Kaiser Foundation\
Health Plan, Inc.\
Southern California Region

[**http://members.kaiserpermanente.org**](http://members.kaiserpermanente.org/)

![](media/image1.wmf){width="1.3770833333333334in"
height="0.38472222222222224in"} **2004**

A Health Maintenance Organization![](media/image2.png){width="1.5in"
height="1.5166666666666666in"}

**Serving:** *Southern California service area*

**Enrollment in this Plan is limited. You must live or work in our\
geographic service area to enroll. See page [9](#service-area) for
requirements.**

![](media/image3.jpeg){width="0.7194444444444444in"
height="0.7194444444444444in"}

**Enrollment codes for this Plan:**

**621 Self Only**

**622 Self and Family**

![](media/image4.bmp)

![](media/image5.png)

**RI 73-822**

![](media/image6.png){width="4.84375in" height="1.1354166666666667in"}

Dear Federal Employees Health Benefits Program Participant:

I am pleased to present this 2004 Federal Employees Health Benefits
(FEHB) Program plan brochure. The brochure describes the benefits this
plan offers you for 2004. Because benefits vary from year to year, you
should review your plan's brochure every Open Season -- especially
Section 2, which explains how the plan changed.

It takes a lot of information to help a consumer make wise healthcare
decisions. The information in this brochure, our FEHB Guide, and our
Web-based resources, make it easier than ever to get information about
plans, to compare benefits and to read customer service satisfaction
ratings for the national and local plans that may be of interest. Just
click on [www.opm.gov/insure]{.underline}!

The FEHB Program continues to be an enviable national model that offers
exceptional choice, and uses private-sector competition to keep costs
reasonable, ensure high-quality care, and spur innovation. The Program,
which began in 1960, is sound and has stood the test of time. It enjoys
one of the highest levels of customer satisfaction of any healthcare
program in the country.

I continue to take aggressive steps to keep the FEHB Program on the
cutting edge of employer-sponsored health benefits. We demand
cost-effective quality care from our FEHB carriers and we have
encouraged Federal agencies and departments to pay the full FEHB health
benefit premium for their employees called to active duty in the Reserve
and National Guard so they can continue FEHB coverage for themselves and
their families. Our carriers have also responded to my request to help
our members to be prepared by making additional supplies of medications
available for emergencies as well as call-up situations and you can help
by getting an Emergency Preparedness Guide at [www.opm.gov]{.underline}.
OPM's *HealthierFeds* campaign is another way the carriers are working
with us to ensure Federal employees and retirees are informed on healthy
living and best-treatment strategies. You can help to contain healthcare
costs and keep premiums down by living a healthy life style.

Open Season is your opportunity to review your choices and to become an
educated consumer to meet your healthcare needs. Use this brochure, the
FEHB Guide, and the web resources to make your choice an informed one.
Finally, if you know someone interested in Federal employment, refer
them to www.usajobs.opm.gov.

> Sincerely,
>
> ![](media/image7.png){width="2.5833333333333335in"
> height="0.7291666666666666in"}
>
> Kay Coles James
>
> Director

![](media/image8.png){width="1.4694444444444446in"
height="1.273611111111111in"}
![](media/image9.png){width="1.4583333333333333in"
height="1.1444444444444444in"}

#### Notice of the Office of Personnel Management's

#### Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

By law, the United States Office of Personnel Management (OPM), which
administers the Federal Employees Health Benefits (FEHB) Program, is
required to protect the privacy of your personal medical information.
OPM is also required to give you this notice to tell you how OPM may use
and give out ("disclose") your personal medical information held by OPM.

OPM **will** use and give out your personal medical information:

-   To you or someone who has the legal right to act for you (your
    personal representative),

-   To the Secretary of the Department of Health and Human Services, if
    necessary, to make sure your privacy is protected,

-   To law enforcement officials when investigating and/or prosecuting
    alleged or civil or criminal actions, and

-   Where required by law.

OPM **has the right** to use and give out your personal medical
information to administer the FEHB Program. For example:

-   To communicate with your FEHB health plan when you or someone you
    have authorized to act on your behalf asks for our assistance
    regarding a benefit or customer service issue.

-   To review, make a decision, or litigate your disputed claim.

-   For OPM and the General Accounting Office when conducting audits.

OPM **may** use or give out your personal medical information for the
following purposes under limited circumstances:

-   For Government health care oversight activities (such as fraud and
    abuse investigations),

-   For research studies that meet all privacy law requirements (such as
    for medical research or education), and

-   To avoid a serious and imminent threat to health or safety.

By law, OPM must have your written permission (an "authorization") to
use or give out your personal medical information for any purpose that
is not set out in this notice. You may take back ("revoke") your written
permission at any time, except if OPM has already acted based on your
permission.

By law, you **have the right** to:

-   See and get a copy of your personal medical information held by OPM.

-   Amend any of your personal medical information created by OPM if you
    believe that it is wrong or if information is missing, and OPM
    agrees. If OPM disagrees, you may have a statement of your
    disagreement added to your personal medical information.

-   Get a listing of those getting your personal medical information
    from OPM in the past 6 years. The listing will not cover your
    personal medical information that was given to you or your personal
    representative, any information that you authorized OPM to release,
    or that was given out for law enforcement purposes or to pay for
    your health care or a disputed claim.

-   Ask OPM to communicate with you in a different manner or at a
    different place (for example, by sending materials to a P.O. Box
    instead of your home address).

-   Ask OPM to limit how your personal medical information is used or
    given out. However, OPM may not be able to agree to your request if
    the information is used to conduct operations in the manners
    described.

-   Get a separate paper copy of this notice.

For more information on exercising your rights set out in this notice,
look at [www.opm.gov/insure](http://www.opm.gov/insure on the web.You)
on the web. You may also call **1-202-606-0191** and ask for OPM's FEHB
Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this
notice, you may file a complaint with OPM at the following address:

Privacy Complaints

United States Office of Personnel Management

P.O. Box 707

Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program.
You also may file a complaint with the Secretary of the United States
Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM
has the right to change the way your personal medical information is
used and given out. If OPM makes any changes, you will get a new notice
by mail within 60 days of the change. The privacy practices listed in
this notice are effective April 14, 2003.

  -----------------------------------------------------------------------
  Table of Contents

  -----------------------------------------------------------------------

Introduction [5](#introduction)

Plain Language [5](#plain-language)

Stop Health Care Fraud! [5](#stop-health-care-fraud)

Preventing Medical Mistakes [6](#__RefHeading___Toc52270399)

Section 1. Facts about this HMO plan
[8](#section-1.-facts-about-this-hmo-plan)

How we pay providers [8](#how-we-pay-providers)

Your Rights [8](#your-rights)

Service Area [9](#service-area)

Section 2. How we change for 2004
[10](#section-2.-how-we-change-for-2004)

Program-wide changes [10](#program-wide-changes)

Changes to this Plan [10](#changes-to-this-plan)

Section 3. How you get care [11](#section-3.-how-you-get-care)

Identification cards [11](#identification-cards)

Where you get covered care [11](#where-you-get-covered-care)

-   
-   

Plan providers [11](#plan-providers)Plan facilities
[11](#__RefHeading___Toc52270411) What you must do to get covered care
[12](#what-you-must-do-to-get-covered-care)

-   
-   
-   

> Primary care [12](#primary-care)Specialty care
> [12](#specialty-care)Hospital care [13](#hospital-care)Circumstances
> beyond our control [13](#circumstances-beyond-our-control)
>
> Services requiring our prior approval
> [13](#services-requiring-our-prior-approval)

Section 4. Your costs for covered services
[14](#section-4.-your-costs-for-covered-services)

-   
-   
-   
-   

Copayments [14](#copayments)Deductible [14](#deductible)Coinsurance
[14](#coinsurance)Fees when you fail to make your copayment
[14](#fees-when-you-fail-to-make-your-copayment) Your catastrophic
protection out-of-pocket maximum for copayments and coinsurance
[14](#your-catastrophic-protection-out-of-pocket-maximum-for-copayments-and-coinsurance)

Section 5. Benefits [15](#section-5.-benefits)

Overview [15](#overview)

> (a). Medical services and supplies provided by physicians and other
> health care professionals
> [16](#a.-medical-services-and-supplies-provided-by-physicians-and-other-health-care-professionals)
>
> (b). Surgical and anesthesia services provided by physicians and other
> health care professionals
> [26](#b.-surgical-and-anesthesia-services-provided-by-physicians-and-other-health-care-professionals)
>
> (c). Services provided by a hospital or other facility, and ambulance
> services [30](#__RefHeading___Toc52270428)
>
> (d). Emergency services/accidents
> [33](#section-5d.-emergency-servicesaccidents)
>
> (e). Mental health and substance abuse benefits
> [37](#e.-mental-health-and-substance-abuse-benefits)
>
> (f). Prescription Drug Benefits
> [39](#section-5f.-prescription-drug-benefits)
>
> (g). Special features [42](#g.-special-features)

-   

```{=html}
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```
-   
-   
-   
-   
-   

> Flexible benefits option [42](#flexible-benefits-option)Services from
> other Kaiser Permanente Plans
> [42](#services-from-other-kaiser-permanente-plans)Travel benefit
> [43](#travel-benefit)24 hour nurse line [43](#hour-nurse-line)Services
> for deaf and hearing impaired
> [43](#services-for-deaf-and-hearing-impaired)Centers of excellence
> [44](#centers-of-excellence)(h). Dental benefits
> [45](#h.-dental-benefits)
>
> (i). Non-FEHB benefits available to Plan members
> [46](#section-5i.-non-fehb-benefits-available-to-plan-members)

Section 6. General exclusions -- things we don't cover
[47](#section-6.-general-exclusions-things-we-dont-cover)

Section 7. Filing a claim for covered services
[48](#section-7.-filing-a-claim-for-covered-services)

Medical, hospital, and drug benefits
[48](#medical-hospital-and-drug-benefits)

Deadline for filing your claim [48](#deadline-for-filing-your-claim)

When we need more information [48](#when-we-need-more-information)

If you have a malpractice claim [48](#if-you-have-a-malpractice-claim)

Section 8. The disputed claims process
[49](#section-8.-the-disputed-claims-process)

Section 9. Coordinating benefits with other coverage
[51](#section-9.-coordinating-benefits-with-other-coverage)

-   
-   
-   
-   
-   

When you have other health coverage [51](#what-is-medicare)What is
Medicare? [51](#what-is-medicare)Should I enroll in Medicare?
[51](#should-i-enroll-in-medicare)If you enroll in Medicare Part B
[52](#part-b)The Original Medicare Plan (Part A or Part B)
[52](#part-a-or-part-b)Medicare+Choice [54](#medicarechoice) TRICARE and
CHAMPVA [55](#tricare-and-champva)

Workers' Compensation [55](#workers-compensation)

Medicaid [55](#medicaid)

> When other Government agencies are responsible for your care
> [56](#when-other-government-agencies-are-responsible-for-your-care)
>
> When others are responsible for injuries
> [56](#when-others-are-responsible-for-injuries)

Section 10. Definitions of terms we use in this brochure
[57](#section-10.-definitions-of-terms-we-use-in-this-brochure)

Section 11. FEHB facts [59](#section-11.-fehb-facts)

> Coverage information [59](#coverage-information)
>
> No pre-existing condition limitation
> [59](#no-pre-existing-condition-limitation)
>
> Where you can get information about enrolling in the FEHB Program
> [59](#where-you-can-get-information-about-enrolling-in-the-fehb-program)
>
> Types of coverage available for you and your family
> [59](#types-of-coverage-available-for-you-and-your-family)
>
> Children's Equity Act [60](#childrens-equity-act)
>
> When benefits and premiums start
> [60](#when-benefits-and-premiums-start)
>
> When you retire [60](#when-you-retire)
>
> When you lose benefits [61](#__RefHeading___Toc52270467)

-   
-   
-   
-   
-   

When FEHB coverage ends [61](#when-fehb-coverage-ends)Spouse equity
coverage [61](#spouse-equity-coverage)Temporary continuation of coverage
(TCC) [61](#converting-to-individual-coverage)Converting to individual
coverage [61](#converting-to-individual-coverage)Getting a Certificate
of Group Health Plan Coverage [62](#__RefHeading___Toc52270472)Two new
Federal Programs complement FEHB benefits
[63](#__RefHeading___Toc52270473)

> The Federal Flexible Spending Account Program -- FSAFEDS
> [63](#__RefHeading___Toc52270474)
>
> The Federal Long Term Care Insurance Program
> [66](#__RefHeading___Toc52270475)

Index [67](#index)

Summary of benefits [68](#summary-of-benefits)

Rate Information [Back cover](#rate_info)

# Introduction

This brochure describes the benefits of Kaiser Foundation Health Plan,
Inc.--Southern California Region, under our contract (CS1044-B) with the
United States Office of Personnel Management, as authorized by the
Federal Employees Health Benefits law. The Southern California Region's
administrative office is:

Kaiser Foundation Health Plan, Inc.

393 East Walnut Street

Pasadena, CA 91188

This brochure is the official statement of benefits. No oral statement
can modify or otherwise affect the benefits, limitations, and exclusions
of this brochure. It is your responsibility to be informed about your
health benefits.

If you are enrolled in this Plan, you are entitled to the benefits
described in this brochure. If you are enrolled in Self and Family
coverage, each eligible family member is also entitled to these
benefits. You do not have a right to benefits that were available before
January 1, 2004, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit
changes are effective January 1, 2004, and changes are summarized on
page [10](#section-2.-how-we-change-for-2004). Rates are shown on the
back cover of this brochure.

# Plain Language

All FEHB brochures are written in plain language to make them
responsive, accessible, and understandable to the public. For instance,

-   Except for necessary technical terms, we use common words. For
    instance, "you" means the enrollee or family member; "we" or "Plan"
    means Kaiser Foundation Health Plan, Inc.

-   We limit acronyms to ones you know. FEHB is the Federal Employees
    Health Benefits Program. OPM is the United States Office of
    Personnel Management. If we use others, we tell you what they mean
    first.

-   Our brochure and other FEHB plans' brochures have the same format
    and similar descriptions to help you compare plans.

If you have comments or suggestions about how to improve this brochure,
let us know. Visit OPM's "Rate Us" feedback area at
[www.opm.gov/insure](http://www.opm.gov/reitre) or e-mail OPM at
<fehbwebcomments@opm.gov>. You may also write to OPM at the United
States Office of Personnel Management, Insurance Services Program,
Program Planning & Evaluation Group, 1900 E Street NW, Washington, DC
20415-3650.

# Stop Health Care Fraud!

Fraud increases the cost of health care for everyone and increases your
Federal Employees Health Benefits (FEHB) Program premium.

OPM's Office of the Inspector General investigates all allegations of
fraud, waste and abuse in the FEHB Program regardless of the agency that
employs you or from which you retired.

**[Protect Yourself from Fraud]{.underline}** -- Here are some things
you can do to prevent fraud:

-   Be wary of giving your plan identification (ID) number over the
    telephone or to people you do not know, except to your doctor, other
    provider, or authorized plan or OPM representative.

-   Let only the appropriate medical professionals review your medical
    record or recommend services.

-   Avoid using health care providers who say that an item or service is
    not usually covered, but they know how to bill us to get it paid.

-   Carefully review explanations of benefits (EOBs) that you receive
    from us.

-   Do not ask your doctor to make false entries on certificates, bills,
    or records in order to get us to pay for an item or service.

-   If you suspect that a provider has charged you for services you did
    not receive, billed you twice for the same service, or
    misrepresented any information, do the following:

-   Call the provider and ask for an explanation. There may be an error.

-   If the provider does not resolve the matter, call our Member Service
    Call Center at **1-800-464-4000** and explain the situation.

-   If we do not resolve the issue:

+-----------------------------------------------------------------------+
| **\                                                                   |
| CALL -- THE HEALTH CARE FRAUD HOTLINE**                               |
|                                                                       |
| **1-202-418-3300**                                                    |
|                                                                       |
| **OR WRITE TO:**                                                      |
|                                                                       |
| The United States Office of Personnel Management\                     |
| Office of the Inspector General Fraud Hotline\                        |
| 1900 E Street, NW, Room 6400                                          |
|                                                                       |
| Washington, DC 20415-1100                                             |
+-----------------------------------------------------------------------+

-   Do not maintain as a family member on your policy:

-   Your former spouse after a divorce decree or annulment is final
    (even if a court order stipulates otherwise); or

-   Your child over age 22 (unless he/she is disabled and incapable of
    self support).

-   If you have any questions about the eligibility of a dependent,
    check with your personnel office if you are employed, with your
    retirement office (such as OPM) if you are retired, or with the
    National Finance Center if you are enrolled under Temporary
    Continuation of Coverage.

-   You can be prosecuted for fraud and your agency may take action
    against you if you falsify a claim to obtain FEHB benefits or try to
    obtain services for someone who is not an eligible family member or
    who is no longer enrolled in the Plan.

  -----------------------------------------------------------------------
  []{#__RefHeading___Toc52270399 .anchor}P[]{#preventing_medical_mistakes
  .anchor}reventing Medical Mistakes

  -----------------------------------------------------------------------

An influential report from the Institute of Medicine estimates that up
to 98,000 Americans die every year from medical mistakes in hospitals
alone. That's about 3,230 preventable deaths in the FEHB Program a year.
While death is the most tragic outcome, medical mistakes cause other
problems such as permanent disabilities, extended hospital stays, longer
recoveries, and even additional treatments. By asking questions,
learning more, and understanding your risks, you can improve the safety
of your own health care, and that of your family members. Take these
simple steps:

1.  **Ask questions if you have doubts or concerns.**

-   Ask questions and make sure you understand the answers.

-   Choose a doctor with whom you feel comfortable talking.

-   Take a relative or friend with you to help you ask questions and
    understand answers.

1.  **Keep and bring a list of all the medicines you take.**

-   Give your doctor and pharmacist a list of all the medicines that you
    take, including non-prescription medicines.

-   Tell them about any drug allergies you have.

-   Ask about side effects and what to avoid while taking the medicine.

-   Read the label when you get your medicine, including all warnings.

-   Make sure your medicine is what the doctor ordered and know how to
    use it.

-   Ask the pharmacist about your medicine if it looks different than
    you expected.

2.  **Get the results of any test or procedure.**

-   Ask when and how you will get the results of test or procedures.

-   Don't assume the results are fine if you do not get them when
    expected.

-   Call your doctor and ask for your results.

-   Ask what the results mean for your care.

3.  **Talk to your doctor about which hospital is best for your health
    needs.**

-   Ask your doctor about which hospital has the best care and results
    for your condition if you have more than one hospital to choose from
    to get the health care you need.

-   Be sure you understand the instructions you get about follow-up care
    when you leave the hospital.

4.  **Make sure you understand what will happen if you need surgery.**

-   Make sure you, your doctor, and your surgeon all agree on exactly
    what will be done during the operation.

-   Ask your doctor, "Who will manage my care when I am in the
    hospital?"

-   Ask your surgeon:

    Exactly what will you be doing?

    About how long will it take?

    What will happen after surgery?

    How can I expect to feel during recovery?

-   Tell the surgeon, anesthesiologist, and nurses about any allergies,
    bad reaction to anesthesia, and any medications you are taking.

    Want more information on patient safety?

```{=html}
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```
-   [**www.ahrq.gov/consumer/pathqpack.htm**](http://www.ahrq.gov/consumer/pathqpack.htm).
    The Agency for Healthcare Research and Quality makes available a
    wide-ranging list of topics not only to inform consumers about
    patient safety but to help choose quality healthcare providers and
    improve the quality of care you receive.

-   [**www.npsf.org**](http://www.npsf.org/). The National Patient
    Safety Foundation has information on how to ensure safer healthcare
    for you and your family.

-   [**www.talkaboutrx.org/consumer.html**](http://www.talkaboutrx.org/consumer.html).
    The National Council on Patient Information and Education is
    dedicated to improving communication about the safe, appropriate use
    of medicines.

