental Charges Maximum: all services for which coverage has been exhausted, all excluded or non-covered benefits, allother services not specifically listed above as a Basic Health Service, complementary alternative medicine (chiropractic,acupuncture, massage therapy, or naturopathy), 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, student coverageoutside the service area, take-home supplies, and travel immunizations.

· Your incurred copays and coinsurance for Pharmacy Dispensed Drugs are capped each calendar year by a Prescription DrugSupplemental Charges Maximum.- All incurred copays, coinsurance, and deductibles (if applicable) for Pharmacy Dispensed Drugs count toward the limit on

Prescription Drug Supplemental Charges Maximum, and are credited toward the calendar year in which they were received.- "Pharmacy Dispensed Drugs" include all covered safe to self-administer pharmacy dispensed drugs, including but not limited to

inhalers, insulin, chemotherapy drugs, contraceptive drugs/devices, and tobacco cessation drugs.- The following items are considered Medical Health Services and count toward the limit on Medical Supplemental Charges

Maximum (and do not count toward the Prescription Drug Supplemental Charges Maximum): skilled administered drugs, diabetessupplies (except supplies to operate diabetes equipment), lancets, syringes, and drugs that are not dispensed from the pharmacybecause they are not safe to self-administer.

- Payments toward any Prescription Drug Deductible also count toward the limit on Prescription Drug Supplemental ChargesMaximum.

· Testing services include electrocardiograms, electroencephalograms, EMG, pulmonary function studies, sleep studies, andtreadmill.

· Up to a 30-consecutive-day supply of tobacco cessation drugs and products is provided when all of the following criteriaare met: 1) prescribed by a licensed Prescriber, 2) available on the Health Plan formulary’s Tobacco Cessation list of approved drugsand 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. ora pharmacy we designate, and 4) member meets Health Plan-approved program-defined requirements for smoking cessation classesor 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 and transplant evaluations for transplant donors. Covered transplants include kidney, pancreas, heart,

heart-lung, liver, lung, simultaneous kidney-pancreas, bone marrow, cornea, small bowel, small bowel-liver transplants, smallbowel and multivisceral transplants, and stem-cell transplants. Health Plan will pay for medical services for living organ and tissuedonors and prospective donors if the medical services meet all of the requirements below. Health Plan pays for these medicalservices as a courtesy to donors and prospective donors, and this document does not give donors or prospective donors any ofthe rights of Kaiser Permanente members.

- Regardless whether the donor is a Kaiser Permanente member or not, the terms, conditions, and Supplemental Charges of thetransplant-recipient Kaiser Permanente member will apply. Supplemental charges for medical services provided to transplantdonors are the responsibility of the transplant-recipient Kaiser Permanente member to pay, and count toward thetransplant-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 aHealth 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-KaiserPermanente 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.




SAMPLE

· Urgent care services are covered for initial urgent care treatment only. "Urgent Care Services" means medically necessaryservices for a condition that requires prompt medical attention but is not an Emergency Medical Condition. Continuing orfollow-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 autoaccident 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 themember receives related to conception, pregnancy, or delivery in connection with a Surrogacy Arrangement. The member must reimburseKaiser Permanente for the costs of Surrogacy Health Services, out of the compensation the member or the member’s payee are entitled toreceive under the Surrogacy Arrangement.




SAMPLE

SAMPLE

Benefits You pay

Drug Rider$10 / $20 /50% / 50%

For each prescription, when the quantity does not exceed:· a 30–consecutive-day supply of a prescribed drug, or· an amount as determined by the formulary.

