YOUR HEALTH IS OUR cause.Out-of-Area PPO Plans

Kaiser Permanente Insurance Company

At Kaiser Permanente, we understand the need to care for the whole

you—mind, body, and spirit. We’re here to help you take an active role

in your own health, so you can enjoy life to the fullest. With Kaiser

Permanente Insurance Company’s Out-of-Area plans, you can enjoy

many Kaiser Permanente perks like discounts on health club membership,

chiropractors, massage therapists, and more. You can also take advantage

of your own personal health coach and online health tools like health

calculators, personalized health improvement plans, and a medical

encyclopedia at kp.org. These are just a few of the ways we’re helping

you connect with your health.

Take a look at Kaiser Permanente Insurance Company’s (KPIC) Out-of-Area PPO Plans.* They’re designed for people who don’t live or work inside the Kaiser Permanente Georgia metro-Atlanta Service Area**, but work for an employer that does. The plans give you access to major medical coverage, while at the same time giving you the freedom to choose your own provider and control your own out-of-pocket costs.

We make it easy to access the care you need when you need it. Each time you need medical care, you can choose either:

Participating Provider (PHCS network)

Non-Participating Provider

n Access to over 450,000 PHCS providers around the country.***

n Lower out-of-pocket costs, in most instances.

n No claim forms.

n Access to any licensed provider.

n Higher out-of-pocket costs, in most instances.

n In most instances the patient completes and files a medical claim form for reimbursement.

* PPO Benefits are underwritten by Kaiser Permanente Insurance Company (KPIC), a subsidiary of Kaiser Foundation Health Plan, Inc. (KFHP).

** The Service Area includes Barrow, Bartow, Butts, Carroll, Cherokee, Clayton, Cobb, Coweta, Dawson, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Hall, Haralson, Heard, Henry, Lamar, Meriwether, Newton, Paulding, Pickens, Pike, Rockdale, Spalding, and Walton counties.

*** Kaiser Permanente Insurance Company (KPIC) has contracted with PHCS, a national preferred provider organization network that contracts with physicians, hospitals, and other health care providers. To find the nearest PHCS provider in your area, please refer to the PHCS provider directory available from your employer or the PHCS Web site at phcs.com.

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Choose your providers

Participating ProvidersWhen you see Participating Providers, usually your out-of-pocket costs are lower. You also have the flexibility to see any physician or hospital participating in our network. (For a listing, visit phcs.com/kaiser or contact your benefits manager.)

You’ll be responsible for a copayment at each physician office visit. For certain services, a deductible and coinsurance (a percentage of the Maximum Allowable Charge*) will apply. Most Participating Providers will file your claims for you and collect the copayment and/or coinsurance at the time you are seen.

Non-Participating ProvidersIf you already have a doctor you know and like, and that provider is not one of our Participating Providers, you can still see him or her. Non-participating Providers include any other licensed doctor you choose.

If you choose this option, your out-of-pocket expenses are generally higher than if you receive care from a Participating Provider. When you see Non-participating Providers, you will be responsible for meeting an annual deductible (for most services) and paying coinsurance. (Payments are based upon the Maximum Allowable Charge* for covered services.) You may have to pay the full cost for each visit up front and file a claim for reimbursement. Claims payment information will be printed on the back of your ID card. It is very important that the claim is sent to the correct address.

For more information about your health care coverage, please see your summary of benefits chart.

* The Maximum Allowable Charge may be less than the amount actually billed by the provider. Covered persons are responsible for payment of any amounts in excess of the Maximum Allowable Charge for a covered service. Maximum Allowable Charge is the lesser of the Usual, Customary, and Reasonable Charges, the Negotiated Rate, and the Actual Billed Charges for covered services.

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Emergency care

If you have a medical emergency, call 911 or go to the nearest emergency room.

An emergency is a condition of sudden onset and sufficient severity that would lead a prudent lay person to conclude that his or her life, health, limbs, or bodily function is in serious jeopardy.