-   [**www.leapfroggroup.org**](http://www.leapfroggroup.org/). The
    Leapfrog Group is active in promoting safe practices in hospital
    care.

-   [**www.ahqa.org**](http://www.ahqa.org/). The American Health
    Quality Association represents organizations and healthcare
    professionals working to improve patient safety.

-   [**www.quic.gov/report**](http://www.quic.gov/report). Find out what
    federal agencies are doing to identify threats to patient safety and
    help prevent mistakes in the nation's healthcare delivery system.

# Section 1. Facts about this HMO plan

This Plan is a health maintenance organization (HMO). We require you to
see specific physicians, hospitals, and other providers that contract
with us. These Plan providers coordinate your health care services. The
Plan is solely responsible for the selection of these providers in your
area. Contact the Plan for a copy of our most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical
exams, well-baby care, and immunizations, in addition to treatment for
illness and injury. Our providers follow generally accepted medical
practice when prescribing any course of treatment.

When you receive services from Plan providers, you will not have to
submit claim forms or pay bills. You only pay the copayments and
coinsurance described in this brochure. When you receive emergency
services or services covered under the travel benefit from non-Plan
providers, you may have to submit claim forms.

**You should join an HMO because you prefer the plan's benefits, not
because a particular provider is available. You cannot change plans
because a provider leaves our Plan. We cannot guarantee that any one
physician, hospital, or other provider will be available and/or remain
under contract with us.**

## How we pay providers

We contract with individual physicians, medical groups, and hospitals to
provide the benefits in this brochure. These Plan providers accept a
negotiated payment from us, and you will only be responsible for your
copayments or coinsurance.

## Your Rights

OPM requires that all FEHB plans provide certain information to their
FEHB members. You may get information about us, our networks, providers,
and facilities. OPM's FEHB Web site
([www.opm.gov/insure](http://www.opm.gov/)) lists the specific types of
information that we must make available to you. Some of the required
information is listed below.

We are a federally qualified health maintenance organization, and we
have provided health care services to Californians for nearly 60 years.
Kaiser Foundation Health Plan, Inc., is a California not-for-profit
organization. This Plan is part of the Kaiser Permanente Medical Care
Program, a group of not-for-profit organizations and contracting medical
groups that serve over 8 million members nationwide. Our Southern
California Permanente Medical Group operates Plan medical offices
throughout Southern California.

If you want more information about us, call **1-800-464-4000**, or write
to 393 East Walnut Street, Pasadena, California 91188. You may visit our
Web site at
[**http://members.kaiserpermanente.org**](http://members.kaiserpermanente.org/)
which lists the specific types of information that we must make
available to you.

## Service Area

To enroll in this Plan, you must live or work in our service area. This
is where our providers practice. Our service area counties are:

Orange and Los Angeles (except zip code 90704, 91050-51, 92712).

Portions of the following counties, as indicated by the zip codes below,
are also within the service area:

  -------------------------- --------------------------------------------
  Imperial:                  92274-75, 93536

  Kern:                      93203, 93205-06, 93215-16, 93220, 93222,
                             93224-26, 93238, 93240-41, 93243, 93250-52,
                             93263, 93268, 93276, 93280, 93285, 93287,
                             93301-09, 93311-14, 93380-90, 93501-02,
                             93504-05, 93518-19, 93531, 93560-61, 93581

  Riverside:                 91752, 92201-03, 92210-11, 92220, 92223,
                             92230, 92234-36, 92240-41, 92253-55, 92258,
                             92260-64, 92270, 92274, 92276, 92282, 92292,
                             92320, 92324, 92373, 92399, 92501-09,
                             92513-19, 92521-22, 92530-32, 92543-46,
                             92548, 92551-57, 92562-64, 92567, 92570-72,
                             92581-87, 92595-96, 92599, 92860, 92877-83

  San Bernardino:            91701, 91708-10, 91729-30, 91737, 91739,
                             91743, 91758, 91761-64, 91766, 91784-86,
                             91798, 92252, 92256, 92268, 92277, 92278,
                             92284-86, 92305, 92307-08, 92313-18,
                             92321-22, 92324-26, 92329, 92333-37,
                             92339-41, 92345-46, 92350, 92352, 92354,
                             92357-59, 92369, 92371-78, 92382, 92385-86,
                             92391-94, 92397, 92399, 92401-08, 92410-15,
                             92418, 92420, 92423-24, 92427, 92880

  San Diego:                 91901-03, 91908-17, 91921, 91931-33, 91935,
                             91941-47, 91950-51, 91962-63, 91976-80,
                             91990, 92007-09, 92014, 92018-27, 92029-30,
                             92033, 92037-40, 92046, 92049, 92051-52,
                             92054-58, 92064-65, 92067-69, 92071-72,
                             92074-75, 92078-79, 92081, 92082-85,
                             92090-93, 92096, 92101-24, 92126-40,
                             92142-43, 92145, 92147, 92149-50, 92152-55,
                             92158-79, 92182, 92184, 92186-87, 92190-99

  Tulare:                    93261, 93288

  Ventura:                   90265, 91304, 91307, 91311, 91319-20,
                             91358-62, 91377, 93001-07, 93009, 93010-12,
                             93015-16, 93020-21, 93022, 93030-35, 93040,
                             93041-44, 93060-61, 93062-66, 93093, 93099
  -------------------------- --------------------------------------------

Ordinarily, you must receive your care from physicians, hospitals, and
other providers who contract with us. However, we are part of the Kaiser
Permanente Medical Care Program, and if you are visiting another Kaiser
Permanente service area, you can receive virtually all of the benefits
of this Plan at any other Kaiser Permanente facility, including our mail
order prescription program. You must pay the charges or copayments
imposed by the Kaiser Permanente Plan you are visiting, with the
exception of mail order prescriptions which are administered by your
home Plan. See Section 5(g), Special Features, for more details. We also
pay for certain follow-up services or continuing care services while you
are traveling outside the service area, as described on page
[45](#travel-benefit); and for emergency care obtained from any non-Plan
provider, as described on page [34](#Emergency). We will not pay for any
other health care services.

If you or a covered family member move outside of our service area, you
can enroll in another plan. If your dependents live out of the area (for
example, if your child goes to college in another state), you should
consider enrolling in a fee-for-service plan or an HMO that has
agreements with affiliates in other areas. If you or a family member
move, you do not have to wait until Open Season to change plans. Contact
your employing or retirement office.

# Section 2. How we change for 2004

Do not rely on these change descriptions; this page is not an official
statement of benefits. For that, go to Section 5 Benefits. Also, we
edited and clarified language throughout the brochure; any language
change not shown here is a clarification that does not change benefits.

## Program-wide changes

-   We added information regarding two new Federal Programs that
    complement FEHB benefits, the Federal Flexible Spending Account
    Programs -- FSAFEDS and the Federal Long Term Care Insurance
    Program. See page [67](#__RefHeading___Toc52270473).

-   We added information regarding Preventing Medical Mistakes. See page
    [6](#preventing_medical_mistakes).

-   We added information regarding enrolling in Medicare. See page
    [54](#what-is-medicare).

-   We revised the Medicare Primary Payer Chart. See page
    [56](#Primary_Payer_Chart).

## Changes to this Plan

-   Your share of the non-Postal premium will increase by 14.6% for Self
    Only or 14.6% for Self and Family.

-   We will provide physical, occupational, and speech therapy along
    with multidisciplinary outpatient rehabilitation as medically
    necessary without any other limitations.

-   We cover urgent care services received from non-Plan providers
    outside our service area at \$10 per visit at an urgent care center
    and \$50 per visit at an emergency room.

-   We decreased the copayment for group mental health visits from \$10
    to \$5.

# Section 3. How you get care

+-----------------------+----------------------------------------------+
| ##                    | We will send you an identification (ID) card |
|  Identification cards | when you enroll. You should carry your ID    |
|                       | card with you at all times. You must show it |
|                       | whenever you receive services from a Plan    |
|                       | provider, or fill a prescription at a Plan   |
|                       | pharmacy. Until you receive your ID card,    |
|                       | use your copy of the Health Benefits         |
|                       | Election Form, SF-2809, your health benefits |
|                       | enrollment confirmation (for annuitants), or |
|                       | your Employee Express confirmation letter.   |
|                       |                                              |
|                       | If you do not receive your ID card within 30 |
|                       | days after the effective date of your        |
|                       | enrollment, or if you need replacement       |
|                       | cards, call us at our Member Service Call    |
|                       | Center at **1-800-464-4000**, or write to us |
|                       | at: Kaiser Permanente California Service     |
|                       | Center -- Federal Account Team, 3840 Murphy  |
|                       | Canyon Road, San Diego, CA 92123. You may    |
|                       | also request replacement cards through our   |
|                       | Web site at                                  |
|                       | [**http://members.kaiserpermanente.o         |
|                       | rg**](http://members.kaiserpermanente.org/). |
+-----------------------+----------------------------------------------+
| ## Where              | You get care from "Plan providers" and "Plan |
|  you get covered care | facilities." You will only pay copayments    |
|                       | and/or coinsurance, and you will not have to |
|                       | file claims.                                 |
+-----------------------+----------------------------------------------+
| ### Plan providers    | Plan providers are physicians and other      |
|                       | health care professionals in our service     |
|                       | area that we contract with to provide        |
|                       | covered services to our members. Health Plan |
|                       | contracts with Southern California           |
|                       | Permanente Medical Group and independent     |
|                       | multispecialty groups of physicians to       |
|                       | provide or arrange all necessary physician   |
|                       | care for Plan members. Medical care is       |
|                       | provided through physicians, nurse           |
|                       | practitioners, and other skilled medical     |
|                       | personnel working as medical teams at Kaiser |
|                       | Permanente facilities. We credential Plan    |
|                       | providers according to national standards.   |
|                       | Specialists in most major specialties are    |
|                       | available as part of the medical teams for   |
|                       | consultation and treatment. Other necessary  |
|                       | medical care, such as physical therapy and   |
|                       | laboratory and X-ray services, is also       |
|                       | available. Plan physicians also arrange any  |
|                       | necessary specialty care.                    |
|                       |                                              |
|                       | We list Plan providers in the provider       |
|                       | directory, which we update periodically. The |
|                       | list is also on our Web site.                |
+-----------------------+----------------------------------------------+
| -   []{#__Ref         | Plan facilities are hospitals and other      |
| Heading___Toc52270411 | facilities in our service area that we       |
|     .anchor}**Plan    | contract with to provide covered services to |
|     facilities**      | our members. Kaiser Permanente offers        |
|                       | comprehensive, affordable health care at 10  |
|                       | major Medical Centers and more than 90       |
|                       | medical offices conveniently located         |
|                       | throughout the Southern California area.     |
|                       |                                              |
|                       | The Plan's facility directory lists the      |
|                       | Plan's facilities and services, with the     |
|                       | locations and phone numbers. Directories are |
|                       | updated on a regular basis and are available |
|                       | at the time of enrollment or upon request by |
|                       | calling our Member Service Call Center at    |
|                       | **1-800-464-4000**. You should use this      |
|                       | directory to:                                |
|                       |                                              |
|                       | -   Receive more information about facility  |
|                       |     locations and services                   |
|                       |                                              |
|                       | -   Receive information about how to get     |
|                       |     established with a Plan physician        |
|                       |                                              |
|                       | You must receive your health services at     |
|                       | Plan facilities, except if you have an       |
|                       | emergency. If you are visiting another       |
|                       | Kaiser Permanente service area, you may      |
|                       | receive health care services at those Kaiser |
|                       | Permanente facilities. Under the             |
|                       | circumstances specified in this brochure,    |
|                       | you may receive follow-up or continuing care |
|                       | while you travel anywhere.                   |
+-----------------------+----------------------------------------------+
| ## What you must d    | It depends on the type of care you need.     |
| o to get covered care | First, you and each family member must       |
|                       | choose a primary care physician. This        |
|                       | decision is important since your primary     |
|                       | care physician provides or arranges for most |
|                       | of your health care.                         |
+-----------------------+----------------------------------------------+
| ### Primary care      | Your primary care physician can be a family  |
|                       | practitioner, pediatrician, gynecologist, or |
|                       | internist. Your primary care physician will  |
|                       | provide most of your health care, or give    |
|                       | you a referral to see a specialist.          |
|                       |                                              |
|                       | Please notify the Plan of the primary care   |
|                       | physician you choose. If you need help       |
|                       | choosing a primary care physician, call the  |
|                       | Plan. You may change your primary care       |
|                       | physician at any time. You are free to see   |
|                       | other Plan physicians if your primary care   |
|                       | physician is not available, and to receive   |
|                       | care at other Kaiser Permanente facilities.  |
|                       |                                              |
|                       | If you want to change primary care           |
|                       | physicians or if your primary care physician |
|                       | leaves the Plan, call us. We will help you   |
|                       | select a new one.                            |
+-----------------------+----------------------------------------------+
| ### Specialty care    | Your primary care physician will refer you   |
|                       | to a specialist for needed care. When you    |
|                       | receive a referral from your primary care    |
|                       | physician, you must return to the primary    |
|                       | care physician after the consultation,       |
|                       | unless your primary care physician           |
|                       | authorized a certain number of visits        |
|                       | without additional referrals. The primary    |
|                       | care physician must provide or authorize all |
|                       | follow-up care. Do not go to the specialist  |
|                       | for return visits unless your primary care   |
|                       | physician gives you a referral. However, you |
|                       | may see a gynecologist, an optometrist, or   |
|                       | our mental health and substance abuse Plan   |
|                       | providers without a referral.                |
|                       |                                              |
|                       | Here are other things you should know about  |
|                       | specialty care:                              |
|                       |                                              |
|                       | -   If you need to see a specialist          |
|                       |     frequently because of a chronic,         |
|                       |     complex, or serious medical condition,   |
|                       |     your primary care physician will develop |
|                       |     a treatment plan that allows you to see  |
|                       |     your specialist for a certain number of  |
|                       |     visits without additional referrals.     |
|                       |     Your primary care physician will use our |
|                       |     criteria when creating your treatment    |
|                       |     plan (the physician may have to get an   |
|                       |     authorization or approval beforehand).   |
|                       |                                              |
|                       | -   If you are seeing a specialist when you  |
|                       |     enroll in our Plan, talk to your primary |
|                       |     care physician. Your primary care        |
|                       |     physician will decide what treatment you |
|                       |     need. If he or she decides to refer you  |
|                       |     to a specialist, ask if you can see your |
|                       |     current specialist. If your current      |
|                       |     specialist does not participate with us, |
|                       |     you must receive treatment from a        |
|                       |     specialist who does. Generally, we will  |
|                       |     not pay for you to see a specialist who  |
|                       |     does not participate with our Plan.      |
|                       |                                              |
|                       | -   If you are seeing a specialist and your  |
|                       |     specialist leaves the Plan, call your    |
|                       |     primary care physician, who will arrange |
|                       |     for you to see another specialist. You   |
|                       |     may receive services from your current   |
|                       |     specialist until we can make             |
|                       |     arrangements for you to see someone      |
|                       |     else.                                    |
|                       |                                              |
|                       | -   If you have a chronic or disabling       |
|                       |     condition and lose access to your        |
|                       |     specialist because we:                   |
|                       |                                              |
|                       | ```{=html}                                   |
|                       | <!-- -->                                     |
|                       | ```                                          |
|                       | -   terminate our contract with your         |
|                       |     specialist for other than cause; or      |
|                       |                                              |
|                       | -   drop out of the Federal Employees Health |
|                       |     Benefits (FEHB) Program and you enroll   |
|                       |     in another FEHB plan; or                 |
|                       |                                              |
|                       | -   reduce our service area and you enroll   |
|                       |     in another FEHB plan,                    |
|                       |                                              |
|                       | > you may be able to continue seeing your    |
|                       | > specialist for up to 90 days after you     |
|                       | > receive notice of the change. Contact us   |
|                       | > or, if we drop out of the Program, contact |
|                       | > your new plan.                             |
|                       |                                              |
|                       | If you are in the second or third trimester  |
|                       | of pregnancy and you lose access to your     |
|                       | specialist based on the above circumstances, |
|                       | you can continue to see your specialist      |
|                       | until the end of your postpartum care, even  |
|                       | if it is beyond the 90 days.                 |
+-----------------------+----------------------------------------------+
| ### Hospital care     | Your Plan primary care physician or          |
|                       | specialist will make necessary hospital      |
|                       | arrangements and supervise your care. This   |
|                       | includes admission to a skilled nursing or   |
|                       | other type of facility.                      |
|                       |                                              |
|                       | If you are in the hospital when your         |
|                       | enrollment in our Plan begins, call our      |
|                       | Member Service Call Center immediately at    |
|                       | **1-800-464-4000**. If you are new to the    |
|                       | FEHB Program, we will arrange for you to     |
|                       | receive care.                                |
|                       |                                              |
|                       | If you changed from another FEHB plan to us, |
|                       | your former plan will pay for the hospital   |
|                       | stay until:                                  |
|                       |                                              |
|                       | -   you are discharged, not merely moved to  |
|                       |     an alternative care center; or           |
|                       |                                              |
|                       | -   the day your benefits from your former   |
|                       |     plan run out; or                         |
|                       |                                              |
|                       | -   the 92nd day after you become a member   |
|                       |     of this Plan,                            |
|                       |                                              |
|                       | whichever happens first.                     |
|                       |                                              |
|                       | These provisions apply only to the hospital  |
|                       | benefit of the hospitalized person. If your  |
|                       | plan terminates participation in the FEHB    |
|                       | Program in whole or in part, or if OPM       |
|                       | orders an enrollment change, this            |
|                       | continuation of coverage provision does not  |
|                       | apply. In such a case, the hospitalized      |
|                       | family member's benefits under the new plan  |
|                       | begin on the effective date of enrollment.   |
+-----------------------+----------------------------------------------+
| ## Circumstanc        | Under certain extraordinary circumstances,   |
| es beyond our control | such as natural disasters, we may have to    |
|                       | delay your services or we may be unable to   |
|                       | provide them. In that case, we will make all |
|                       | reasonable efforts to provide you with the   |
|                       | necessary care.                              |
+-----------------------+----------------------------------------------+
| ## Services requiri   | Your primary care physician has authority to |
| ng our prior approval | refer you for most services. In certain      |
|                       | cases your primary care physician can        |
|                       | arrange for specialty services through a     |
|                       | process we call a referral. Your physician   |
|                       | must write a referral for services such as   |
|                       | neurology, orthopedics, rheumatology,        |
|                       | endocrinology, and any service that will not |
|                       | be provided by Plan physicians.              |
|                       |                                              |
|                       | If a Plan physician determines that a        |
|                       | referral for medical care is necessary,      |
|                       | those arrangements will be prepared in       |
|                       | writing and in advance of such medical care. |
|                       | If you receive care outside the Plan without |
|                       | a referral, you will be responsible for      |
|                       | those expenses. We encourage you to          |
|                       | participate in your medical care and discuss |
|                       | any questions about our referral process     |
|                       | with your primary care physician. If your    |
|                       | request for referral is denied, please       |
|                       | contact our Member Service Call Center at\   |
|                       | **1-800-464-4000** or refer to Section 8 of  |
|                       | this brochure.                               |
+-----------------------+----------------------------------------------+

# Section 4. Your costs for covered services

You must share the cost of some services. You are responsible for:

+-----------------------+----------------------------------------------+
| ### Copayments        | A copayment is a fixed amount of money you   |
|                       | pay to the provider, facility, pharmacy,     |
|                       | etc., when you receive services. Example:    |
|                       | When you see your primary care physician,    |
|                       | you pay a copayment of \$10 per office       |
|                       | visit.                                       |
+-----------------------+----------------------------------------------+
| ### Deductible        | We do not have a deductible.                 |
+-----------------------+----------------------------------------------+
| ### Coinsurance       | Coinsurance is the percentage of our         |
|                       | allowance that you must pay for certain      |
|                       | services you receive. Example: In our Plan,  |
|                       | you pay 50% of our allowance for infertility |
|                       | services.                                    |
+-----------------------+----------------------------------------------+
| ###                   | If you do not pay your copayment at the time |
|  Fees when you fail t | you receive services, we will bill you. You  |
| o make your copayment | will be required to pay a \$13.50 charge for |
|                       | each bill sent for unpaid services.          |
+-----------------------+----------------------------------------------+
| ## Your catastrophic  | After your copayments and coinsurance total  |
| protection out-of-poc | \$1,500 per person or \$3,000 per family     |
| ket maximum for copay | enrollment in any calendar year, you do not  |
| ments and coinsurance | have to pay any more for covered services.   |
|                       | However, copayments or coinsurance for the   |
|                       | following services do not count toward your  |
|                       | catastrophic protection out-of-pocket        |
|                       | maximum. You must continue to pay copayments |
|                       | or coinsurance for these services:           |
|                       |                                              |
|                       | -   Prescription drugs                       |
|                       |                                              |
|                       | -   Durable medical equipment                |
|                       |                                              |
|                       | -   Orthopedic and prosthetic devices        |
|                       |                                              |
|                       | -   Dental services                          |
|                       |                                              |
|                       | -   Contraceptive devices                    |
|                       |                                              |
|                       | -   Chiropractic services                    |
|                       |                                              |
|                       | -   The \$25 charge paid for follow-up or    |
|                       |     continuing care outside the service area |
|                       |                                              |
|                       | Be sure to keep accurate records of your     |
|                       | copayments and coinsurance, since you are    |
|                       | responsible for informing us when you reach  |
|                       | the maximum.                                 |
+-----------------------+----------------------------------------------+

# Section 5. Benefits

#  -- 

# OVERVIEW

# *(See page [10](#section-2.-how-we-change-for-2004) for how our benefits changed this year and page [72](#summary-of-benefits) for a benefits summary.)*

**NOTE:** This benefits section is divided into subsections. Please read
the important things you should keep in mind at the beginning of each
subsection. Also read the General Exclusions in Section 6; they apply to
the benefits in the following subsections. To obtain claim forms, claims
filing advice, or more information about our benefits, contact us at\
**1-800-464-4000** or our Web site at
[**http://members.kaiserpermanente.org**](http://members.kaiserpermanente.org/).