$10 pergenericMaintenancedrugprescription,$20 perprescriptionfor all othergeneric drugprescriptions,50% ofapplicablecharges perbrand-namedrugprescription,and50% ofapplicablecharges perSpecialtydrugprescriptionafterPrescriptionDrugDeductible

Self-administered drugs are covered only when all of the followingcriteria are met:· prescribed by a Kaiser Permanente physician/licensed prescriber, or a

prescriber we designate,· on the Health Plan formulary. Senior Advantage members with

Medicare Part D are entitled to drugs on the Health Plan formulary andKaiser Permanente Hawaii Medicare Drug Formulary. Drugs must beused in accordance with formulary guidelines or restrictions,

· the drug is one for which a prescription is required by law,· obtained at pharmacies in the Service Area that are operated by Kaiser

Foundation Hospital or Kaiser Foundation Health Plan, Inc., orpharmacies we designate, and

· drug does not require administration by nor observation by medicalpersonnel.

Prescription Drug Supplemental Charges Maximum (applicable toPharmacy Dispensed Drugs only)

$4,650 permember;$9,300 perfamily unit (2or moremembers) peraccumulationperiod

kpgroup_drug_summary_chart_16r.docx 1/20161

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Prescription Drug Deductible (applicable to Specialty drug prescriptionsonly)

$400 permember;$800 perfamily unit (2or moremembers) peraccumulationperiod

Insulin $20 pergeneric drugprescriptionand50% ofapplicablecharges perbrand-namedrugprescription

Diabetes supplies are described in the prescribed drugs section.

Exclusions:· 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-prescriptionsubstances 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 inthe prescribed drugs section.

· Drugs and their associated dosage strengths and forms in the same therapeutic categoryas a non-prescription drug that have the same indication as the non-prescription drug.

· Drugs obtained from a non-Kaiser Permanente pharmacy.· Non-prescription 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.· Brand-name/specialty 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, except for Senior Advantage Members with Medicare Part D.· Drugs related to sexual/erectile 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.


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Questions and answers about the drug rider

1. How does the drug rider work?When you visit a Kaiser Permanente physician, a licensed prescriber or a prescriber we designate, and they

prescribe a drug for which a prescription is legally required, you can take it to any Kaiser Permanentepharmacy or pharmacy we designate.- In most cases you will be charged only $10 for a generic Maintenance drug prescription, $20 each for

all other generic drug prescriptions, 50% of applicable charges for a brand-name drug prescription,and 50% of applicable charges for a Specialty drug prescription (after satisfaction of the PrescriptionDrug Deductible) when it does not exceed a 30-consecutive-day supply of a prescribed drug (or anamount as determined by the formulary). Each refill of the same prescription will also be provided atthe same charge.

- If you go to a non-Kaiser Permanente pharmacy, you will be responsible for 100% of charges.

2. Where are Kaiser Permanente pharmacies located?Most Kaiser Permanente Clinics have a pharmacy on premises. Please consult the Member Handbook for

the 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 automaticallycovered under your prescription drug rider depending on which plan you’ve selected. Even thoughnonformulary drugs are generally not covered under your prescription drug rider, your KaiserPermanente physician can sometimes request a nonformulary drug for you, specifically when formularyalternatives have failed or use of nonformulary drug is medically necessary, provided -- the drug is notexcluded under the prescription drug rider.

Kaiser Permanente pharmacies may substitute a chemical or generic equivalent for abrand-name/specialty drug unless this is prohibited by your Kaiser Permanente physician. If you want abrand-name/specialty drug for which there is a generic equivalent, or if you request a non-formularydrug, you will be charged Member Rates for these selections, since they are not covered under yourprescription drug rider. If your KP physician deems a higher priced drug to be medically necessarywhen a less expensive drug is available, you pay the usual drug copayment. If you request the higherpriced drug and it has not been deemed medically necessary, you will be charged Member Rates.

4. Do I need to present any identification when I receive drugs?Yes, 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 Centerat 432-5955 on Oahu or 1-800-966-5955 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’s supply per prescription.

However, as a convenience to you, our Kaiser Permanente Pharmacies will dispense up to athree-month’s supply of certain prescriptions upon request (you will be responsible for three copaymentamounts). Dispensing a three-month’s supply is done in good faith, presuming you will remain a KaiserPermanente member for the next three months. If you terminate your membership with Kaiser Permanentebefore the end of the three-month period, we will bill you the retail price for your remaining drugs. Forexample, if you end your membership after two months, we will bill you for the remaining one-month’ssupply. Unless otherwise directed by Kaiser Permanente, refills may be allowed when 75% of thecurrent prescription supply is taken/administered according to prescriber’s directions.