If you receive emergency treatment, you will be required to pay a copayment. If you are admitted to the hospital, the emergency copayment will be waived. In the event you are admitted to a hospital as a result of an emergency, you, your doctor, or another responsible party should notify SHPS at 1-800-448-9776 within 24 hours of admission, or as soon as reasonably possible. This will allow us to consult with the physician providing your care, and to coordinate further medical care if necessary. Emergency care will be reviewed for eligibility and medical necessity in accordance with terms of the Group Policy.

Choose your pharmacies

Participating pharmaciesWith your KPIC Out-of-Area PPO membership, you can fill covered prescriptions at any of our Participating pharmacies (through the MedImpact MedCare Pharmacy Network*) around the country.

Some of the larger Participating pharmacies include, but are not limited to:*

n Rite Aid n Target Stores n Costco

n K-Mart n Publix n Walgreens

n Kroger n The Medicine Shoppe

* Note: Participating Pharmacies are subject to change, and all individual stores within a chain may not necessarily participate. Participating pharmacies contract with MedImpact Healthcare Systems, Inc., a national Pharmacy Benefits Management (PBM) company. Some local independently owned pharmacies not listed in this brochure may contract with MedImpact. To find out if a specific pharmacy is part of MedImpact’s MedCare pharmacy network, contact MedImpact at 1-800-788-2949, or visit MedImpact.com.

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Your benefits include generic preferred, brand preferred, and brand non-preferred prescription drugs. Copayments for each will be different, with brand non-preferred generally having the highest copayments. In some plans, you also have to pay a pharmacy deductible when using these benefit levels. The three categories of drugs are defined below:

Generic Preferred drug—a prescription drug that does not bear the trademark of a specific manufacturer. It is chemically the same as, and generally costs less than, a brand name prescription drug.

Brand Preferred drug—a prescription drug that has been patented, is only produced by one manufacturer, and is listed by us as a drug preferred or favored to be dispensed.

Brand Non-preferred drug—a prescription drug that has been patented, is only produced by one manufacturer, and is not listed by us as a drug preferred or favored to be dispensed.

For questions about the coverage level for a specific drug, or for a complete list of Participating pharmacies in your area, please contact MedImpact at 1-800-788-2949. See the accompanying summary of benefits for specific benefit information.

Non-participating pharmaciesYou can go to any licensed pharmacy and pay a coinsurance for prescriptions. However, it is important to remember that when filling your prescription at non-participating pharmacies, you most likely will have to pay full price for the medication and then submit a claim form for reimbursement. Your plan may also have a pharmacy deductible.

For more informationThe enclosed summary of benefits chart (if included) will provide you with additional information about your health coverage.

Once enrolled in the Out-of-Area PPO Plan, you will receive more detailed information including a KPIC Certificate of Insurance, a Schedule of Coverage, and your KPIC ID card. Your ID card lists the toll-free numbers for you to call should you have any questions regarding eligibility or claims. (See the “Frequently asked q uestions” section on pages 6-7 for more details.)

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Q. How do I select a doctor?A. You can choose from one of our Participating Providers by visiting the PHCS Web site at phcs.com/kaiser or calling PHCS at 1-888-541-7427. To select a doctor that’s not listed on the PHCS Web site (Non-participating Provider), just call that doctor’s office directly.

Q. What are my benefits?A. A summary of benefits may accompany this brochure. For a complete enrollment kit, see your employer. For a more detailed description about your benefits, read your Certificate of Insurance and Schedule of Coverage. If you have questions about benefits, contact a KPIC Member Services representative.

Q. Will the provider or pharmacy file claims for me?A. Most Participating Providers or pharmacies will file your claims for you. However, if your provider or pharmacy chooses not to file the claim, you will have to pay the full cost at the time of service and file a claim for reimbursement. When you visit a non-participating Provider or pharmacy, you will most likely have to pay at the time of service and file a claim to be reimbursed.

Q. How do I get medical claim forms?A. To get a medical claim form, contact your employer or call the Kaiser Permanente Insurance Company Member Services Department at 1-800-392-8649, 7 a.m.-9 p.m. (EST), Monday through Friday. Claims should be mailed to:

Kaiser Permanente Insurance Company P.O. Box 261130 Plano, TX 75026

This information will also be printed on the back of your ID card. It is very important that the medical claim be sent to the correct address for timely processing.