(a) Medical services and supplies provided by physicians and other
    health care professionals [16](#section-5)-[25](#aLast)

+---------------------------------+------------------------------------+
| -   Diagnostic and treatment    | -   Hearing services (testing,     |
|     services                    |     treatment, and supplies)       |
|                                 |                                    |
| -   Lab, X-ray, and other       | -   Vision services (testing,      |
|     diagnostic tests            |     treatment, and supplies)       |
|                                 |                                    |
| -   Preventive care, adult      | -   Foot care                      |
|                                 |                                    |
| -   Preventive care, children   | -   Orthopedic and prosthetic      |
|                                 |     devices                        |
| -   Maternity care              |                                    |
|                                 | -   Durable medical equipment      |
| -   Family planning             |     (DME)                          |
|                                 |                                    |
| -   Infertility services        | -   Home health services           |
|                                 |                                    |
| -   Allergy care                | -   Chiropractic and alternative   |
|                                 |     treatments                     |
| -   Treatment therapies         |                                    |
|                                 | -   Educational classes and        |
| -   Physical and occupational   |     programs                       |
|     therapies                   |                                    |
|                                 |                                    |
| -   Speech therapy              |                                    |
+---------------------------------+------------------------------------+

(b) Surgical and anesthesia services provided by physicians and other
    health care professionals [26](#section-5-1)-[30](#bLast)

+---------------------------------+------------------------------------+
| -   Surgical procedures         | -   Oral and maxillofacial surgery |
|                                 |                                    |
| -   Reconstructive surgery      | -   Organ/tissue transplants       |
|                                 |                                    |
|                                 | -   Anesthesia                     |
+---------------------------------+------------------------------------+

(c) Services provided by a hospital or other facility, and ambulance
    services [31](#section-1)-[33](#cLast)

+---------------------------------+------------------------------------+
| -   Inpatient hospital          | -   Skilled nursing care benefits  |
|                                 |                                    |
| -   Outpatient hospital or      | -   Hospice care                   |
|     ambulatory surgical center  |                                    |
|                                 | -   Ambulance                      |
+---------------------------------+------------------------------------+

(d) Emergency services/accidents
    [34](#section-5d.-emergency-servicesaccidents)-[37](#dLast)

+---------------------------------+------------------------------------+
| -   Emergency within our        | -   Ambulance                      |
|     service area                |                                    |
|                                 |                                    |
| -   Emergency outside our       |                                    |
|     service area                |                                    |
+---------------------------------+------------------------------------+

(e) Mental health and substance abuse benefits
    [38](#section-5-3)-[40](#eLast)

(f) Prescription drug benefits
    [41](#section-5f.-prescription-drug-benefits)-[43](#fLast)

(g) Special features [44](#section-5-4)-[46](#gLast)

+---------------------------------+------------------------------------+
| -   Flexible benefits option    | -   24 hour nurse line             |
|                                 |                                    |
| -   Services from other Kaiser  | -   Services for deaf and hearing  |
|     Permanente Plans            |     impaired                       |
|                                 |                                    |
| -   Travel benefit              | -   Centers of excellence          |
+---------------------------------+------------------------------------+

(h) Dental benefits [47](#hFirst)

(i) Non-FEHB benefits available to Plan members
    [48](#section-5i.-non-fehb-benefits-available-to-plan-members)

    Summary of benefits [72](#summary-of-benefits)

# Section 5

# (a). Medical services and supplies provided by physicians and other health care professionals

+---+---+-------------------------------------+----------------+---+----+
|   | * | > **Here are some important things  |                | * |    |
|   | * | > to keep in mind about these       |                | * |    |
|   | I | > benefits:**                       |                | I |    |
|   | * |                                     |                | * |    |
|   | * | -   Please remember that all        |                | * |    |
|   |   |     benefits are subject to the     |                |   |    |
|   | * |     definitions, limitations, and   |                | * |    |
|   | * |     exclusions in this brochure and |                | * |    |
|   | M |     we cover them only when we      |                | M |    |
|   | * |     determine they are medically    |                | * |    |
|   | * |     necessary.                      |                | * |    |
|   |   |                                     |                |   |    |
|   | * | -   Plan physicians must provide or |                | * |    |
|   | * |     arrange your care.              |                | * |    |
|   | P |                                     |                | P |    |
|   | * | -   We have no calendar year        |                | * |    |
|   | * |     deductible.                     |                | * |    |
|   |   |                                     |                |   |    |
|   | * | -   Be sure to read Section 4,      |                | * |    |
|   | * |     *Your costs for covered         |                | * |    |
|   | O |     services,* for valuable         |                | O |    |
|   | * |     information about how           |                | * |    |
|   | * |     cost-sharing works. Also read   |                | * |    |
|   |   |     Section 9 about coordinating    |                |   |    |
|   | * |     benefits with other coverage,   |                | * |    |
|   | * |     including with Medicare.        |                | * |    |
|   | R |                                     |                | R |    |
|   | * | -   Note: Instead of a \$10 charge, |                | * |    |
|   | * |     you pay only \$5 if you enroll  |                | * |    |
|   |   |     in our Medicare+Choice Plan and |                |   |    |
|   | * |     assign your Medicare benefits   |                | * |    |
|   | * |     to the Plan.                    |                | * |    |
|   | T |                                     |                | T |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   |   |                                     |                |   |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   | A |                                     |                | A |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   |   |                                     |                |   |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   | N |                                     |                | N |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   |   |                                     |                |   |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
|   | T |                                     |                | T |    |
|   | * |                                     |                | * |    |
|   | * |                                     |                | * |    |
+---+---+-------------------------------------+----------------+---+----+
| > |   |                                     | **You pay**    |   |    |
|   |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
| B |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
| n |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
| f |   |                                     |                |   |    |
| i |   |                                     |                |   |    |
| t |   |                                     |                |   |    |
| > |   |                                     |                |   |    |
|   |   |                                     |                |   |    |
| d |   |                                     |                |   |    |
| e |   |                                     |                |   |    |
| s |   |                                     |                |   |    |
| c |   |                                     |                |   |    |
| r |   |                                     |                |   |    |
| i |   |                                     |                |   |    |
| p |   |                                     |                |   |    |
| t |   |                                     |                |   |    |
| i |   |                                     |                |   |    |
| o |   |                                     |                |   |    |
| n |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
| * |   |                                     |                |   |    |
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+---+---+-------------------------------------+----------------+---+----+
| A |   |                                     | > Nothing      |   |    |
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+---+---+-------------------------------------+----------------+---+----+

+---------------------------------------------+------------------------+
| Lab, X-ray, and other diagnostic tests      | You pay                |
+---------------------------------------------+------------------------+
| Tests, such as:                             | Nothing                |
|                                             |                        |
| -   Blood tests                             |                        |
|                                             |                        |
| -   Urinalysis                              |                        |
|                                             |                        |
| -   Non-routine pap tests                   |                        |
|                                             |                        |
| -   Pathology                               |                        |
|                                             |                        |
| -   X-rays                                  |                        |
|                                             |                        |
| -   Non-routine mammograms                  |                        |
|                                             |                        |
| -   CAT scans/MRI                           |                        |
|                                             |                        |
| -   Ultrasound                              |                        |
|                                             |                        |
| -   Electrocardiogram and EEG               |                        |
+---------------------------------------------+------------------------+
| Preventive care, adult                      |                        |
+---------------------------------------------+------------------------+
| Routine screenings, such as:                | Nothing                |
|                                             |                        |
| -   Total blood cholesterol                 |                        |
|                                             |                        |
| -   Colorectal cancer screening, including  |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Fecal occult blood test                 |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Sigmoidoscopy - every five years        |                        |
|     starting at age 50                      |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Routine Prostate Specific Antigen (PSA) |                        |
|     test - one annually for men age 40 and  |                        |
|     older                                   |                        |
|                                             |                        |
| -   Routine pap test                        |                        |
|                                             |                        |
| > Note: You should consult with your        |                        |
| > physician to determine what is            |                        |
| > appropriate for you.                      |                        |
+---------------------------------------------+------------------------+
| Routine mammogram---covered for women age   | Nothing                |
| 35 and older, as follows:                   |                        |
|                                             |                        |
| -   Age 35 through 39, one during this      |                        |
|     five-year period                        |                        |
|                                             |                        |
| -   Age 40 through 64, one every calendar   |                        |
|     year                                    |                        |
|                                             |                        |
| -   At age 65 and older, once every two     |                        |
|     consecutive calendar years              |                        |
|                                             |                        |
| > Note: In addition to routine screening,   |                        |
| > we cover mammograms when medically        |                        |
| > necessary to diagnose or treat your       |                        |
| > illness.                                  |                        |
+---------------------------------------------+------------------------+
| Routine immunizations, including but not    | Nothing                |
| limited to:                                 |                        |
|                                             |                        |
| -   Tetanus-diphtheria (Td) booster -- once |                        |
|     every 10 years, ages 19 and over        |                        |
|     (except as provided for under childhood |                        |
|     immunizations)                          |                        |
|                                             |                        |
| -   Influenza/Pneumococcal vaccines         |                        |
|                                             |                        |
| -   Hepatitis vaccinations                  |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| Preventive care, adult *(continued)*        | You pay                |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| > *Physical exams required for:*            |                        |
|                                             |                        |
| -   *Obtaining or continuing employment*    |                        |
|                                             |                        |
| -   *Insurance*                             |                        |
|                                             |                        |
| -   *Travel*                                |                        |
+---------------------------------------------+------------------------+
| Preventive care, children                   |                        |
+---------------------------------------------+------------------------+
| -   Well-child preventive care visits (23   | Nothing                |
|     months and younger)                     |                        |
|                                             |                        |
| -   Childhood immunizations recommended by  |                        |
|     the American Academy of Pediatrics      |                        |
+---------------------------------------------+------------------------+
| -   Well-child care charges for routine     | \$10 per office visit  |
|     examinations age 24 months and older,   |                        |
|     such as:                                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Eye exams to determine the need for     |                        |
|     vision correction                       |                        |
|                                             |                        |
| -   Ear exams to determine the need for     |                        |
|     hearing correction                      |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| > *Physical exams required for:*            |                        |
|                                             |                        |
| -   *Obtaining or continuing employment*    |                        |
|                                             |                        |
| -   *Insurance*                             |                        |
+---------------------------------------------+------------------------+
| Maternity care                              |                        |
+---------------------------------------------+------------------------+
| Complete maternity (obstetrical) care, such | Nothing                |
| as:                                         |                        |
|                                             |                        |
| -   Prenatal care                           |                        |
|                                             |                        |
| -   Delivery                                |                        |
|                                             |                        |
| -   First scheduled postnatal care visit    |                        |
|                                             |                        |
|     Note: Here are some things to keep in   |                        |
|     mind:                                   |                        |
|                                             |                        |
| -   You may remain in the hospital up to 48 |                        |
|     hours after a regular delivery and 96   |                        |
|     hours after a cesarean delivery. We     |                        |
|     will extend your inpatient stay if      |                        |
|     medically necessary.                    |                        |
|                                             |                        |
| -   We cover routine nursery care of the    |                        |
|     newborn child during the covered        |                        |
|     portion of the mother's maternity stay. |                        |
|     We will cover other care of an infant   |                        |
|     who requires non-routine treatment only |                        |
|     if we cover the infant under a Self and |                        |
|     Family enrollment.                      |                        |
|                                             |                        |
| -   We pay hospitalization and surgeon      |                        |
|     services (delivery) the same as for     |                        |
|     illness and injury. See Section 5(c)    |                        |
|     for hospital benefits and Section 5(b)  |                        |
|     for surgery benefits*.*                 |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Routine sonograms to determine fetal   |                        |
|     age, size, or sex*                      |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| Family planning                             | You pay                |
+---------------------------------------------+------------------------+
| -   Voluntary sterilization (See Surgical   | \$10 per office visit  |
|     procedures Section 5 (b))               |                        |
|                                             |                        |
| -   Genetic counseling                      |                        |
|                                             |                        |
| -   Insertion of surgically implanted       |                        |
|     time-release contraceptive drugs or     |                        |
|     injectable contraceptive drugs          |                        |
|                                             |                        |
| > Note: The following devices or            |                        |
| > contraceptives are provided at no charge: |                        |
| > intrauterine devices (IUDs); implanted    |                        |
| > time-release contraceptive drugs and      |                        |
| > injectable contraceptive drugs. We cover  |                        |
| > oral contraceptives, cervical caps, and   |                        |
| > diaphragms under the prescription drug    |                        |
| > benefit.                                  |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Reversal of voluntary surgical         |                        |
|     sterilization*                          |                        |
+---------------------------------------------+------------------------+
| Infertility services                        |                        |
+---------------------------------------------+------------------------+
| Diagnosis and treatment of infertility,     | 50% of our allowance   |
| such as:                                    |                        |
|                                             |                        |
| -   Artificial insemination:                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Intravaginal insemination (IVI)         |                        |
|                                             |                        |
| -   Intracervical insemination (ICI)        |                        |
|                                             |                        |
| -   Intrauterine insemination (IUI)         |                        |
|                                             |                        |
| > Note: We cover fertility drugs under the  |                        |
| > prescription drug benefit.                |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| > *These exclusions apply to fertile as     |                        |
| > well as infertile individuals or          |                        |
| > couples:*                                 |                        |
|                                             |                        |
| -   *Assisted reproductive technology (ART) |                        |
|     procedures, such as:*                   |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *In vitro fertilization*                |                        |
|                                             |                        |
| -   *Embryo transfer and GIFT*              |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   *Services and supplies related to       |                        |
|     excluded ART procedures*                |                        |
|                                             |                        |
| -   *Cost of donor sperm and donor eggs and |                        |
|     services related to their procurement   |                        |
|     and storage*                            |                        |
+---------------------------------------------+------------------------+
| Allergy care                                |                        |
+---------------------------------------------+------------------------+
| Allergy testing                             | \$10 per office visit  |
+---------------------------------------------+------------------------+
| Allergy treatment and injections            | \$3 per office visit   |
+---------------------------------------------+------------------------+
| Allergy serum                               | Nothing                |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Provocative food testing*              |                        |
|                                             |                        |
| -   *Sublingual allergy desensitization*    |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| Treatment therapies                         | You pay                |
+---------------------------------------------+------------------------+
| -   Chemotherapy and radiation therapy      | Nothing for services   |
|                                             | provided by a          |
|     Note: We limit high-dose chemotherapy   | non-physician provider |
|     in association with autologous bone     |                        |
|     marrow transplants to those transplants | \$10 for services      |
|     listed under Organ/Tissue Transplants   | provided by a          |
|     on page [30](#OrganTissueTransplants).  | physician              |
|                                             |                        |
| -   Intravenous (IV)/Infusion therapy --    |                        |
|     Home IV and antibiotic therapy          |                        |
+---------------------------------------------+------------------------+
| -   Respiratory and inhalation therapy      | \$10 per office visit  |
|                                             |                        |
| -   Growth hormone therapy (GHT)            |                        |
|                                             |                        |
|     Note: We cover human growth hormone     |                        |
|     under the prescription drug benefit.    |                        |
|                                             |                        |
| -   Dialysis -- hemodialysis and peritoneal |                        |
|     dialysis                                |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Chemotherapy supported by a bone       |                        |
|     marrow transplant or with stem cell     |                        |
|     support, for any diagnosis not listed   |                        |
|     as covered*                             |                        |
+---------------------------------------------+------------------------+
| Physical and occupational therapies         |                        |
+---------------------------------------------+------------------------+
| -   Physical therapy by qualified physical  | \$10 per outpatient    |
|     therapists to restore bodily function   | visit                  |
|     when you have a total or partial loss   |                        |
|     of bodily function due to illness or    | > Nothing for          |
|     injury.                                 | > inpatient            |
|                                             |                        |
| -   Occupational therapy by occupational    |                        |
|     therapists to assist you in achieving   |                        |
|     and maintaining self-care and improved  |                        |
|     functioning in other activities of      |                        |
|     daily life.                             |                        |
|                                             |                        |
| -   Cardiac rehabilitation following a      |                        |
|     heart transplant, bypass surgery, or a  |                        |
|     myocardial infarction.                  |                        |
|                                             |                        |
| -   Multidisciplinary outpatient            |                        |
|     rehabilitation includes diagnostic and  |                        |
|     restorative services comprising a       |                        |
|     program of physical, speech,            |                        |
|     occupational, and respiratory therapy,  |                        |
|     as well as certain other items and      |                        |
|     services that are medically necessary   |                        |
|     for rehabilitation.                     |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Long-term rehabilitative therapy*      |                        |
|                                             |                        |
| -   *Exercise programs*                     |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| Speech therapy                              | You pay                |
+---------------------------------------------+------------------------+
| -   Speech therapy by speech therapists     | \$10 per outpatient    |
|     when medically necessary                | visit                  |
|                                             |                        |
|                                             | > Nothing for          |
|                                             | > inpatient            |
+---------------------------------------------+------------------------+
| Hearing services (testing, treatment, and   |                        |
| supplies)                                   |                        |
+---------------------------------------------+------------------------+
| Hearing testing                             | \$10 per office visit  |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Hearing aids*                          |                        |
|                                             |                        |
| -   *Hearing tests to determine the most    |                        |
|     appropriate hearing aid*                |                        |
+---------------------------------------------+------------------------+
| []{#VISION .anchor}Vision services          |                        |
| (testing, treatment, and supplies)          |                        |
+---------------------------------------------+------------------------+
| -   Diagnosis and treatment of diseases of  | \$10 per office visit  |
|     the eye                                 |                        |
|                                             |                        |
| -   Eye refractions to determine the need   |                        |
|     for vision correction and provide a     |                        |
|     prescription for eyeglasses             |                        |
+---------------------------------------------+------------------------+
| Therapeutic contact lenses for the          | Nothing                |
| condition of aniridia for up to two lenses  |                        |
| per eye in a 12-month period                |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Eyeglasses or contact lenses (except   |                        |
|     for the condition of aniridia)*         |                        |
|                                             |                        |
| -   *Eye exercises and orthoptics*          |                        |
|                                             |                        |
| -   *Radial keratotomy and other refractive |                        |
|     surgery*                                |                        |
+---------------------------------------------+------------------------+
| Foot care                                   |                        |
+---------------------------------------------+------------------------+
| Routine foot care when you are under active | \$10 per office visit  |
| treatment for a metabolic or peripheral     |                        |
| vascular disease, such as diabetes          |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Cutting, trimming, or removal of       |                        |
|     corns, calluses, or the free edge of    |                        |
|     toenails, and similar routine treatment |                        |
|     of conditions of the foot, except as    |                        |
|     stated above*                           |                        |
|                                             |                        |
| -   *Treatment of weak, strained, or flat   |                        |
|     feet, or bunions or spurs; and of any   |                        |
|     instability, imbalance, or subluxation  |                        |
|     of the foot (unless the treatment is by |                        |
|     open cutting surgery)*                  |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| Orthopedic and prosthetic devices           | You pay                |
+---------------------------------------------+------------------------+
| We cover internally implanted FDA-approved  | Nothing                |
| devices, including but not limited to:      |                        |
|                                             |                        |
| -   Artificial joints                       |                        |
|                                             |                        |
| -   Pacemakers                              |                        |
|                                             |                        |
| -   Cochlear implants                       |                        |
|                                             |                        |
| -   Intraocular implants following cataract |                        |
|     removal                                 |                        |
|                                             |                        |
| -   Surgically implanted breast implants    |                        |
|     following a mastectomy                  |                        |
|                                             |                        |
| > Note: See Section 5(b) for coverage of    |                        |
| > the surgery to insert the device.         |                        |
+---------------------------------------------+------------------------+
| We cover FDA-approved devices that are in   | 20% of our allowance   |
| general use and are required because of a   |                        |
| defect in form or function of a permanently |                        |
| inoperative or malfunctioning body part,    |                        |
| including but not limited to:               |                        |
|                                             |                        |
| -   Artificial limbs and eyes and stump     |                        |
|     hose                                    |                        |
|                                             |                        |
| -   Externally worn breast prostheses and   |                        |
|     surgical bras, including necessary      |                        |
|     replacements, following a mastectomy    |                        |
|                                             |                        |
| -   Corrective orthopedic appliances for    |                        |
|     non-dental treatment of                 |                        |
|     temporomandibular joint (TMJ) pain      |                        |
|     dysfunction syndrome                    |                        |
|                                             |                        |
| -   Podiatric devices (including footwear)  |                        |
|     to prevent or treat diabetes-related    |                        |
|     complications when prescribed by a Plan |                        |
|     podiatrist, physiatrist, or orthopedist |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Enteral formula for members who require |                        |
|     tube feeding per Medicare guidelines    |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Ostomy and urological supplies in       |                        |
|     accord with the Plan's formulary        |                        |
|     guidelines                              |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Comfort, convenience, or luxury        |                        |
|     equipment or features*                  |                        |
|                                             |                        |
| -   *Heel pads and heel cups*               |                        |
|                                             |                        |
| -   *Lumbosacral supports*                  |                        |
|                                             |                        |
| -   *Corsets, trusses, elastic stockings,   |                        |
|     support hose, and other supportive      |                        |
|     devices*                                |                        |
|                                             |                        |
| -   *Shoes or arch supports, even if        |                        |
|     custom-made, except to treat            |                        |
|     diabetes-related complications when     |                        |
|     prescribed by a Plan podiatrist,        |                        |
|     physiatrist, or orthopedist*            |                        |
+---------------------------------------------+------------------------+
| Durable medical equipment (DME)             |                        |
+---------------------------------------------+------------------------+
| -   During a covered stay in a Plan         | Nothing                |
|     hospital or skilled nursing facility    |                        |
|                                             |                        |
| > We limit coverage to the standard item    |                        |
| > that meets your medical needs consistent  |                        |
| > with our Plan DME formulary guidelines.   |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| Durable medical equipment (DME)             | You pay                |
| *(continued)*                               |                        |
+---------------------------------------------+------------------------+
| For use in the home when intended to be     | 20% of our allowance   |
| used repeatedly. Includes but is not        |                        |
| limited to:                                 |                        |
|                                             |                        |
| -   Oxygen and oxygen dispensing equipment  |                        |
|                                             |                        |
| -   Hospital beds                           |                        |
|                                             |                        |
| -   Wheelchairs including motorized when    |                        |
|     medically necessary                     |                        |
|                                             |                        |
| -   Crutches                                |                        |
|                                             |                        |
| -   Walkers                                 |                        |
|                                             |                        |
| -   Blood glucose testing monitors and      |                        |
|     related supplies                        |                        |
|                                             |                        |
| -   Insulin pumps                           |                        |
|                                             |                        |
| -   Infant apnea monitors                   |                        |
|                                             |                        |
| -   Repairs and replacements resulting from |                        |
|     normal use                              |                        |
|                                             |                        |
| > We limit coverage to the standard item    |                        |
| > that meets your medical needs consistent  |                        |
| > with our Plan DME formulary guidelines.   |                        |
| > We decide whether to rent or purchase the |                        |
| > item, and choose the vendor.              |                        |
| >                                           |                        |
| > Note: We only provide DME in the Plan's   |                        |
| > service area.                             |                        |
+---------------------------------------------+------------------------+
| -   External devices used for the treatment | 50% of our allowance   |
|     of sexual dysfunction                   |                        |
|                                             |                        |
| > We limit coverage to the standard item    |                        |
| > that meets your medical needs consistent  |                        |
| > with our Plan DME formulary guidelines.   |                        |
| > We decide whether to rent or purchase the |                        |
| > item, and choose the vendor.              |                        |
| >                                           |                        |
| > Note: We only provide DME in the Plan's   |                        |
| > service area.                             |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Comfort, convenience, or luxury        |                        |
|     equipment or features*                  |                        |
|                                             |                        |
| -   *Devices not medical in nature, such as |                        |
|     sauna baths, exercise and hygiene       |                        |
|     equipment*                              |                        |
|                                             |                        |
| -   *Electronic monitors of the function of |                        |
|     the heart or lungs, except for infant   |                        |
|     apnea monitors*                         |                        |
|                                             |                        |
| -   *Devices to perform medical tests on    |                        |
|     blood or other bodily substances or     |                        |
|     excretions, except diabetic testing     |                        |
|     equipment and supplies*                 |                        |
|                                             |                        |
| -   *Dental appliances*                     |                        |
|                                             |                        |
| -   *Experimental or research equipment*    |                        |
|                                             |                        |
| -   *Modifications to the home or auto*     |                        |
|                                             |                        |
| -   *Items which are no longer medically    |                        |
|     necessary must be paid for or returned* |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| Home health services                        | You pay                |
+---------------------------------------------+------------------------+
| -   Home health care ordered by a Plan      | Nothing                |
|     physician and provided by a registered  |                        |
|     nurse (RN), licensed practical nurse    |                        |
|     (LPN), licensed vocational nurse (LVN), |                        |
|     or home health aide                     |                        |
|                                             |                        |
| -   Services include oxygen therapy,        |                        |
|     intravenous therapy, and medications    |                        |
|                                             |                        |
| Note: We only provide these services in the |                        |
| Plan's service area.                        |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Nursing care requested by, or for the  |                        |
|     convenience of, the patient or the      |                        |
|     patient's family*                       |                        |
|                                             |                        |
| -   *Home care primarily for personal       |                        |
|     assistance that does not include a      |                        |
|     medical component and is not            |                        |
|     diagnostic, therapeutic, or             |                        |
|     rehabilitative*                         |                        |
|                                             |                        |
| -   *Services outside of our service area*  |                        |
+---------------------------------------------+------------------------+
| Chiropractic and alternative treatments     |                        |
+---------------------------------------------+------------------------+
| Chiropractic services covering the          | \$15 per office visit  |
| diagnosis or treatment of                   |                        |
| neuromusculoskeletal disorders limited to   |                        |
| 20 visits per year. You can access services |                        |
| in the following ways:                      |                        |
|                                             |                        |
| > Chiropractic services are provided        |                        |
| > through American Specialty Health Plans   |                        |
| > (ASH Plans). You will have direct access  |                        |
| > to a participating ASHP chiropractor      |                        |
| > without the need to obtain a Plan         |                        |
| > physician referral. You can obtain a list |                        |
| > of ASH Plans Participating Providers by   |                        |
| > calling\                                  |                        |
| > **1-800-678-9133**.                       |                        |
| >                                           |                        |
| > Specific details of this chiropractic     |                        |
| > benefit are listed in the ASH Plans'      |                        |
| > evidence of coverage/disclosure form. You |                        |
| > phone the ASH Plans chiropractor you have |                        |
| > selected for an initial examination.      |                        |
| > After the initial examination and except  |                        |
| > for chiropractic emergency services, your |                        |
| > ASH Plans chiropractor is responsible to  |                        |
| > obtain authorization from ASH Plans for   |                        |
| > any additional chiropractic services on   |                        |
| > your behalf. ASH Plans will not cover any |                        |
| > chiropractic services if you were         |                        |
| > referred through your Plan physician.     |                        |
| >                                           |                        |
| > Note: When necessary and prescribed by an |                        |
| > ASH Plans chiropractor, you may receive   |                        |
| > up to \$50 of chiropractic appliances per |                        |
| > calendar year.                            |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Naturopathic services*                 |                        |
|                                             |                        |
| -   *Hypnotherapy*                          |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| Educational classes and programs            | You pay                |
+---------------------------------------------+------------------------+
| We cover a wide range of health education   | > Nothing              |
| programs to help protect and improve your   | >                      |
| health. Examples of covered health          | > Nothing              |
| education topics include: smoking           | >                      |
| cessation, pregnancy, depression, and       | > Nominal charges      |
| living with chronic conditions.             |                        |
|                                             |                        |
| -   Selected health education programs and  |                        |
|     materials including information on how  |                        |
|     to use our services                     |                        |
|                                             |                        |
| -   Individual health education visits      |                        |
|                                             |                        |
| -   Other health education programs,        |                        |
|     materials, and services                 |                        |
|                                             |                        |
| > Note: Call the Member Service Call Center |                        |
| > at **1-800-464-4000** for information on  |                        |
| > classes near you.[]{#aLast .anchor}       |                        |
+---------------------------------------------+------------------------+