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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 ofqualified prescription drugs covered under your drug rider for the price of 60 by using our convenientmail 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 432-7979 (Oahu) or 1-888-867-2118

(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) orpicking 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) 432-5510 (Oahu), or toll free 1-866-250-1805

(Neighbor Islands), Monday to Friday, 8:30 a.m. to 5 p.m. TTY users may call 1-877-447-5990.

So the next time you’ve used two-thirds of your existing supply of prescription medications, try usingone of these convenient options.

If you must pick up your prescriptions at a clinic pharmacy, refillable prescriptions are usually ready forpickup at the designated pharmacy in one business day. Prescriptions requiring a physician’s approvalare usually ready in two business days. Call the pharmacy or Kaiser Permanente Hawaii's automatedprescription refill line in advance to make sure that your prescription is ready. Orders not picked upwithin one week are returned to stock.

*We are not licensed to mail medications out of state. There are restrictions for delivery of certainmedications and supplies, including but not limited to controlled medications, injections, medicationsaffected by temperature, and medications excluded by Kaiser Permanente’s Pharmacy & TherapeuticCommittee.

7. What are the definitions of the different classes of drugs?· Generic drugs are drugs approved by the U.S. Food and Drug Administration (FDA), have the same

active ingredient of the Brand-name drugs, are produced and sold under their Generic names after thepatent of the Brand-name drug expires, and are on the Health Plan formulary.

· Maintenance drugs are those which are used to treat chronic conditions, such as asthma, hypertension,diabetes, hyperlipidemia, cardiovascular disease, and mental health.

· Generic Maintenance drugs are specific Generic drugs used for the treatment of chronic conditions andare on Health Plan’s approved list. However, not all Generic drugs used for the treatment of chronicconditions are considered Generic “Maintenance” drugs.

· Brand-name drugs are drugs approved by the U.S. Food and Drug Administration (FDA), produced andsold under the original manufacturer’s Brand-name, and are on the Health Plan formulary.

· Specialty drugs are very high-cost drugs approved by the U.S. Food and Drug Administration (FDA)that are on the Health Plan formulary.

8. What is a Prescription Drug Deductible?A Prescription Drug Deductible is the amount that Members must pay for Specialty drug prescriptionsbefore coverage begins for those drugs. Once the Prescription Drug Deductible is met, Members will


SAMPLE

pay the applicable charges as described under the You Pay column above for Specialty drugprescriptions. The “per Member” Prescription Drug Deductible amount counts toward the “per familyunit” Prescription Drug Deductible amount. Once the “per Member” Prescription Drug Deductible issatisfied, no further Prescription Drug Deductible will be due for that Member for the remainder of theAccumulation Period. Once the “per family unit” Prescription Drug Deductible is satisfied, no further“per Member” Prescription Drug Deductibles will be due for the remainder of the Accumulation Period.The Prescription Drug Deductible is separate from any other deductible that may be described in otherparts of your employer’s Service Agreement. Payments toward the Prescription Drug Deductible do notcount toward any other deductible. Consequently, payments toward any other deductible do not counttoward the Prescription Drug Deductible.


SAMPLE

kpgroup_optical_150_pediatric_summary_16r.docx rev. 10/2015

Your base health plan coverage provides: Care in the Medical Office

Routine eye examinations for eyeglasses Diagnosis, treatment and continued care for conditions related to disease or injuries of the eye by an eye

specialist

Care in the Hospital

Physicians and surgeons services Room and board, general nursing care, anesthesia, use of operating room and medications

Optical rider 150 provides these additional services and benefits

Optical rider 150 with Pediatric Vision Care

Benefits You pay

$150 allowance for adults 19 years of age and older (see section below, titled, "Pediatric Vision Care" for optical coverage for pediatric members through age 18)

When prescription is filled at Kaiser Permanente Optical Center, allowance may be used toward the following eyewear and services:

Glasses frames/lens/lens treatment

Or

All costs greater than the $150 allowance during the Accumulation Period

Contact lens/contact lens exam and fitting services

Limitations:

The $150 allowance is a one-time benefit during the Accumulation Period. If the entire allowance is not used during your initial visit any unused portion of the allowance cannot be used for the remainder of the Accumulation Period and will not be carried forward to the next Accumulation Period.