Q. How do I get pharmacy claim forms?A. To get a pharmacy claim form, call the MedImpact Pharmacy Help Desk at 1-800-788-2949, 8–1 a.m. (EST) Monday through Friday, from 9 a.m.–10 p.m. (EST) on Saturday, and from 10 a.m.–10 p.m. on Sunday. You can also visit medimpact.com.

Pharmacy claims should be mailed to:

MedImpact Healthcare Systems, Inc. 10680 Treena Street; 5th Floor San Diego, CA 92131

It is very important that the pharmacy claim be sent to the correct address for timely processing.

Q. Which pharmacies are participating in my local area?A. To locate the most convenient local pharmacy, call the MedImpact Pharmacy Help Desk at 1-800-788-2949. You can also visit medimpact.com and use the Pharmacy Locator.

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Frequently asked questions

Q. How do I transfer a prescription to a Participating pharmacy?A. Simply tell the pharmacist at the Participating pharmacy that you would like to transfer a prescription. Give the pharmacist the name and phone number of the pharmacy you previously used and the prescription number from the drug label. The pharmacist will do the rest.

Q. Will I have to get preauthorization to receive care?A. In some cases, yes. Preauthorization is required for certain covered services. That means you must get preapproval before receiving these services. KPIC has partnered with SHPS, a leader in utilization management, to make sure that you receive the appropriate medical services and control your out-of-pocket costs.

For a listing of covered services and more information on preauthorization, please see the summary of benefits and the Preauthorization Brochure that may be enclosed. Failure to obtain preauthorization may result in penalties against your benefit payment, or we may deny all or part of your claim. For preauthori-zation, call SHPS at 1-800-448-9776, 24 hours a day, seven days a week.

Q. Does an emergency room visit require preauthorization?A. No. You can get emergency care from the nearest available facility. If you are admitted to the hospital for emergency care or surgery, you or another responsible party are required to notify SHPS at the number on the back of your health plan card within 24 hours of the admission or as soon as reasonably possible: 1-800-448-9776 (available 24 hours a day, seven days a week).

Q. If my doctor says he/she does not accept Kaiser Permanente Insurance Company patients, who should he/she call to confirm my coverage?A. Call Kaiser Permanente Insurance Company Member Services Department at 1-800-392-8649, 7 a.m.-9 p.m. (EST), Monday through Friday.

Q. Can I receive care from a Kaiser Permanente Medical Center?A. No. Under the terms of your benefits as a KPIC Out-of-Area PPO member, Kaiser Permanente Medical Centers and their providers are not a part of your Participating Provider network.

Q. How do I identify myself as a KPIC Out-of-Area PPO member?A. Simply show your ID card whenever you get medical care or get a prescription filled.

Q. Whom do I call regarding a Participating Provider or to get an up-to-date provider listing?A. The Participating Providers are contracted with PHCS, the nation’s largest preferred provider network. You can contact PHCS at 1-888-541-7427, 8 a.m.-8 p.m. (EST), Monday through Friday. You can also visit PHCS’s web site, phcs.com/kaiser, to find a Participating Provider.

Q. Whom do I call for more information?A. If you or your physician’s office have specific questions about benefits, medical claims, and eligibility, call a Kaiser Permanente Insurance Company Member Services representative at 1-800-392-8649, 7 a.m.-9 p.m. (EST), Monday through Friday.

If you have questions about a pharmacy claim or the coverage level of a specific drug, call the MedImpact Pharmacy Help Desk at 1-800-788-2949, 8–1 a.m. (EST) Monday through Friday, from 9 a.m.–10 p.m. (EST) on Saturday, and from 10 a.m.–10 p.m. on Sunday. 7

Important information

Written information on topics related to coverage offered to employer groups in the small group market is available and can be obtained by calling (404) 364-7105.

Topics include:

1) Factors that affect rate setting and rate adjustments.

2) Provisions related to renewing coverage.

3) Plan designs and premiums available to small groups.

Note: Kaiser Permanente group plans do not include a pre-existing condition clause.

OOA-080311 07/08 ©2008 Kaiser Permanente Insurance Company

Kaiser Permanente Insurance Company