# Section 5

# (b). Surgical and anesthesia services provided by physicians and other health care professionals

+---+---+-------------------------------------+----------------+---+---+
|   | * | > **Here are some important things  |                | * |   |
|   | * | > to keep in mind about these       |                | * |   |
|   | I | > benefits:**                       |                | I |   |
|   | * |                                     |                | * |   |
|   | * | -   Please remember that all        |                | * |   |
|   |   |     benefits are subject to the     |                |   |   |
|   | * |     definitions, limitations, and   |                | * |   |
|   | * |     exclusions in this brochure and |                | * |   |
|   | M |     we cover them only when we      |                | M |   |
|   | * |     determine they are medically    |                | * |   |
|   | * |     necessary.                      |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   Plan physicians must provide or |                | * |   |
|   | * |     arrange your care.              |                | * |   |
|   | P |                                     |                | P |   |
|   | * | -   We have no calendar year        |                | * |   |
|   | * |     deductible.                     |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   Be sure to read Section 4,      |                | * |   |
|   | * |     *Your costs for covered         |                | * |   |
|   | O |     services,* for valuable         |                | O |   |
|   | * |     information about how           |                | * |   |
|   | * |     cost-sharing works. Also read   |                | * |   |
|   |   |     Section 9 about coordinating    |                |   |   |
|   | * |     benefits with other coverage,   |                | * |   |
|   | * |     including with Medicare.        |                | * |   |
|   | R |                                     |                | R |   |
|   | * | -   The amounts listed below are    |                | * |   |
|   | * |     for the charges billed by a     |                | * |   |
|   |   |     physician or other health care  |                |   |   |
|   | * |     professional for your surgical  |                | * |   |
|   | * |     care. Look in Section 5(c) for  |                | * |   |
|   | T |     charges associated with the     |                | T |   |
|   | * |     facility (i.e., hospital,       |                | * |   |
|   | * |     surgical center, etc.).         |                | * |   |
|   |   |                                     |                |   |   |
|   | * | -   YOUR PHYSICIAN MUST GET A       |                | * |   |
|   | * |     REFERRAL FOR SOME SURGICAL      |                | * |   |
|   | A |     PROCEDURES. Please refer to the |                | A |   |
|   | * |     referral information shown in   |                | * |   |
|   | * |     Section 3 to be sure which      |                | * |   |
|   |   |     services require a referral and |                |   |   |
|   | * |     identify which surgeries        |                | * |   |
|   | * |     require a referral.             |                | * |   |
|   | N |                                     |                | N |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
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|   | T |                                     |                | T |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | **You pay**    |   |   |
|   |   |                                     |                |   |   |
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| A |   |                                     | \$10 per       |   |   |
| c |   |                                     | office visit   |   |   |
| o |   |                                     | when provided  |   |   |
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+---+---+-------------------------------------+----------------+---+---+

+---------------------------------------------+------------------------+
| Surgical procedures *(continued)*           | You pay                |
+---------------------------------------------+------------------------+
| Note: The following devices or              | \$10 per office visit  |
| contraceptives are provided at no charge:   | when provided on an    |
| intrauterine devices (IUDs), implanted      | outpatient basis       |
| time-release contraceptive drugs and        |                        |
| injectable contraceptive drugs. We cover    | > Nothing when         |
| oral contraceptives, cervical caps, and     | > provided on an       |
| diaphragms under the prescription drug      | > inpatient basis      |
| benefit.                                    |                        |
|                                             |                        |
| -   Treatment for sexual dysfunction or     |                        |
|     inadequacy                              |                        |
|                                             |                        |
| -   Insertion of internal prosthetic        |                        |
|     devices. See Section 5(a)--\            |                        |
|     Orthopedic and prosthetic devices for   |                        |
|     device coverage information.            |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Reversal of voluntary surgical         |                        |
|     sterilization*                          |                        |
|                                             |                        |
| -   *Routine treatment of conditions of the |                        |
|     foot*                                   |                        |
+---------------------------------------------+------------------------+
| Reconstructive surgery                      |                        |
+---------------------------------------------+------------------------+
| -   Surgery to correct a functional defect  | \$10 per office visit  |
|                                             | when provided on an    |
| -   Surgery to correct a condition caused   | outpatient basis       |
|     by injury or illness if:                |                        |
|                                             | > Nothing when         |
| ```{=html}                                  | > provided on an       |
| <!-- -->                                    | > inpatient basis      |
| ```                                         |                        |
| -   the condition produced a major effect   |                        |
|     on the member's appearance; and         |                        |
|                                             |                        |
| -   the condition can reasonably be         |                        |
|     expected to be corrected by such        |                        |
|     surgery                                 |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Surgery to correct a condition that     |                        |
|     existed at or from birth and is a       |                        |
|     significant deviation from the common   |                        |
|     form or norm. Examples of congenital    |                        |
|     anomalies are: protruding ear           |                        |
|     deformities; cleft lip; cleft palate;   |                        |
|     birth marks; webbed fingers; and webbed |                        |
|     toes                                    |                        |
|                                             |                        |
| -   All stages of breast reconstruction     |                        |
|     surgery following a mastectomy, such    |                        |
|     as:                                     |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   surgery to produce a symmetrical        |                        |
|     appearance on the other breast;         |                        |
|                                             |                        |
| -   treatment of any physical               |                        |
|     complications, such as lymphedemas; and |                        |
|                                             |                        |
| -   breast prostheses and surgical bras and |                        |
|     replacements (see Prosthetic devices)   |                        |
|                                             |                        |
| Note: If you need a mastectomy, you may     |                        |
| choose to have the procedure performed on   |                        |
| an inpatient basis and remain in the        |                        |
| hospital up to 48 hours after the           |                        |
| procedure.                                  |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Cosmetic surgery -- any surgical       |                        |
|     procedure (or any portion of a          |                        |
|     procedure) performed primarily to       |                        |
|     improve physical appearance through     |                        |
|     change in bodily form, except repair of |                        |
|     accidental injury*                      |                        |
|                                             |                        |
| -   *Surgeries related to sex               |                        |
|     transformation*                         |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| Oral and maxillofacial surgery              | You pay                |
+---------------------------------------------+------------------------+
| Oral surgical procedures, limited to:       | \$10 per office visit  |
|                                             | when provided on an    |
| -   Reduction of fractures or dislocations  | outpatient basis       |
|     of the jaw or facial bones              |                        |
|                                             | > Nothing when         |
| -   Surgical correction of cleft lip, cleft | > provided on an       |
|     palate, or severe functional            | > inpatient basis      |
|     malocclusion                            |                        |
|                                             |                        |
| -   Removal of stones from salivary ducts   |                        |
|                                             |                        |
| -   Excision of leukoplakia or malignancies |                        |
|                                             |                        |
| -   Excision of cysts and incision of       |                        |
|     abscesses when done as independent      |                        |
|     procedures                              |                        |
|                                             |                        |
| -   Medical and surgical treatment of TMJ   |                        |
|                                             |                        |
| -   Other surgical procedures that do not   |                        |
|     involve the teeth or their supporting   |                        |
|     structures                              |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Oral implants and transplants*         |                        |
|                                             |                        |
| -   *Procedures that involve the teeth or   |                        |
|     their supporting structures (such as    |                        |
|     the periodontal membrane, gingiva, and  |                        |
|     alveolar bone)*                         |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| []{#OrganTissueTransplants                  | You pay                |
| .anchor}Organ/tissue transplants            |                        |
+---------------------------------------------+------------------------+
| Limited to:                                 | \$10 per office visit  |
|                                             | when provided on an    |
| -   Cornea                                  | outpatient basis       |
|                                             |                        |
| -   Heart                                   | > Nothing when         |
|                                             | > provided on an       |
| -   Heart/Lung                              | > inpatient basis      |
|                                             |                        |
| -   Kidney                                  |                        |
|                                             |                        |
| -   Kidney/Pancreas                         |                        |
|                                             |                        |
| -   Liver                                   |                        |
|                                             |                        |
| -   Lung: Single -- Double                  |                        |
|                                             |                        |
| -   Pancreas                                |                        |
|                                             |                        |
| -   Allogeneic (donor) bone marrow          |                        |
|     transplants                             |                        |
|                                             |                        |
| -   Autologous bone marrow transplants      |                        |
|     (autologous stem cell and peripheral    |                        |
|     stem cell support) for the following    |                        |
|     conditions: acute lymphocytic or        |                        |
|     non-lymphocytic leukemia; advanced      |                        |
|     Hodgkin's lymphoma; advanced            |                        |
|     non-Hodgkin's lymphoma; advanced        |                        |
|     neuroblastoma; breast cancer; multiple  |                        |
|     myeloma; epithelial ovarian cancer; and |                        |
|     testicular, mediastinal,                |                        |
|     retroperitoneal, and ovarian germ cell  |                        |
|     tumors                                  |                        |
|                                             |                        |
| -   Intestinal transplants (small           |                        |
|     intestine) and the small intestine with |                        |
|     the liver or small intestine with       |                        |
|     multiple organs such as the liver,      |                        |
|     stomach, and pancreas                   |                        |
|                                             |                        |
| > Limited benefits - Treatment for breast   |                        |
| > cancer, multiple myeloma, and epithelial  |                        |
| > ovarian cancer may be provided in a       |                        |
| > National Cancer Institute (NCI)- or       |                        |
| > National Institutes of Health             |                        |
| > (NIH)-approved clinical trial at a        |                        |
| > Plan-designated center of excellence and  |                        |
| > if approved by the Plan's medical         |                        |
| > director in accordance with the Plan's    |                        |
| > protocols.                                |                        |
|                                             |                        |
| Note: We cover related medical and hospital |                        |
| expenses of the donor when we cover your    |                        |
| transplant.                                 |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Donor screening tests and donor search |                        |
|     expenses, except those performed for    |                        |
|     the actual donor*                       |                        |
|                                             |                        |
| -   *Implants of non-human artificial       |                        |
|     organs*                                 |                        |
|                                             |                        |
| -   *Transplants not listed as covered*     |                        |
+---------------------------------------------+------------------------+
| Anesthesia                                  |                        |
+---------------------------------------------+------------------------+
| Professional services provided during a     | Nothing                |
| surgical procedure                          |                        |
|                                             |                        |
| -   Hospital (inpatient)                    |                        |
|                                             |                        |
| -   Ambulatory surgery center               |                        |
|     (outpatient)[]{#bLast .anchor}          |                        |
+---------------------------------------------+------------------------+