Exclusions:

Contact lenses or lenses, not medically required Non-prescription eyewear such as cosmetic colored

contact lenses, non-prescription athletic, industrial safety and sunglass eyewear

Any medical services or eyewear from non-Kaiser Permanente providers or non-Kaiser Permanente optical facilities

Contact lens exams (if the $150 allowance has been exhausted)

All costs exceeding the $150 allowance

SAMPLE

kpgroup_optical_150_pediatric_summary_16r.docx rev. 10/2015

Optical rider 150 with Pediatric Vision Care

Benefits You pay

Pediatric Vision Care (optical care for pediatric Members up to age 19): Eye examination, once per Accumulation Period. No charge

When prescribed by a Kaiser Permanente optometrist or physician, one pair of polycarbonate single vision, lined bifocal or lined trifocal lenses per Accumulation Period year

No charge

One frame per Accumulation Period

Note: Frame must be from the “value collection frames” available at Vision Essentials by Kaiser Permanente clinic locations

No charge

In lieu of frames and lenses, one pair of non-disposable contact lenses (including fitting and dispensing) or an initial supply of disposable contact lenses (including fitting and dispensing) per Accumulation Period.

Covered contact lenses include:

o Standard (one pair annually): one contact lens per eye (total of two lenses), or

o Monthly (six-month supply): six lenses per eye (total of 12 lenses), or

o Bi-weekly (three-month supply): six lenses per eye (total of 12 lenses), or

o Dailies (one-month supply): 30 lenses per eye (total of 60 lenses)

No charge

When determined by a Kaiser Permanente Optometrist or physician, medically necessary contact lenses

Note: Contact lenses may be medically necessary and appropriate in the treatment of certain conditions such as Keratoconus, Pathological Myopia, Aphakia, Anisometropia, Aniseikonia, Aniridia, Corneal Disorders, Post-traumatic Disorders, Irregular, and Astigmatism.

No charge

One low vision hand-held or page magnifier device (including fitting and dispensing), once every 24 months

No charge

For members who are 18 years of age and under, the lens material will be impact resistant polycarbonate.

SAMPLE

SAMPLE

1

HDS Group Number 2995

CHILDREN(Benefitends atage 19)

ADULTS &CHILDREN

ages 19through 25

N/A $1,200

$350/child$700 for 2 or N/Amore children

$10/person $0/person

100% 100%100% 100%

70% 70%

100% 100%

100% 100%70% 70%

100% 100%70% 70%

100% N/A100% 100%100% N/A100% N/A70% 70%

50% 50%70% 70%70% 70%50% 50%N/A 50%70% 70%70% 70%

50% N/A

50% 50%

Note: This summary includes a brief description of your HDS dental benefits. All benefits are governed by the provisions of Kaiser's agreement with Hawaii Dental Service and HDS’s procedure code guidelines. All dental claims must be filed within 12 months of the date of service to be eligible for HDS claims payment.