# 

+---+---+-------------------------------------+----------------+---+---+
| # |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
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| m |   |                                     |                |   |   |
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| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
|   | # | > **Here are some important things  |                | * |   |
|   | # | > to keep in mind about these       |                | * |   |
|   | # | > benefits:**                       |                | I |   |
|   | # |                                     |                | * |   |
|   | # | -   Please remember that all        |                | * |   |
|   | # |     benefits are subject to the     |                |   |   |
|   | # |     definitions, limitations, and   |                | * |   |
|   |   |     exclusions in this brochure and |                | * |   |
|   | I |     we cover them only when we      |                | M |   |
|   |   |     determine they are medically    |                | * |   |
|   | * |     necessary.                      |                | * |   |
|   | * |                                     |                |   |   |
|   | M | -   Plan physicians must provide or |                | * |   |
|   | * |     arrange your care and you must  |                | * |   |
|   | * |     be hospitalized in a Plan       |                | P |   |
|   |   |     facility.                       |                | * |   |
|   | * |                                     |                | * |   |
|   | * | -   We have no calendar year        |                |   |   |
|   | P |     deductible.                     |                | * |   |
|   | * |                                     |                | * |   |
|   | * | -   Be sure to read Section 4,      |                | O |   |
|   |   |     *Your costs for covered         |                | * |   |
|   | * |     services,* for valuable         |                | * |   |
|   | * |     information about how           |                |   |   |
|   | O |     cost-sharing works. Also read   |                | * |   |
|   | * |     Section 9 about coordinating    |                | * |   |
|   | * |     benefits with other coverage,   |                | R |   |
|   |   |     including with Medicare.        |                | * |   |
|   | * |                                     |                | * |   |
|   | * | -   The amounts listed below are    |                |   |   |
|   | R |     for the charges billed by the   |                | * |   |
|   | * |     facility (i.e., hospital or     |                | * |   |
|   | * |     surgical center) or ambulance   |                | T |   |
|   |   |     service for your surgery or     |                | * |   |
|   | * |     care. Any costs associated with |                | * |   |
|   | * |     the professional charge (i.e.,  |                |   |   |
|   | T |     physicians, etc.) are covered   |                | * |   |
|   | * |     in Sections 5(a) or (b).        |                | * |   |
|   | * |                                     |                | A |   |
|   |   |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                |   |   |
|   | A |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | N |   |
|   |   |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                |   |   |
|   | N |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | T |   |
|   |   |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                |   |   |
|   | T |                                     |                |   |   |
|   | * |                                     |                |   |   |
|   | * |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | **You pay**    |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| B |   |                                     |                |   |   |
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| n |   |                                     |                |   |   |
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| > |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| D |   |                                     |                |   |   |
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| s |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| [ |   |                                     |                |   |   |
| ] |   |                                     |                |   |   |
| { |   |                                     |                |   |   |
| # |   |                                     |                |   |   |
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+---+---+-------------------------------------+----------------+---+---+
| R |   |                                     | Nothing        |   |   |
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| . |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+

+---------------------------------------------+------------------------+
| Inpatient hospital *(continued)*            | You pay                |
+---------------------------------------------+------------------------+
| Other hospital services and supplies, such  | Nothing                |
| as:                                         |                        |
|                                             |                        |
| -   Operating, recovery, maternity, and     |                        |
|     other treatment rooms                   |                        |
|                                             |                        |
| -   Prescribed drugs and medicines          |                        |
|                                             |                        |
| -   Diagnostic laboratory tests and X-rays  |                        |
|                                             |                        |
| -   Administration of blood and blood       |                        |
|     products                                |                        |
|                                             |                        |
| -   Blood or blood plasma                   |                        |
|                                             |                        |
| -   Dressings, splints, casts, and sterile  |                        |
|     tray services                           |                        |
|                                             |                        |
| -   Medical supplies and equipment,         |                        |
|     including oxygen                        |                        |
|                                             |                        |
| -   Anesthetics, including nurse            |                        |
|     anesthetist services                    |                        |
|                                             |                        |
| -   Plan physicians' and surgeons' services |                        |
|     and supplies, including consultation    |                        |
|     and treatment by specialists            |                        |
|                                             |                        |
| -   Take-home items                         |                        |
|                                             |                        |
| > Note: You may receive covered hospital    |                        |
| > services for certain dental procedures if |                        |
| > a Plan physician determines you need to   |                        |
| > be hospitalized for reasons unrelated to  |                        |
| > the dental procedure. The conditions for  |                        |
| > which we will provide hospitalization     |                        |
| > include hemophilia and heart disease. The |                        |
| > need for anesthesia, by itself, is not    |                        |
| > such a condition.                         |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Custodial care and care in an          |                        |
|     intermediate care facility*             |                        |
|                                             |                        |
| -   *Personal comfort items, such as barber |                        |
|     services, guest meals, and beds*        |                        |
|                                             |                        |
| -   *Private nursing care unless medically  |                        |
|     necessary*                              |                        |
|                                             |                        |
| -   *Inpatient dental procedures*           |                        |
+---------------------------------------------+------------------------+
| []{#BenefitOutpatient .anchor}Outpatient    |                        |
| hospital or ambulatory surgical center      |                        |
+---------------------------------------------+------------------------+
| -   Operating, recovery, and other          | Nothing                |
|     treatment rooms                         |                        |
|                                             |                        |
| -   Prescribed drugs and medicines          |                        |
|                                             |                        |
| -   Dressings, casts, and sterile trays     |                        |
|                                             |                        |
| -   Diagnostic laboratory tests, X-rays,    |                        |
|     and pathology services                  |                        |
|                                             |                        |
| -   Administration of blood, blood plasma,  |                        |
|     and other biologicals                   |                        |
|                                             |                        |
| -   Blood and blood plasma                  |                        |
|                                             |                        |
| -   Pre-surgical testing                    |                        |
|                                             |                        |
| -   Dressings, casts, and sterile tray      |                        |
|     services                                |                        |
|                                             |                        |
| -   Medical supplies, including oxygen      |                        |
|                                             |                        |
| -   Anesthetics and anesthesia service      |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| Skilled nursing care benefits               | You pay                |
+---------------------------------------------+------------------------+
| Up to 100 days per benefit period when you  | Nothing                |
| need full-time skilled nursing care. Your   |                        |
| benefit period begins when you enter a      |                        |
| hospital or skilled nursing facility and    |                        |
| ends when you have not been a patient in    |                        |
| either a hospital or skilled nursing        |                        |
| facility for 60 consecutive days.           |                        |
|                                             |                        |
| All necessary services are covered,         |                        |
| including;                                  |                        |
|                                             |                        |
| -   Bed, board, and general nursing care    |                        |
|                                             |                        |
| -   Prescribed drugs and their              |                        |
|     administration, biologicals, supplies,  |                        |
|     and equipment ordinarily provided or    |                        |
|     arranged by the skilled nursing         |                        |
|     facility                                |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Custodial care*                        |                        |
|                                             |                        |
| -   *Care in an intermediate care facility* |                        |
+---------------------------------------------+------------------------+
| Hospice care                                |                        |
+---------------------------------------------+------------------------+
| Supportive and palliative care for a        | Nothing                |
| terminally ill member:                      |                        |
|                                             |                        |
| -   You must reside in the service area     |                        |
|                                             |                        |
| -   Services are provided in the home       |                        |
|                                             |                        |
| -   Services are provided in a              |                        |
|     Plan-approved hospice facility          |                        |
|                                             |                        |
| > Services include inpatient care,          |                        |
| > outpatient care, and family counseling. A |                        |
| > Plan physician must certify that you have |                        |
| > a terminal illness, with a life           |                        |
| > expectancy of approximately twelve months |                        |
| > or less.                                  |                        |
|                                             |                        |
| Note: Hospice is a program for caring for   |                        |
| the terminally ill that emphasizes          |                        |
| supportive services, such as home care and  |                        |
| pain control, rather than curative care of  |                        |
| the terminal illness. A person who is       |                        |
| terminally ill may elect to receive hospice |                        |
| benefits. These palliative and supportive   |                        |
| services include nursing care, medical      |                        |
| social services, physician services, and    |                        |
| short-term inpatient care for pain control  |                        |
| and acute and chronic symptom management.   |                        |
| We also provide counseling and bereavement  |                        |
| services for the individual and family      |                        |
| members, and therapy for purposes of        |                        |
| symptom control to enable the person to     |                        |
| continue life with as little disruption as  |                        |
| possible. If you make a hospice election,   |                        |
| you are not entitled to receive other       |                        |
| health care services that are related to    |                        |
| the terminal illness. If you have made a    |                        |
| hospice election, you may revoke that       |                        |
| election at any time, and your standard     |                        |
| health benefits will be covered.            |                        |
+---------------------------------------------+------------------------+
| Ambulance                                   |                        |
+---------------------------------------------+------------------------+
| Professional ambulance service, to a        | Nothing                |
| facility we designate when medically        |                        |
| appropriate                                 |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Transports that we determine are not   |                        |
|     medically necessary*[]{#cLast .anchor}  |                        |
+---------------------------------------------+------------------------+

## Section 5(d). Emergency services/accidents {#section-5d.-emergency-servicesaccidents .Section-5-Subsection}

+---+---+------------------------------------------------------+---+----+
|   | * | > **Here are some important things to keep in mind   | * | ## |
|   | * | > about these benefits:**                            | * | ## |
|   | I |                                                      | I | #  |
|   | * | -   Please remember that all benefits are subject to | * |    |
|   | * |     the definitions, limitations, and exclusions in  | * |    |
|   |   |     this brochure and we cover them only when we     |   |    |
|   | * |     determine they are medically necessary.          | * |    |
|   | * |                                                      | * |    |
|   | M | -   We have no calendar year deductible.             | M |    |
|   | * |                                                      | * |    |
|   | * | -   Be sure to read Section 4, *Your costs for       | * |    |
|   |   |     covered services,* for valuable information      |   |    |
|   | * |     about how cost-sharing works. Also read Section  | * |    |
|   | * |     9 about coordinating benefits with other         | * |    |
|   | P |     coverage, including with Medicare.               | P |    |
|   | * |                                                      | * |    |
|   | * |                                                      | * |    |
|   |   |                                                      |   |    |
|   | * |                                                      | * |    |
|   | * |                                                      | * |    |
|   | O |                                                      | O |    |
|   | * |                                                      | * |    |
|   | * |                                                      | * |    |
|   |   |                                                      |   |    |
|   | * |                                                      | * |    |
|   | * |                                                      | * |    |
|   | R |                                                      | R |    |
|   | * |                                                      | * |    |
|   | * |                                                      | * |    |
|   |   |                                                      |   |    |
|   | * |                                                      | * |    |
|   | * |                                                      | * |    |
|   | T |                                                      | T |    |
|   | * |                                                      | * |    |
|   | * |                                                      | * |    |
|   |   |                                                      |   |    |
|   | * |                                                      | * |    |
|   | * |                                                      | * |    |
|   | A |                                                      | A |    |
|   | * |                                                      | * |    |
|   | * |                                                      | * |    |
|   |   |                                                      |   |    |
|   | * |                                                      | * |    |
|   | * |                                                      | * |    |
|   | N |                                                      | N |    |
|   | * |                                                      | * |    |
|   | * |                                                      | * |    |
|   |   |                                                      |   |    |
|   | # |                                                      | * |    |
|   | # |                                                      | * |    |
|   | # |                                                      | T |    |
|   | # |                                                      | * |    |
|   | # |                                                      | * |    |
|   | # |                                                      |   |    |
|   | # |                                                      |   |    |
|   |   |                                                      |   |    |
|   | T |                                                      |   |    |
+---+---+------------------------------------------------------+---+----+
| > |   |                                                      |   |    |
|   |   |                                                      |   |    |
| * |   |                                                      |   |    |
| * |   |                                                      |   |    |
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| * |   |                                                      |   |    |
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| > |   |                                                      |   |    |
| > |   |                                                      |   |    |
|   |   |                                                      |   |    |
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+---+---+------------------------------------------------------+---+----+

+---------------------------------------------+------------------------+
| > **Benefit Description**                   | **You pay**            |
+---------------------------------------------+------------------------+
| []{#BenefitEmergIn .anchor}Emergency within |                        |
| our service area                            |                        |
+---------------------------------------------+------------------------+
| -   Emergency room visit for emergency      | \$50 per visit         |
|     services                                |                        |
|                                             |                        |
| > Note: We waive the \$50 if you are        |                        |
| > admitted to the hospital.                 |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Elective care or non-emergency care    |                        |
|     (unless you receive prior               |                        |
|     authorization)*                         |                        |
|                                             |                        |
| -   *Urgent care at a non-Plan urgent care  |                        |
|     center*                                 |                        |
+---------------------------------------------+------------------------+
| []{#BenefitEmergOut .anchor}Emergency       |                        |
| outside our service area                    |                        |
+---------------------------------------------+------------------------+
| Emergency care as an outpatient or          | \$50 per visit         |
| inpatient at a hospital, including          |                        |
| physicians' services                        | > The amount you would |
|                                             | > be charged if you    |
| -   Emergency room visit for emergency      | > were a member in     |
|     services                                | > that service area    |
|                                             |                        |
| -   Emergency care at an urgent care center |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Emergency care in a Kaiser Foundation   |                        |
|     hospital in another Kaiser Foundation   |                        |
|     Health Plan service area                |                        |
|                                             |                        |
| Note: See the "Travel Benefit" for coverage |                        |
| of continuing or follow-up care.            |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | *All charges*          |
|                                             |                        |
| -   *Elective care or non-emergency care at |                        |
|     non-Plan facilities (unless you receive |                        |
|     prior authorization)*                   |                        |
+---------------------------------------------+------------------------+
| Urgent care outside our service area        |                        |
+---------------------------------------------+------------------------+
| -   Urgent care at an urgent care center    | \$10 per visit         |
|                                             |                        |
| -   Urgent care at an emergency room        | \$50 per visit         |
|                                             |                        |
| Note: An urgent care need is one that       |                        |
| requires prompt medical attention, but is   |                        |
| not a medical emergency.                    |                        |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| Ambulance                                   | You pay                |
+---------------------------------------------+------------------------+
| Professional ambulance service, when        | \$50 per trip          |
| medically appropriate                       |                        |
|                                             |                        |
| We cover emergency services of a licensed   |                        |
| ambulance when:                             |                        |
|                                             |                        |
| -   Your treating physician determines that |                        |
|     you must be transported to another      |                        |
|     facility when you are not clinically    |                        |
|     stable because the care you need is not |                        |
|     available at the treating facility.     |                        |
|                                             |                        |
| -   You are not already being treated, and  |                        |
|     you reasonably believe that your        |                        |
|     condition requires ambulance            |                        |
|     transportation.                         |                        |
+---------------------------------------------+------------------------+
| > *Not covered:*                            | *All charges*          |
|                                             |                        |
| -   *Transports we determine are not        |                        |
|     medically necessary*[]{#dLast .anchor}  |                        |
+---------------------------------------------+------------------------+

# Section 5

# (e). Mental health and substance abuse benefits

+---+---+-------------------------------------+----------------+---+---+
|   | * | > When you get our approval for     |                | * | # |
|   | * | > services and follow a treatment   |                | * | # |
|   | I | > plan we approve, cost-sharing,    |                | I | # |
|   | * | > and limitations for Plan mental   |                | * | # |
|   | * | > health and substance abuse        |                | * | # |
|   |   | > benefits will be no greater than  |                |   |   |
|   | * | > for similar benefits for other    |                | * |   |
|   | * | > illnesses and conditions.         |                | * |   |
|   | M | >                                   |                | M |   |
|   | * | > **Here are some important things  |                | * |   |
|   | * | > to keep in mind about these       |                | * |   |
|   |   | > benefits:**                       |                |   |   |
|   | * |                                     |                | * |   |
|   | * | -   Please remember that all        |                | * |   |
|   | P |     benefits are subject to the     |                | P |   |
|   | * |     definitions, limitations, and   |                | * |   |
|   | * |     exclusions in this brochure and |                | * |   |
|   |   |     we cover them only when we      |                |   |   |
|   | * |     determine they are clinically   |                | * |   |
|   | * |     appropriate to treat your       |                | * |   |
|   | O |     condition.                      |                | O |   |
|   | * |                                     |                | * |   |
|   | * | ```{=html}                          |                | * |   |
|   |   | <!-- -->                            |                |   |   |
|   | * | ```                                 |                | * |   |
|   | * | -   Plan physicians must provide or |                | * |   |
|   | R |     arrange your care.              |                | R |   |
|   | * |                                     |                | * |   |
|   | * | ```{=html}                          |                | * |   |
|   |   | <!-- -->                            |                |   |   |
|   | * | ```                                 |                | * |   |
|   | * | -   We have no calendar year        |                | * |   |
|   | T |     deductible.                     |                | T |   |
|   | * |                                     |                | * |   |
|   | * | #####                               |                | * |   |
|   |   | Be sure to read Section 4, *Your co |                |   |   |
|   | * | sts for covered services,* for valu |                | * |   |
|   | * | able information about how cost-sha |                | * |   |
|   | A | ring works. Also read Section 9 abo |                | A |   |
|   | * | ut coordinating benefits with other |                | * |   |
|   | * |  coverage, including with Medicare. |                | * |   |
|   |   |                                     |                |   |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | N |                                     |                | N |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   |   |                                     |                |   |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
|   | T |                                     |                | T |   |
|   | * |                                     |                | * |   |
|   | * |                                     |                | * |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | **You pay**    |   |   |
|   |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| B |   |                                     |                |   |   |
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| n |   |                                     |                |   |   |
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|   |   |                                     |                |   |   |
| D |   |                                     |                |   |   |
| e |   |                                     |                |   |   |
| s |   |                                     |                |   |   |
| c |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
| t |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| o |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
| * |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| [ |   |                                     |                |   |   |
| ] |   |                                     |                |   |   |
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| s |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | > Your         |   |   |
|   |   |                                     | > cost-sharing |   |   |
| W |   |                                     | > re           |   |   |
| e |   |                                     | sponsibilities |   |   |
| > |   |                                     | > are no       |   |   |
|   |   |                                     | > greater than |   |   |
| c |   |                                     | > for other    |   |   |
| o |   |                                     | > illnesses or |   |   |
| v |   |                                     | > conditions   |   |   |
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+---+---+-------------------------------------+----------------+---+---+
| > |   |                                     | > \$10 per     |   |   |
|   |   |                                     | > individual   |   |   |
| D |   |                                     | > office visit |   |   |
| i |   |                                     | >              |   |   |
| a |   |                                     | > \$5 per      |   |   |
| g |   |                                     | > group office |   |   |
| n |   |                                     | > visit        |   |   |
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| p |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| i |   |                                     |                |   |   |
| m |   |                                     |                |   |   |
| a |   |                                     |                |   |   |
| r |   |                                     |                |   |   |
| y |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
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|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
|   |   |                                     |                |   |   |
| p |   |                                     |                |   |   |
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| a |   |                                     |                |   |   |
| n |   |                                     |                |   |   |
| . |   |                                     |                |   |   |
+---+---+-------------------------------------+----------------+---+---+

*(Mental health and substance abuse benefits continue on next page)*

+---------------------------------------------+---+------------------------+
| Mental health and substance abuse benefits  |   | You pay                |
| *(continued)*                               |   |                        |
+---------------------------------------------+---+------------------------+
| > Note: Your Plan provider will develop a   | > |                        |
| > treatment plan to assist you in improving |   |                        |
| > or maintaining your condition and         | \ |                        |
| > functional level, or to prevent relapse   | $ |                        |
| > and will determine which diagnostic and   | 1 |                        |
| > treatment services are appropriate for    | 0 |                        |
| > you.                                      | > |                        |
|                                             |   |                        |
|                                             | p |                        |
|                                             | e |                        |
|                                             | r |                        |
|                                             | > |                        |
|                                             |   |                        |
|                                             | i |                        |
|                                             | n |                        |
|                                             | d |                        |
|                                             | i |                        |
|                                             | v |                        |
|                                             | i |                        |
|                                             | d |                        |
|                                             | u |                        |
|                                             | a |                        |
|                                             | l |                        |
|                                             | > |                        |
|                                             |   |                        |
|                                             | o |                        |
|                                             | f |                        |
|                                             | f |                        |
|                                             | i |                        |
|                                             | c |                        |
|                                             | e |                        |
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|                                             |   |                        |
|                                             | v |                        |
|                                             | i |                        |
|                                             | s |                        |
|                                             | i |                        |
|                                             | t |                        |
|                                             | > |                        |
|                                             | > |                        |
|                                             |   |                        |
|                                             | \ |                        |
|                                             | $ |                        |
|                                             | 5 |                        |
|                                             | > |                        |
|                                             |   |                        |
|                                             | p |                        |
|                                             | e |                        |
|                                             | r |                        |
|                                             | > |                        |
|                                             |   |                        |
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|                                             | r |                        |
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|                                             | p |                        |
|                                             | > |                        |
|                                             |   |                        |
|                                             | o |                        |
|                                             | f |                        |
|                                             | f |                        |
|                                             | i |                        |
|                                             | c |                        |
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|                                             | > |                        |
|                                             |   |                        |
|                                             | v |                        |
|                                             | i |                        |
|                                             | s |                        |
|                                             | i |                        |
|                                             | t |                        |
+---------------------------------------------+---+------------------------+
| -   Inpatient psychiatric care              |   | > Nothing              |
|                                             |   |                        |
| -   Hospital alternative services, such as  |   |                        |
|     partial hospitalization and intensive   |   |                        |
|     outpatient psychiatric treatment        |   |                        |
|     programs                                |   |                        |
|                                             |   |                        |
| -   Inpatient substance abuse care          |   |                        |
|                                             |   |                        |
| -   Methadone treatment for a pregnant      |   |                        |
|     woman throughout the pregnancy and for  |   |                        |
|     two months after delivery               |   |                        |
|                                             |   |                        |
| > Note: All inpatient admissions and        |   |                        |
| > hospital alternative services treatment   |   |                        |
| > programs require approval by a Plan       |   |                        |
| > physician.                                |   |                        |
+---------------------------------------------+---+------------------------+
| > Recovery services for alcoholism and drug |   | > \$100 per stay       |
| > abuse in a non-medical residential care   |   |                        |
| > facility                                  |   |                        |
| >                                           |   |                        |
| > Note: All inpatient and alternative       |   |                        |
| > services treatment programs require       |   |                        |
| > approval by a Plan physician. We cover up |   |                        |
| > to 60 days per calendar year and no more  |   |                        |
| > than 120 days in any five consecutive     |   |                        |
| > year period of non-medical residential    |   |                        |
| > recovery care.                            |   |                        |
+---------------------------------------------+---+------------------------+
| > *Not covered:*                            |   | > *All charges*        |
|                                             |   |                        |
| -   *Care that is not clinically            |   |                        |
|     appropriate for the treatment of your   |   |                        |
|     condition*                              |   |                        |
|                                             |   |                        |
| -   *Services we have not approved*         |   |                        |
|                                             |   |                        |
| -   *Intelligence, IQ, aptitude ability,    |   |                        |
|     learning disorders, or interest testing |   |                        |
|     not necessary to determine the          |   |                        |
|     appropriate treatment of a psychiatric  |   |                        |
|     condition*                              |   |                        |
|                                             |   |                        |
| -   *Evaluation or therapy on court order   |   |                        |
|     or as a condition of parole or          |   |                        |
|     probation, or otherwise required by the |   |                        |
|     criminal justice system, unless         |   |                        |
|     determined by a Plan physician to be    |   |                        |
|     medically necessary and appropriate*    |   |                        |
|                                             |   |                        |
| -   *Services that are custodial in nature* |   |                        |
|                                             |   |                        |
| -   *Services rendered or billed by a       |   |                        |
|     school or a member of its staff*        |   |                        |
|                                             |   |                        |
| -   *Services provided under a Federal,     |   |                        |
|     state, or local government program*     |   |                        |
|                                             |   |                        |
| -   *Psychoanalysis or psychotherapy        |   |                        |
|     credited toward earning a degree or     |   |                        |
|     furtherance of education or training    |   |                        |
|     regardless of diagnosis or symptoms*    |   |                        |
+---------------------------------------------+---+------------------------+
| > **Limitation** We may limit your benefits |   |                        |
| > if you do not obtain a treatment          |   |                        |
| > plan[]{#eLast .anchor}.                   |   |                        |
+---------------------------------------------+---+------------------------+

## Section 5(f). Prescription drug benefits {#section-5f.-prescription-drug-benefits .Section-5-Subsection}

+-----+---+-------------------------------------------------+---+-------+
|     | # | > []{#BenefitRx .anchor}**Here are some         | * |       |
|     | # | > important things to keep in mind about these  | * |       |
|     | # | > benefits:**                                   | I |       |
|     | # |                                                 | * |       |
|     | # | -   We cover prescribed drugs and medications,  | * |       |
|     | # |     as described in the chart beginning on the  |   |       |
|     | # |     next page.                                  | * |       |
|     |   |                                                 | * |       |
|     | I | -   Please remember that all benefits are       | M |       |
|     |   |     subject to the definitions, limitations,    | * |       |
|     | * |     and exclusions in this brochure and we      | * |       |
|     | * |     cover them only when we determine they are  |   |       |
|     | M |     medically necessary.                        | * |       |
|     | * |                                                 | * |       |
|     | * | -   We have no calendar year deductible.        | P |       |
|     |   |                                                 | * |       |
|     | * | -   Be sure to read Section 4, *Your costs for  | * |       |
|     | * |     covered services*, for valuable information |   |       |
|     | P |     about how cost-sharing works. Also read     | * |       |
|     | * |     Section 9 about coordinating benefits with  | * |       |
|     | * |     other coverage, including with Medicare.    | O |       |
|     |   |                                                 | * |       |
|     | * |                                                 | * |       |
|     | * |                                                 |   |       |
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+-----+---+-------------------------------------------------+---+-------+
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|     | n |                                                 |   |       |
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|     | P |                                                 |   |       |
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|     | . |                                                 |   |       |
+-----+---+-------------------------------------------------+---+-------+

*(Prescription drug benefits begin on the next page)*

+---------------------------------------------+------------------------+
| > **Benefit Description**                   | **You pay**            |
+---------------------------------------------+------------------------+
| Covered medications and supplies            |                        |
+---------------------------------------------+------------------------+
| We cover the following medications and      | Nothing                |
| supplies prescribed by a Plan physician and |                        |
| obtained from a Plan pharmacy or through    |                        |
| our mail order program:                     |                        |
|                                             |                        |
| -   Certain self-administered IV drugs and  |                        |
|     fluids requiring specific types of      |                        |
|     parenteral infusion, and the supplies   |                        |
|     required for their administration       |                        |
|                                             |                        |
| -   Amino acid-modified products used to    |                        |
|     treat congenital errors of amino acid   |                        |
|     metabolism                              |                        |
|                                             |                        |
| -   Diabetes urine-testing supplies         |                        |
|                                             |                        |
| -   Vaccines and immunizations approved for |                        |
|     use by the Food and Drug Administration |                        |
|                                             |                        |
| -   Elemental dietary enteral formula when  |                        |
|     used as a primary therapy for regional  |                        |
|     enteritis                               |                        |
+---------------------------------------------+------------------------+
| -   Drugs and medicines that by Federal law | \$10 per prescription  |
|     of the United States require a          | for generic drugs      |
|     physician's prescription for their      |                        |
|     purchase, except as excluded below. We  | > \$25 per             |
|     also cover certain drugs that do not    | > prescription for     |
|     require a prescription by law if they   | > brand-name drugs     |
|     are listed on our drug formulary.       | >                      |
|                                             | > All charges if you   |
| -   Insulin                                 | > request a brand-name |
|                                             | > drug in place of a   |
| -   Certain insulin administration devices  | > generic drug         |
|                                             |                        |
| -   Disposable needles and syringes for the |                        |
|     administration of covered medications   |                        |
|                                             |                        |
| -   Smoking cessation drugs are covered     |                        |
|     only if you participate in a Plan       |                        |
|     approved behavioral intervention        |                        |
|     program                                 |                        |
|                                             |                        |
| > Note: The brand-name drug copayment will  |                        |
| > apply to compounded products listed on    |                        |
| > our drug formulary, or that include       |                        |
| > ingredients requiring a prescription by   |                        |
| > law.                                      |                        |
+---------------------------------------------+------------------------+
| -   Oral contraceptives                     | \$10 per prescription  |
|                                             | for generic drugs and  |
| ```{=html}                                  | \$25 per prescription  |
| <!-- -->                                    | for brand-name drugs   |
| ```                                         | (up to a 3-cycle       |
| -   Cervical caps and diaphragms            | supply); all charges   |
|                                             | if you request a       |
|                                             | brand-name drug in     |
|                                             | place of a generic     |
|                                             | drug                   |
|                                             |                        |
|                                             | > \$25 per device      |
+---------------------------------------------+------------------------+

+---------------------------------------------+------------------------+
| Covered medications and supplies            | You pay                |
| *(continued)*                               |                        |
+---------------------------------------------+------------------------+
| -   Fertility drugs                         | 50% of our allowance   |
|                                             |                        |
| -   Sexual dysfunction drugs                |                        |
|                                             |                        |
| ```{=html}                                  |                        |
| <!-- -->                                    |                        |
| ```                                         |                        |
| -   Episodic drugs will be provided up to a |                        |
|     maximum of 27 doses in any 100-day      |                        |
|     period. Additional prescribed doses     |                        |
|     during the same 100 days will be        |                        |
|     dispensed at our allowance.             |                        |
|                                             |                        |
| -   Maintenance drugs that require doses at |                        |
|     regulated intervals                     |                        |
+---------------------------------------------+------------------------+
| *Not covered:*                              | *All charges*          |
|                                             |                        |
| -   *Drugs and supplies for cosmetic        |                        |
|     purposes*                               |                        |
|                                             |                        |
| -   *Vitamins and nutritional supplements   |                        |
|     that can be purchased without a         |                        |
|     prescription*                           |                        |
|                                             |                        |
| -   *Nonprescription drugs, unless they are |                        |
|     included in our drug formulary*         |                        |
|                                             |                        |
| -   *Medical supplies, such as dressings    |                        |
|     and antiseptics*                        |                        |
|                                             |                        |
| -   *Drugs to enhance athletic performance* |                        |
|                                             |                        |
| -   *Drugs that shorten the duration of the |                        |
|     common cold*                            |                        |
|                                             |                        |
| -   *Drugs for the promotion, prevention,   |                        |
|     or other treatment of hair loss or      |                        |
|     growth*                                 |                        |
|                                             |                        |
| -   *Compounded products unless the product |                        |
|     is listed on our drug formulary, or one |                        |
|     of the ingredients requires a           |                        |
|     prescription by law*                    |                        |
|                                             |                        |
| -   *Any requested packaging of drugs (such |                        |
|     as dose packaging) other than the       |                        |
|     dispensing pharmacy's standard          |                        |
|     packaging*                              |                        |
|                                             |                        |
| > *Note: If a drug for which a prescription |                        |
| > is required by law is excluded and we had |                        |
| > been covering and providing it to you for |                        |
| > a use approved by the FDA, we will        |                        |
| > continue to provide the drug upon payment |                        |
| > of 50% of our allowance if a Plan         |                        |
| > physician continues to prescribe the drug |                        |
| > for the same condition.*                  |                        |
| >                                           |                        |
| > []{#fLast .anchor}                        |                        |
+---------------------------------------------+------------------------+

# Section 5

# (g). Special features

+---------------------+------------------------------------------------+
| Feature             | Description                                    |
+---------------------+------------------------------------------------+
| ### Flexibl         | > Under the flexible benefits option, we       |
| e benefits option { | > determine the most effective way to provide  |
| #flexible-benefits- | > services.                                    |
| option .unnumbered} |                                                |
|                     | -   We may identify medically appropriate      |
|                     |     alternatives to traditional care and       |
|                     |     coordinate other treatments as a less      |
|                     |     costly alternative benefit.                |
|                     |                                                |
|                     | -   Alternative treatments are subject to our  |
|                     |     ongoing review.                            |
|                     |                                                |
|                     | -   By approving an alternative treatment, we  |
|                     |     cannot guarantee you will get it in the    |
|                     |     future.                                    |
|                     |                                                |
|                     | -   The decision to offer an alternative       |
|                     |     treatment is solely ours, and we may       |
|                     |     withdraw it at any time and resume regular |
|                     |     contract benefits.                         |
|                     |                                                |
|                     | ```{=html}                                     |
|                     | <!-- -->                                       |
|                     | ```                                            |
|                     | -   Our decision to offer or withdraw          |
|                     |     alternative treatments is not subject to   |
|                     |     OPM review under the disputed claims       |
|                     |     process.                                   |
+---------------------+------------------------------------------------+
| ### Service         | > When you visit the service area of another   |
| s from other Kaiser | > Kaiser Permanente plan, you are entitled to  |
|  Permanente Plans { | > receive virtually all the benefits described |
| #services-from-othe | > in this brochure (including our mail order   |
| r-kaiser-permanente | > prescription program) at any Kaiser          |
| -plans .unnumbered} | > Permanente medical office or medical center. |
|                     | > You must pay the charges or copayments       |
|                     | > imposed by the Kaiser Permanente Plan you    |
|                     | > are visiting, with the exception of mail     |
|                     | > order prescriptions which are administered   |
|                     | > by your home Plan. You will have to pay the  |
|                     | > charges imposed by the Plan you are          |
|                     | > visiting. If the Plan you are visiting has a |
|                     | > benefit that is different from the benefits  |
|                     | > of this Plan, you are not entitled to        |
|                     | > receive that benefit.                        |
|                     | >                                              |
|                     | > Some services covered by this Plan, such as  |
|                     | > artificial reproductive services and the     |
|                     | > services of specialized rehabilitation       |
|                     | > facilities, will not be available in other   |
|                     | > Kaiser Permanente service areas. If a        |
|                     | > benefit is limited to a specific number of   |
|                     | > visits or days, you are entitled to receive  |
|                     | > only the number of visits or days covered by |
|                     | > the Plan in which you are enrolled.          |
|                     | >                                              |
|                     | > If you are seeking routine, non-emergent, or |
|                     | > non-urgent services, you should call the     |
|                     | > Kaiser Permanente Member Services Department |
|                     | > in that service area and request an          |
|                     | > appointment. You may obtain routine          |
|                     | > follow-up or continuing care from these      |
|                     | > Plans, even when you have obtained the       |
|                     | > original services in the service area of     |
|                     | > this Plan. If you require emergency services |
|                     | > as the result of unexpected or unforeseen    |
|                     | > illness that requires immediate attention,   |
|                     | > you should go directly to the nearest Kaiser |
|                     | > Permanente facility to receive care.         |
|                     | >                                              |
|                     | > At the time you register for services, you   |
|                     | > will be asked to pay the charges required by |
|                     | > the local Plan.                              |
|                     | >                                              |
|                     | > If you plan to travel to an area with        |
|                     | > another Kaiser Permanente plan and wish to   |
|                     | > obtain more information about the benefits   |
|                     | > available to you from the Kaiser Permanente  |
|                     | > Plan, please call our Member Service Call    |
|                     | > Center at\                                   |
|                     | > **1-800-464-4000**.                          |
+---------------------+------------------------------------------------+

+----------------------+-----------------------------------------------+
| ### Trav             | > Kaiser Permanente's travel benefits for     |
| el benefit {#travel- | > Federal employees provide you with          |
| benefit .unnumbered} | > outpatient follow-up and/or continuing      |
|                      | > medical care when you are temporarily       |
|                      | > outside your home service area by more than |
|                      | > 100 miles or outside of any other Kaiser    |
|                      | > Permanente service area. These benefits are |
|                      | > in addition to your emergency and urgent    |
|                      | > care benefits and include:                  |
|                      |                                               |
|                      | -   Outpatient follow-up care necessary to    |
|                      |     complete a course of treatment after a    |
|                      |     covered emergency. Services include       |
|                      |     removal of stitches, a catheter, or a     |
|                      |     cast.                                     |
|                      |                                               |
|                      | -   Outpatient continuing care for conditions |
|                      |     diagnosed and treated within the previous |
|                      |     90 days by a Kaiser Permanente health     |
|                      |     care provider or affiliated Plan          |
|                      |     provider. Services include dialysis and   |
|                      |     prescription drug monitoring.             |
|                      |                                               |
|                      | -   You pay \$25 for each follow-up and/or    |
|                      |     continuing care office visit. This amount |
|                      |     will be deducted from the payment we make |
|                      |     to you.                                   |
|                      |                                               |
|                      | -   Your benefit is limited to \$1,200 each   |
|                      |     calendar year**.**                        |
|                      |                                               |
|                      | -   For more information about this benefit   |
|                      |     call **1-800-464-4000**.                  |
|                      |                                               |
|                      | -   File claims as shown on page              |
|                      |     [50](#sec                                 |
|                      | tion-7.-filing-a-claim-for-covered-services). |
|                      |                                               |
|                      | > *The following are not included in your     |
|                      | > travel benefits coverage:*                  |
|                      |                                               |
|                      | -   *Non-emergency hospitalization*           |
|                      |                                               |
|                      | -   *Infertility treatments*                  |
|                      |                                               |
|                      | -   *Medical and hospital costs resulting     |
|                      |     from a normal full-term delivery of a     |
|                      |     baby outside the service area*            |
|                      |                                               |
|                      | -   *Transplants*                             |
|                      |                                               |
|                      | -   *DME*                                     |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   *Prescription drugs*                      |
|                      |                                               |
|                      | -   *Home health services*                    |
+----------------------+-----------------------------------------------+
| ### 24 hour n        | > For any of your health concerns, 24 hours a |
| urse line {#hour-nur | > day, 7 days a week, you may talk with a     |
| se-line .unnumbered} | > registered nurse who will discuss treatment |
|                      | > options and answer your health questions.   |
|                      | > You can obtain an advice nurse phone number |
|                      | > for the nearest Kaiser Permanente facility  |
|                      | > in the white pages of your phone book under |
|                      | > "Kaiser Permanente."                        |
+----------------------+-----------------------------------------------+
| ### Services for     | > We provide a TTY/text telephone number      |
|  deaf and hearing im | > **1-800-777-1370**. Sign language services  |
| paired {#services-fo | > are also available.                         |
| r-deaf-and-hearing-i |                                               |
| mpaired .unnumbered} |                                               |
+----------------------+-----------------------------------------------+
| ###                  | > Kaiser Permanente's National Transplant     |
|  Centers of excellen | > Network (NTN) was created to offer members  |
| ce  {#centers-of-exc | > greater choice of and access into Centers   |
| ellence .unnumbered} | > of Excellence (COE) that exceed minimum     |
|                      | > quality standards for experience (based on  |
|                      | > volume of cases and transplant team         |
|                      | > composition), outcomes, and service         |
|                      | > (waiting time and access to the Center).    |
|                      | > The goal is to ensure that members are      |
|                      | > treated at Centers where optimal outcomes   |
|                      | > can be expected, measured, and managed.     |
|                      | > Currently, the NTN contains 20 Centers that |
|                      | > include 70 transplant programs. Transplant  |
|                      | > services provided through the NTN are       |
|                      | > heart, lung, heart/lung, liver,             |
|                      | > simultaneous kidney/pancreas, pancreas,     |
|                      | > small bowel, and bone marrow/stem cell      |
|                      | > (autologous and allogeneic).[]{#gLast       |
|                      | > .anchor}                                    |
+----------------------+-----------------------------------------------+