The most you will pay before your dental plan begins to pay 100% of your benefit. This amount

Effective 2016

• Other X-rays – full mouth X-rays limited to once every five years

SUMMARY OF BENEFITS

HDS PLAN PAYS

calendar year

does not include out-of-pocket payments made for non-covered services and alternate

PLAN MAXIMUM per person per calendar year – age 19 and overThe most HDS will pay for each person for all covered dental services performed during the

MAXIMUM OUT OF POCKET per calendar year – age 18 and under

Kaiser Permanente Small Group Dental 2995

Cleanings or

DEDUCTIBLE AMOUNT per calendar year – does not apply to benefits covered at 100%

• Examination – twice per calendar year• Bitewing X-rays – twice per calendar year through age 18; once per calendar year thereafter

PREVENTIVE

• Expectant mothers – three times per calendar year, combination of Cleanings or Gum treatment • Diabetic patients – four times per calendar year, combination of

DIAGNOSTIC

• Cleanings – twice per calendar year

(*) Asterisk indicates wait period of 3 months (**) Hyphen indicates wait period of 12 months

FIXED BRIDGES AND DENTURES (Prosthodontics) – once every seven years

Gum treatment• Fluoride – twice per calendar year; through age 18• Fluoride (high risk) – once per calendar year• Space maintainers – through age 18• Sealants – through age 18FILLINGS

eligible under this employer’s plan.

Limited to those cases involving repair of cleft lip and/or cleft palate, severe facial birth defects,

• Silver fillings• White-colored fillings – limited to front teethCROWNS AND GOLD RESTORATIONS – once every seven yearsROOT CANAL THERAPY (Endodontics)GUM TREATMENT (Periodontics)

IMPLANTSORAL SURGERY (Oral and Maxillofacial Surgery)ADJUNCTIVE GENERAL SERVICES• Treatment for relief of pain but not to cure (Palliative Treatment)ORTHODONTICS – when medically necessary

Form Kaiser Permanente Small Group Dental 2995 0615

or an incurred injury that affects the function of speech, swallowing, and/or chewing.ORTHODONTICS – $1000 lifetime maximum per childFOR DEPENDENT CHILDREN OF AN ENROLLED SUBSCRIBER THROUGH AGE 25 ONLYOrthodontic services are not covered if services were started prior to the date the patient

SAMPLE

SEARCH REQUEST• Log on to the HDS website at • for an HDS participating • to receive an e-mail when

www.hawaiidentalservice.com dentist by specialty, location, your claim is processed handicap accessibility,

• Click on "New User" weekend hours, and more • to receive EOB statements through e-mail

• Complete the "Member Registration" form • for a Delta Dental participating dentist in the Mainland, Guam • an HDS membership card to

• Select "yes" to "Request electronic Explanation or Saipan be mailed to youof Benefits"

VIEW DOWNLOAD & PRINT• Click on "Register User" button • your own tooth chart—see • a summary of your benefits

what services have been for tax purposes• An e-mail will be sent to you with a link. performed on each tooth

Click on the link to activate your account. • blank claim forms• your Explanation of Benefits (EOB) statements (and print them out) • an HDS membership card

• on a claim and rate your dentist • dentist ratings • an EOB statement

• whether you and/or your • a list of frequently asked • HDS Notice of Privacy dependents are eligible for questions Practices HDS benefits

• HDS contact information• what services are covered by your plan

• what the limits are of each type of covered service and how much you have used

Phone: 808-529-9248 Hawaii Dental Service

Toll-free: 1-800-232-2533 ext. 248 Attn: Customer Service

Fax: 808-529-9366 700 Bishop Street, Suite 700Toll-free fax: 1-866-590-7988 Honolulu, HI 96813-4196

Monday through Friday E-mail:7:30 a.m. - 4:30 p.m. [email protected] Standard Time

CHECK

How to Contact HDS

Customer Service Representatives Send Written Correspondence to:

Form Kaiser Permanente Small Group Dental 2995 0615

Access to HDS Information 24/7

Visit HDS Online at www.HawaiiDentalService.com to:

ACCESS YOUR ONLINE ACCOUNT TODAY!

SAMPLE

http://www.hawaiidentalservice.com/

Documents

SAMPLE - Kaiser Permanenteinfo.kaiserpermanente.org/healthplans/plandocuments/hawaii/pdfs/2016... · KP Gold - $17 Plan (formerly called KP Gold - $12 Plan) Medical deductible will