# Section 5

# (h). Dental benefits

+---+---+------------------------------------------------------+---+----+---+
|   | * | > **Here are some important things to keep in mind   | * |    |   |
|   | * | > about these benefits:**                            | * |    |   |
|   | I |                                                      | I |    |   |
|   | * | -   Please remember that all benefits are subject to | * |    |   |
|   | * |     the definitions, limitations, and exclusions in  | * |    |   |
|   |   |     this brochure and are payable only when we       |   |    |   |
|   | * |     determine they are medically necessary.          | * |    |   |
|   | * |                                                      | * |    |   |
|   | M | -   We cover hospitalization for dental procedures   | M |    |   |
|   | * |     at a Plan hospital we designate only when a      | * |    |   |
|   | * |     non-dental physical impairment exists which      | * |    |   |
|   |   |     makes hospitalization necessary to safeguard the |   |    |   |
|   | * |     health of the patient. See Section 5(c) for      | * |    |   |
|   | * |     inpatient hospital benefits. We do not cover the | * |    |   |
|   | P |     dental procedure except as described below.      | P |    |   |
|   | * |                                                      | * |    |   |
|   | * | ```{=html}                                           | * |    |   |
|   |   | <!-- -->                                             |   |    |   |
|   | * | ```                                                  | * |    |   |
|   | * | -   Be sure to read Section 4, *Your costs for       | * |    |   |
|   | O |     covered services,* for valuable information      | O |    |   |
|   | * |     about how cost-sharing works. Also read Section  | * |    |   |
|   | * |     9 about coordinating benefits with other         | * |    |   |
|   |   |     coverage, including with Medicare.               |   |    |   |
|   | * |                                                      | * |    |   |
|   | * |                                                      | * |    |   |
|   | R |                                                      | R |    |   |
|   | * |                                                      | * |    |   |
|   | * |                                                      | * |    |   |
|   |   |                                                      |   |    |   |
|   | * |                                                      | * |    |   |
|   | * |                                                      | * |    |   |
|   | T |                                                      | T |    |   |
|   | * |                                                      | * |    |   |
|   | * |                                                      | * |    |   |
|   |   |                                                      |   |    |   |
|   | * |                                                      | * |    |   |
|   | * |                                                      | * |    |   |
|   | A |                                                      | A |    |   |
|   | * |                                                      | * |    |   |
|   | * |                                                      | * |    |   |
|   |   |                                                      |   |    |   |
|   | * |                                                      | * |    |   |
|   | * |                                                      | * |    |   |
|   | N |                                                      | N |    |   |
|   | * |                                                      | * |    |   |
|   | * |                                                      | * |    |   |
|   |   |                                                      |   |    |   |
|   | * |                                                      | * |    |   |
|   | * |                                                      | * |    |   |
|   | T |                                                      | T |    |   |
|   | * |                                                      | * |    |   |
|   | * |                                                      | * |    |   |
+---+---+------------------------------------------------------+---+----+---+
| [ |   |                                                      |   |    |   |
| ] |   |                                                      |   |    |   |
| { |   |                                                      |   |    |   |
| # |   |                                                      |   |    |   |
| B |   |                                                      |   |    |   |
| e |   |                                                      |   |    |   |
| n |   |                                                      |   |    |   |
| e |   |                                                      |   |    |   |
| f |   |                                                      |   |    |   |
| i |   |                                                      |   |    |   |
| t |   |                                                      |   |    |   |
| D |   |                                                      |   |    |   |
| e |   |                                                      |   |    |   |
| n |   |                                                      |   |    |   |
| t |   |                                                      |   |    |   |
| a |   |                                                      |   |    |   |
| l |   |                                                      |   |    |   |
| . |   |                                                      |   |    |   |
| a |   |                                                      |   |    |   |
| n |   |                                                      |   |    |   |
| c |   |                                                      |   |    |   |
| h |   |                                                      |   |    |   |
| o |   |                                                      |   |    |   |
| r |   |                                                      |   |    |   |
| } |   |                                                      |   |    |   |
| D |   |                                                      |   |    |   |
| e |   |                                                      |   |    |   |
| n |   |                                                      |   |    |   |
| t |   |                                                      |   |    |   |
| a |   |                                                      |   |    |   |
| l |   |                                                      |   |    |   |
| b |   |                                                      |   |    |   |
| e |   |                                                      |   |    |   |
| n |   |                                                      |   |    |   |
| e |   |                                                      |   |    |   |
| f |   |                                                      |   |    |   |
| i |   |                                                      |   |    |   |
| t |   |                                                      |   |    |   |
| s |   |                                                      |   |    |   |
+---+---+------------------------------------------------------+---+----+---+
| W |   |                                                      |   |    |   |
| e |   |                                                      |   |    |   |
| h |   |                                                      |   |    |   |
| a |   |                                                      |   |    |   |
| v |   |                                                      |   |    |   |
| e |   |                                                      |   |    |   |
| n |   |                                                      |   |    |   |
| o |   |                                                      |   |    |   |
| d |   |                                                      |   |    |   |
| e |   |                                                      |   |    |   |
| n |   |                                                      |   |    |   |
| t |   |                                                      |   |    |   |
| a |   |                                                      |   |    |   |
| l |   |                                                      |   |    |   |
| b |   |                                                      |   |    |   |
| e |   |                                                      |   |    |   |
| n |   |                                                      |   |    |   |
| e |   |                                                      |   |    |   |
| f |   |                                                      |   |    |   |
| i |   |                                                      |   |    |   |
| t |   |                                                      |   |    |   |
| s |   |                                                      |   |    |   |
| . |   |                                                      |   |    |   |
+---+---+------------------------------------------------------+---+----+---+

# Section 5(i). Non-FEHB benefits available to Plan members

The benefits on this page are not part of the FEHB contract or premium,
**and you cannot file an FEHB disputed claim about them**. Fees you pay
for these services do not count toward FEHB deductibles or catastrophic
protection out-of-pocket maximums.

**[Eyewear discount]{.underline}**

As a Kaiser Permanente FEHB Program Member, you and your eligible
dependents will be able to purchase eyewear at significant savings. When
you visit any of the Southern California Health Plan Optical
Departments, you will receive 25 percent off our allowance for frames
and lenses and options such as no-line bifocals and prescription and
non-prescription sunglasses. You will also be able to receive 25 percent
off our allowance for cosmetic contact lenses and the required lens
fitting.

*Limitations & exclusions:* This discount will apply only to purchased
eyewear under the FEHBP basic coverage. The vision discount may not be
coordinated with any other Kaiser Permanente Health Plan vision benefit.
This discount will also not apply to any sale, promotional, or packaged
eyewear program or for any contact lens Extended Purchase Agreement
(which includes products purchased in this Agreement) or to low-vision
aids or devices.

**[Expanded dental benefits]{.underline}**

Kaiser Permanente is pleased to offer Federal employees, retirees, and
dependents a choice of dental coverages to supplement your medical plan.

*Option I: KPIC's Dental Assistance Insurance Plan*

Underwritten by Kaiser Permanente Insurance Company (KPIC) and
administered by Delta Dental Plan of California, KPIC's Dental
Assistance Insurance Plan uses a Table of Allowances that allows you the
freedom to see any licensed dentist of your choice. The Table of
Allowances lists the dollar amount KPIC will pay for each covered dental
service. Your calendar year deductible is \$50 per person, up to a
maximum of \$150 for the family. There is no deductible on diagnostic
and preventive services. KPIC's Dental Assistance Insurance Plan offers
a full range of services: diagnostic, preventive, restorative,
endodontics, periodontics, oral surgery, and both fixed and removable
prosthodontics.

*Option II: DeltaCare*

DeltaCare offers dental health maintenance organization (HMO) benefits
that are administered by PMI, an affiliate of Delta Dental Plan of
California. You select a dentist from the network of contracting
DeltaCare dental offices that is most convenient for you and your
family. With DeltaCare, there are no claim forms to worry about.
DeltaCare also provides a full range of services that includes
preventive, restorative, endodontics, periodontics, prosthetics, oral
surgery, and orthodontics. Under this program, the subscriber pays a
specific copayment for most covered services.

  ------------------ ----------------- --------------- ------------------
  Premium\*          Option I/KPIC's   Option          
                     Dental Assistance II/DeltaCare    
                     Insurance Plan                    

                     Monthly Premium   Monthly Premium Quarterly Premium

  Self Only          \$25.59           \$10.31         \$30.93

  Self & One Party   \$45.52           \$17.25         \$51.75

  Self & Two or More \$68.42           \$26.16         \$78.47
  ------------------ ----------------- --------------- ------------------

These dental plans are not part of the FEHB contract or premium;
enrollment is voluntary. Enrollment in either dental plan is for a
period of one year. This does not apply if your employment is
terminated. Payment for either the KPIC or PMI dental plan will be
automatically withdrawn from the checking, savings, or credit union
account you specify.

*How to enroll*

Please use the enclosed postage-paid card to send in your application.
If you would like more information on either dental plan, please call:

> Delta Dental: (800) 933-9312
>
> KPIC Dental Assistance Insurance Plan: Federal dental group number is
> 9874
>
> PMI DeltaCare: (800) 422-4234
>
> PMI DeltaCare Federal dental group number is 8161

\* These rates are effective January 1, 2004 through December 31, 2004.

# Section 6. General exclusions -- things we don't cover

The exclusions in this section apply to all benefits. **Although we may
list a specific service as a benefit, we will not cover it unless your
Plan physician determines it is medically necessary to prevent,
diagnose, or treat your illness, disease, injury, or condition.**

We do not cover the following:

-   Care by non-Plan providers except for authorized referrals or
    emergencies (see Section 5(d)), services under the Travel Benefit
    (see Section 5(g)), and services received from other Kaiser
    Permanente plans (see Section 5(g));

-   Services, drugs, or supplies you receive while you are not enrolled
    in this Plan;

-   Services, drugs, or supplies that are not medically necessary;

-   Services, drugs, or supplies not required according to accepted
    standards of medical, dental, or psychiatric practice;

-   Experimental or investigational procedures, treatments, drugs, or
    devices;

-   Services, drugs, or supplies related to abortions, except when the
    life of the mother would be endangered if the fetus were carried to
    term or when the pregnancy is the result of an act of rape or
    incest;

-   Services, drugs, or supplies you receive without charge while in
    active military service;

-   Services, drugs, or supplies related to sex transformations; or

-   Services, drugs, or supplies you receive from a provider or facility
    barred from the FEHB Program.

# Section 7. Filing a claim for covered services

When you see Plan physicians, receive services at Plan hospitals and
facilities, or fill your prescription drugs at Plan pharmacies, you will
not have to file claims. Just present your identification card and pay
your copayment or coinsurance.

You will only need to file a claim when you receive emergency services
or urgent care outside our service area from non-Plan providers or when
you use the travel benefit. Sometimes these providers bill us directly.
Check with the provider. If you need to file the claim, here is the
process:

+-----------------------+----------------------------------------------+
| ## Medical, hospit    | In most cases, providers and facilities file |
| al, and drug benefits | claims for you. Physicians must file on the  |
|                       | form HCFA-1500, Health Insurance Claim Form. |
|                       | Facilities will file on the UB-92 form. For  |
|                       | claims questions and assistance, call our    |
|                       | Member Service Call Center at                |
|                       | **1-800-464-4000**.                          |
|                       |                                              |
|                       | When you must file a claim -- such as for    |
|                       | services you receive outside of the Plan's   |
|                       | service area -- submit it on the HCFA-1500   |
|                       | or a claim form that includes the            |
|                       | information shown below. Bills and receipts  |
|                       | should be itemized and show:                 |
|                       |                                              |
|                       | -   Covered member's name and ID number;     |
|                       |                                              |
|                       | -   Name and address of the physician or     |
|                       |     facility that provided the service or    |
|                       |     supply;                                  |
|                       |                                              |
|                       | -   Dates you received the services or       |
|                       |     supplies;                                |
|                       |                                              |
|                       | -   Diagnosis;                               |
|                       |                                              |
|                       | -   Type of each service or supply;          |
|                       |                                              |
|                       | -   The charge for each service or supply;   |
|                       |                                              |
|                       | -   Follow-up services rendered out-of-area; |
|                       |                                              |
|                       | -   A copy of the explanation of benefits,   |
|                       |     payments, or denial from any primary     |
|                       |     payer \-- such as the Medicare Summary   |
|                       |     Notice (MSN); and                        |
|                       |                                              |
|                       | -   Receipts, if you paid for your services. |
|                       |                                              |
|                       | **Submit your claims to:**                   |
|                       |                                              |
|                       | Kaiser Foundation Health Plan, Inc.          |
|                       |                                              |
|                       | Claims Department                            |
|                       |                                              |
|                       | P.O. Box 7102                                |
|                       |                                              |
|                       | Pasadena, CA 91109-9880                      |
+-----------------------+----------------------------------------------+
| ## Deadline           | Send us all of the documents for your claim  |
| for filing your claim | as soon as possible. You must submit the     |
|                       | claim by December 31 of the year after the   |
|                       | year you received the service, unless timely |
|                       | filing was prevented by administrative       |
|                       | operations of Government or legal            |
|                       | incapacity, provided the claim was submitted |
|                       | as soon as reasonably possible.              |
+-----------------------+----------------------------------------------+
| ## When we            | Please reply promptly when we ask for        |
| need more information | additional information. We may delay         |
|                       | processing or deny your claim if you do not  |
|                       | respond.                                     |
+-----------------------+----------------------------------------------+
| ## If you hav         | If you have a malpractice claim because of   |
| e a malpractice claim | services you did receive, or did not         |
|                       | receive, from a Plan provider, you must      |
|                       | submit the claim to binding arbitration. The |
|                       | Plan has the information that describes the  |
|                       | arbitration process. Contact our Member      |
|                       | Service Call Center at **1-800-464-4000**    |
|                       | for copies of our requirements. These will   |
|                       | explain how you can begin the binding        |
|                       | arbitration process.                         |
+-----------------------+----------------------------------------------+

# Section 8. The disputed claims process

Follow this Federal Employees Health Benefits Program disputed claims
process if you disagree with our decision on your claim or request for
services, drugs, or supplies--including a request for a referral:

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | (a) Write to us within six months from the date of our decision; |
| * |     and                                                          |
| * |                                                                  |
|   | (b) Send your request to us at: Kaiser Permanente, Member        |
|   |     Relations, 393 E. Walnut Street, Pasadena, CA                |
|   |                                                                  |
|   | 91188; and                                                       |
|   |                                                                  |
|   | (c) Include a statement about why you believe our initial        |
|   |     decision was wrong, based on specific benefit provisions     |
|   |                                                                  |
|   | in this brochure; and                                            |
|   |                                                                  |
|   | (d) Include copies of documents that support your claim, such as |
|   |     physicians' letters, operative reports, bills,               |
|   |                                                                  |
|   | medical records, and explanation of benefits (EOB) forms.        |
+---+------------------------------------------------------------------+
| * | We have 30 days from the date we receive your request to:        |
| * |                                                                  |
| 2 | (a) Pay the claim (or, if applicable, arrange for the health     |
| * |     care provider to give you the care); or                      |
| * |                                                                  |
|   | (b) Write to you and maintain our denial--go to step 4; or       |
|   |                                                                  |
|   | (c) Ask you or your provider for more information. If we ask     |
|   |     your provider, we will send you a copy of our                |
|   |                                                                  |
|   | request--go to step 3.                                           |
+---+------------------------------------------------------------------+
| * | You or your provider must send the information so that we        |
| * | receive it within 60 days of our request. We will then decide    |
| 3 | within 30 more days.                                             |
| * |                                                                  |
| * | If we do not receive the information within 60 days, we will     |
|   | decide within 30 days of the date the information was due. We    |
|   | will base our decision on the information we already have.       |
|   |                                                                  |
|   | We will write to you with our decision.                          |
+---+------------------------------------------------------------------+
| * | If you do not agree with our decision, you may ask OPM to review |
| * | it.                                                              |
| 4 |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | You must write to OPM within:                                    |
|   |                                                                  |
|   | -   90 days after the date of our letter upholding our initial   |
|   |     decision; or                                                 |
|   |                                                                  |
|   | -   120 days after you first wrote to us--if we did not answer   |
|   |     that request in some way within 30 days; or                  |
|   |                                                                  |
|   | -   120 days after we asked for additional information.          |
+---+------------------------------------------------------------------+
|   | Write to OPM at: United States Office of Personnel Management,   |
|   | Insurance Services Programs, Health Insurance Group 3, 1900 E    |
|   | Street, NW, Washington, DC 20415-3630.                           |
+---+------------------------------------------------------------------+
|   | Send OPM the following information:                              |
|   |                                                                  |
|   | -   A statement about why you believe our decision was wrong,    |
|   |     based on specific benefit provisions in this brochure;       |
|   |                                                                  |
|   | -   Copies of documents that support your claim, such as         |
|   |     physicians' letters, operative reports, bills, medical       |
|   |     records, and explanation of benefits (EOB) forms;            |
|   |                                                                  |
|   | -   Copies of all letters you sent to us about the claim;        |
|   |                                                                  |
|   | -   Copies of all letters we sent to you about the claim; and    |
|   |                                                                  |
|   | -   Your daytime phone number and the best time to call.         |
|   |                                                                  |
|   | Note: If you want OPM to review more than one claim, you must    |
|   | clearly identify which documents apply to which claim.           |
+---+------------------------------------------------------------------+
|   | Note: You are the only person who has a right to file a disputed |
|   | claim with OPM. Parties acting as your representative, such as   |
|   | medical providers, must include a copy of your specific written  |
|   | consent with the review request.                                 |
|   |                                                                  |
|   | Note: The above deadlines may be extended if you show that you   |
|   | were unable to meet the deadline because of reasons beyond your  |
|   | control.                                                         |
+---+------------------------------------------------------------------+
| * | OPM will review your disputed claim request and will use the     |
| * | information it collects from you and us to decide whether our    |
| 5 | decision is correct. OPM will send you a final decision within   |
| * | 60 days. There are no other administrative appeals.              |
| * |                                                                  |
+---+------------------------------------------------------------------+
|   | If you do not agree with OPM's decision, your only recourse is   |
|   | to sue. If you decide to sue, you must file the suit against OPM |
|   | in Federal court by December 31 of the third year after the year |
|   | in which you received the disputed services, drugs, or supplies  |
|   | or from the year in which you were denied precertification or    |
|   | prior approval. This is the only deadline that may not be        |
|   | extended.                                                        |
|   |                                                                  |
|   | OPM may disclose the information it collects during the review   |
|   | process to support their disputed claim decision. This           |
|   | information will become part of the court record.                |
+---+------------------------------------------------------------------+
|   | You may not sue until you have completed the disputed claims     |
|   | process. Further, Federal law governs your lawsuit, benefits,    |
|   | and payment of benefits. The Federal court will base its review  |
|   | on the record that was before OPM when OPM decided to uphold or  |
|   | overturn our decision. You may recover only the amount of        |
|   | benefits in dispute.                                             |
+---+------------------------------------------------------------------+

> **NOTE: If you have a serious or life-threatening condition** (one
> that may cause permanent loss of bodily functions or death if not
> treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or
    preauthorization/prior referral, then call us at **1-888-987-7247**
    and we will expedite our review; or

(b) We denied your initial request for care or a referral, then:

-   If we expedite our review and maintain our denial, we will inform
    OPM so that they can give your claim expedited treatment too, or

-   You may call OPM's Health Insurance Group 3 at **1-202-606-0755**
    between 8 a.m. and 5 p.m. Eastern time.

# Section 9. Coordinating benefits with other coverage

+-----------------------+----------------------------------------------+
| ## When you have      | You must tell us if you or a covered family  |
| other health coverage | member have coverage under another group     |
|                       | health plan or have automobile insurance     |
|                       | that pays health care expenses without       |
|                       | regard to fault. This is called "double      |
|                       | coverage."                                   |
|                       |                                              |
|                       | When you have double coverage, one plan      |
|                       | normally pays its benefits in full as the    |
|                       | primary payer and the other plan pays a      |
|                       | reduced benefit as the secondary payer. We,  |
|                       | like other insurers, determine which         |
|                       | coverage is primary according to the         |
|                       | National Association of Insurance            |
|                       | Commissioners' guidelines.                   |
|                       |                                              |
|                       | When we are the primary payer, we will pay   |
|                       | the benefits described in this brochure.     |
|                       |                                              |
|                       | When we are the secondary payer, we will     |
|                       | determine our allowance. After the primary   |
|                       | plan pays, we will pay what is left of our   |
|                       | allowance, up to our regular benefit. We     |
|                       | will not pay more than our allowance. If we  |
|                       | are the secondary payer, and you received    |
|                       | your services from Plan providers, we may    |
|                       | bill the primary carrier.                    |
+-----------------------+----------------------------------------------+
| ### What is Medicare? | Medicare is a Health Insurance Program for:  |
|                       |                                              |
|                       | -   People 65 years of age and older.        |
|                       |                                              |
|                       | -   Some people with disabilities, under 65  |
|                       |     years of age.                            |
|                       |                                              |
|                       | -   People with End-Stage Renal Disease      |
|                       |     (permanent kidney failure requiring      |
|                       |     dialysis or a transplant).               |
|                       |                                              |
|                       | Medicare has two parts:                      |
|                       |                                              |
|                       | -   Part A (Hospital Insurance). Most people |
|                       |     do not have to pay for Part A. If you or |
|                       |     your spouse worked for at least 10 years |
|                       |     in Medicare-covered employment, you      |
|                       |     should be able to qualify for            |
|                       |     premium-free Part A insurance. (Someone  |
|                       |     who was a Federal employee on January 1, |
|                       |     1983 or since automatically qualifies.)  |
|                       |     Otherwise, if you are age 65 or older,   |
|                       |     you may be able to buy it. Contact       |
|                       |     **1-800-MEDICARE** for more information. |
|                       |                                              |
|                       | -   Part B (Medical Insurance). Most people  |
|                       |     pay monthly for Part B. Generally, Part  |
|                       |     B premiums are withheld from your        |
|                       |     monthly Social Security check or your    |
|                       |     retirement check.                        |
|                       |                                              |
|                       | If you are eligible for Medicare, you may    |
|                       | have choices in how you get your health      |
|                       | care. Medicare+Choice is the term used to    |
|                       | describe the various health plan choices     |
|                       | available to Medicare beneficiaries. The     |
|                       | information in the next few pages shows how  |
|                       | we coordinate benefits with Medicare,        |
|                       | depending on the type of Medicare managed    |
|                       | care plan you have.                          |
+-----------------------+----------------------------------------------+
| ### Should            | The decision to enroll in Medicare is yours. |
| I enroll in Medicare? | We encourage you to apply for Medicare       |
|                       | benefits 3 months before you turn age 65.    |
|                       | It's easy. Just call the Social Security     |
|                       | Administration toll-free number              |
|                       | **1-800-772-1213** to set up an appointment  |
|                       | to apply. If you do not apply for one or     |
|                       | both Parts of Medicare, you can still be     |
|                       | covered under the FEHB Program.              |
|                       |                                              |
|                       | If you can get premium-free Part A coverage, |
|                       | we advise you to enroll in it. Most Federal  |
|                       | employees and annuitants are entitled to     |
|                       | Medicare Part A at age 65 **without cost**.  |
|                       | When you don't have to pay premiums for      |
|                       | Medicare Part A, it makes good sense to      |
|                       | obtain the coverage. It can reduce your      |
|                       | out-of-pocket expenses as well as costs to   |
|                       | the FEHB, which can help keep FEHB premiums  |
|                       | down.                                        |
|                       |                                              |
|                       | Everyone is charged a premium for Medicare   |
|                       | Part B coverage. The Social Security         |
|                       | Administration can provide you with premium  |
|                       | and benefit information. Review the          |
|                       | information and decide if it makes sense for |
|                       | you to buy the Medicare Part B coverage.     |
+-----------------------+----------------------------------------------+
| ### If yo             | If you enroll in Medicare Part B, we require |
| u enroll in Medicare  | you to assign your Medicare Part B benefits  |
|                       | to the Plan for its services.                |
| ### Part B            |                                              |
| {#part-b .unnumbered} |                                              |
+-----------------------+----------------------------------------------+
| ### The O             | The Original Medicare Plan (Original         |
| riginal Medicare Plan | Medicare) is available everywhere in the     |
|                       | United States. It is the way everyone used   |
| ### (Part A           | to get Medicare benefits and is the way most |
| or Part B) {#part-a-o | people get their Medicare Part A and Part B  |
| r-part-b .unnumbered} | benefits now. You may go to any doctor,      |
|                       | specialist, or hospital that accepts         |
|                       | Medicare. The Original Medicare Plan pays    |
|                       | its share and you pay your share. Some       |
|                       | things are not covered under Original        |
|                       | Medicare, like prescription drugs.           |
|                       |                                              |
|                       | When you are enrolled in Original Medicare   |
|                       | along with this Plan, you still need to      |
|                       | follow the rules in this brochure for us to  |
|                       | cover your care. We will not waive any of    |
|                       | our copayments.                              |
|                       |                                              |
|                       | **Claims process when you have the Original  |
|                       | Medicare Plan** --                           |
|                       |                                              |
|                       | You probably will never have to file a claim |
|                       | form when you have both our Plan and the     |
|                       | Original Medicare Plan.                      |
|                       |                                              |
|                       | -   When we are the primary payer, we        |
|                       |     process the claim first.                 |
|                       |                                              |
|                       | -   When Original Medicare is the primary    |
|                       |     payer, Medicare processes your claim     |
|                       |     first. In most cases, your claim will be |
|                       |     coordinated automatically and we will    |
|                       |     then provide secondary benefits for      |
|                       |     covered charges. You will not need to do |
|                       |     anything. To find out if you need to do  |
|                       |     something to file your claim, call us at |
|                       |     **1-800-443-0815**.                      |
+-----------------------+----------------------------------------------+

**(Primary payer chart begins on next page.)**

Medicare always makes the final determination as to whether they are the
primary payer. The following chart illustrates whether Medicare or this
Plan should be the primary payer for you according to your employment
status and other factors determined by Medicare. It is critical that you
tell us if you or a covered family member has Medicare coverage so we
can administer these requirements correctly.

+-------------------------------------------------------+------+------+
| > []{#Primary_Payer_Chart .anchor}**Primary Payer     |      |      |
| > Chart**                                             |      |      |
+-------------------------------------------------------+------+------+
| **A. When you -- or your covered spouse -- are age 65 | *    |      |
| or over and have Medicare and you...**                | *The |      |
|                                                       | pri  |      |
|                                                       | mary |      |
|                                                       | p    |      |
|                                                       | ayer |      |
|                                                       | for  |      |
|                                                       | the  |      |
|                                                       | in   |      |
|                                                       | divi |      |
|                                                       | dual |      |
|                                                       | with |      |
|                                                       | Medi |      |
|                                                       | care |      |
|                                                       | is.  |      |
|                                                       | ..** |      |
+-------------------------------------------------------+------+------+
|                                                       | **Me | **   |
|                                                       | dica | This |
|                                                       | re** | Pl   |
|                                                       |      | an** |
+-------------------------------------------------------+------+------+
| 1\) Are an active employee with the Federal           |      |     |
| government and**...**                                 |      |      |
|                                                       |      |      |
| -   You have FEHB coverage on your own or through     |      |      |
|     your spouse who is also an active employee        |      |      |
+-------------------------------------------------------+------+------+
| -   You have FEHB coverage through your spouse who is |     |      |
|     an annuitant                                      |      |      |
+-------------------------------------------------------+------+------+
| 2\) Are an annuitant and**...**                       |     |      |
|                                                       |      |      |
| -   You have FEHB coverage on your own or through     |      |      |
|     your spouse who is also an annuitant              |      |      |
+-------------------------------------------------------+------+------+
| -   You have FEHB coverage through your spouse who is |      |     |
|     an active employee                                |      |      |
+-------------------------------------------------------+------+------+
| 3\) Are a reemployed annuitant with the Federal       | \*  |      |
| government and your position is excluded from the     |      |      |
| FEHB (your employing office will know if this is the  |      |      |
| case)                                                 |      |      |
+-------------------------------------------------------+------+------+
| 4\) Are a reemployed annuitant with the Federal       |      |     |
| government and your position is not excluded from     |      |      |
|                                                       |      |      |
| > the FEHB (your employing office will know if this   |      |      |
| > is the case) and**...**                             |      |      |
|                                                       |      |      |
| -   You have FEHB coverage on your own or through     |      |      |
|     your spouse who is also an active employee        |      |      |
+-------------------------------------------------------+------+------+
| -   You have FEHB coverage through your spouse who is |     |      |
|     an annuitant                                      |      |      |
+-------------------------------------------------------+------+------+
| 5\) Are a Federal judge who retired under title 28,   | ##   |      |
| U.S.C., or a Tax Court judge who retired under        | #### |      |
| Section 7447 of title 26, U.S.C. (or if your covered  |  \* |      |
| spouse is this type of judge)                         |      |      |
+-------------------------------------------------------+------+------+
| 6\) Are enrolled in Part B only, regardless of your   |     |     |
| employment status                                     | for  | for  |
|                                                       | Part | o    |
|                                                       | B    | ther |
|                                                       | serv | serv |
|                                                       | ices | ices |
+-------------------------------------------------------+------+------+
| 7\) Are a former Federal employee receiving Workers'  |     |      |
| Compensation and the Office of Workers' Compensation  | \*\* |      |
| Programs has determined that you are unable to return |      |      |
| to duty                                               |      |      |
+-------------------------------------------------------+------+------+
| **B. When you or a covered family member...**         |      |      |
+-------------------------------------------------------+------+------+
| ###### 1) Have Medicare sole                          |      |     |
| ly based on end stage renal disease (ESRD) and**...** |      |      |
|                                                       |      |      |
| -   It is within the first 30 months of eligibility   |      |      |
|     for or entitlement to Medicare due to ESRD        |      |      |
|     (30-month coordination period)                    |      |      |
+-------------------------------------------------------+------+------+
| -   It is beyond the 30-month coordination period and |     |      |
|     you or a family member are still entitled to      |      |      |
|     Medicare due to ESRD                              |      |      |
+-------------------------------------------------------+------+------+
| 2\) Become eligible for Medicare due to ESRD while    |      |     |
| already a Medicare beneficiary and**...**             |      | for  |
|                                                       |      | 30   |
| -   This Plan was the primary payer before            |      | -mo. |
|     eligibility due to ESRD                           |      | Coor |
|                                                       |      | dina |
|                                                       |      | tion |
|                                                       |      | pe   |
|                                                       |      | riod |
+-------------------------------------------------------+------+------+
| -   Medicare was the primary payer before eligibility |     |      |
|     due to ESRD                                       |      |      |
+-------------------------------------------------------+------+------+
| **C. When either you or your spouse are eligible for  |      |      |
| Medicare solely due to disability and you...**        |      |      |
+-------------------------------------------------------+------+------+
| 1\) Are an active employee with the Federal           |      |     |
| government and**...**                                 |      |      |
|                                                       |      |      |
| -   You have FEHB coverage on your own or through     |      |      |
|     your spouse who is also an active employee        |      |      |
+-------------------------------------------------------+------+------+
| -   You have FEHB coverage through your spouse who is |     |      |
|     an annuitant                                      |      |      |
+-------------------------------------------------------+------+------+
| 2\) Are an annuitant and**...**                       |     | [    |
|                                                       |      | ]{.m |
| -   You have FEHB coverage on your own or through     |      | ark} |
|     your spouse who is also an annuitant              |      |      |
+-------------------------------------------------------+------+------+
| -   You have FEHB coverage through your spouse who is |      |     |
|     an active employee                                |      |      |
+-------------------------------------------------------+------+------+
| **D. Are covered under the FEHB Spouse Equity         |     |      |
| provision as a former spouse**                        |      |      |
+-------------------------------------------------------+------+------+

\* Unless you have FEHB coverage through your spouse who is an active
employee

\*\* Workers' Compensation is primary for claims related to your
condition under Workers' Compensation

+------------------------+---------------------------------------------+
| ### Medicare+Choice    | If you are eligible for Medicare, you may   |
|                        | choose to enroll in and get your Medicare   |
|                        | benefits from a Medicare+Choice plan. These |
|                        | are health care choices (like HMOs) in some |
|                        | areas of the country. In most               |
|                        | Medicare+Choice plans, you can only go to   |
|                        | doctors, specialists, or hospitals that are |
|                        | part of the plan. Medicare+Choice plans     |
|                        | provide all the benefits that Original      |
|                        | Medicare covers. Some cover extras, like    |
|                        | prescription drugs. To learn more about     |
|                        | enrolling in a Medicare+Choice plan,        |
|                        | contact Medicare at **1-800-MEDICARE**      |
|                        | (**1-800-633-4227**) or at                  |
|                        | [www.medicare.gov](../www.medicare.gov).    |
|                        |                                             |
|                        | If you enroll in a Medicare+Choice plan,    |
|                        | the following options are available to you: |
|                        |                                             |
|                        | **This Plan and our Medicare+Choice plan:** |
|                        | You may enroll in our Medicare+Choice plan, |
|                        | Kaiser Permanente Senior Advantage, and     |
|                        | also remain enrolled in our FEHB Plan.      |
|                        | There is no additional premium to enroll in |
|                        | Senior Advantage. In this case, we have     |
|                        | lowered or waived some of our copayments    |
|                        | and coinsurance for your FEHB and Medicare  |
|                        | coverage. If you would like information     |
|                        | about our Medicare+Choice plan, please call |
|                        | **1-800-443-0815**. Your Kaiser Permanente  |
|                        | Senior Advantage-FEHBP benefits that we     |
|                        | lowered or waived are:                      |
|                        |                                             |
|                        | -   **Prescriptions:** \$20 for each brand  |
|                        |     name drug for up to a 100-day supply.   |
|                        |     The same price applies to mail-order    |
|                        |     drugs.                                  |
|                        |                                             |
|                        | -   **Physician office visits:** \$5 for    |
|                        |     physician/specialist office visits      |
|                        |                                             |
|                        | -   **Preventive services:** \$5            |
|                        |                                             |
|                        | -   **Routine physical and hearing exams:** |
|                        |     \$5 for routine physical and hearing    |
|                        |     exam                                    |
|                        |                                             |
|                        | -   **Urgently needed care:** \$5 for each  |
|                        |     visit to a Plan facility; \$50 for each |
|                        |     visit to a non-Plan facility in or out  |
|                        |     of the Plan's service area; Worldwide   |
|                        |     coverage                                |
|                        |                                             |
|                        | -   **Vision services:**                    |
|                        |                                             |
|                        | ```{=html}                                  |
|                        | <!-- -->                                    |
|                        | ```                                         |
|                        | -   \$5 for routine eye exam                |
|                        |                                             |
|                        | -   A flat allowance of \$150 every 24      |
|                        |     months will be applied to lenses,       |
|                        |     frames and contact lenses. A separate   |
|                        |     allowance of \$150 per eye per lifetime |
|                        |     will apply to post cataract eyewear     |
|                        |     covered by Medicare.                    |
|                        |                                             |
|                        | ```{=html}                                  |
|                        | <!-- -->                                    |
|                        | ```                                         |
|                        | -   **Dental services:**                    |
|                        |                                             |
|                        | ```{=html}                                  |
|                        | <!-- -->                                    |
|                        | ```                                         |
|                        | -   \$0 for oral exams or X-rays            |
|                        |                                             |
|                        | -   \$15 for cleanings, up to two office    |
|                        |     visits each year                        |
|                        |                                             |
|                        | -   No referral necessary for network       |
|                        |     providers                               |
|                        |                                             |
|                        | **You will also enjoy:**                    |
|                        |                                             |
|                        | -   Health/Wellness Education: No           |
|                        |     copayments for covered health education |
|                        |     classes                                 |
|                        |                                             |
|                        | -   No deductibles and virtually no         |
|                        |     paperwork                               |
|                        |                                             |
|                        | -   On-line access to health information    |
|                        |     and resources at our award-winning      |
|                        |     members only Web site                   |
|                        |                                             |
|                        | -   Quarterly member communication in our   |
|                        |     "Senior Outlook" magazine               |
|                        |                                             |
|                        | You must use Kaiser Permanente Plan and     |
|                        | affiliated providers and continue to pay    |
|                        | Medicare premiums.                          |
+------------------------+---------------------------------------------+
| ###  {#                | **This Plan and another plan's              |
| section-6 .unnumbered} | Medicare+Choice plan:** You may enroll in   |
|                        | another plan's Medicare+Choice plan and     |
|                        | also remain enrolled in our FEHB plan. We   |
|                        | will still provide benefits when your       |
|                        | Medicare+Choice plan is primary if you use  |
|                        | our Plan providers, but we will not waive   |
|                        | or lower any of our copayments or           |
|                        | coinsurance. If you enroll in a             |
|                        | Medicare+Choice plan, tell us. We will need |
|                        | to know whether you are in the Original     |
|                        | Medicare Plan or in a Medicare+Choice plan  |
|                        | so we can correctly coordinate benefits     |
|                        | with Medicare.                              |
|                        |                                             |
|                        | **Suspended FEHB coverage to enroll in a    |
|                        | Medicare+Choice plan:** If you are an       |
|                        | annuitant or former spouse, you can suspend |
|                        | your FEHB coverage to enroll in a           |
|                        | Medicare+Choice plan, eliminating your FEHB |
|                        | premium. (OPM does not contribute to your   |
|                        | Medicare+Choice plan premium.) For          |
|                        | information on suspending your FEHB         |
|                        | enrollment, contact your retirement office. |
|                        | If you later want to re-enroll in the FEHB  |
|                        | Program, generally you may do so only at    |
|                        | the next Open Season unless you             |
|                        | involuntarily lose coverage or move out of  |
|                        | the Medicare+Choice plan's service area.    |
+------------------------+---------------------------------------------+
| ## TRICARE and CHAMPVA | TRICARE is the health care program for      |
|                        | eligible dependents of military persons and |
|                        | retirees of the military. TRICARE includes  |
|                        | the CHAMPUS program. CHAMPVA provides       |
|                        | health coverage to disabled Veterans and    |
|                        | their eligible dependents. If TRICARE or    |
|                        | CHAMPVA and this Plan cover you, we pay     |
|                        | first. See your TRICARE or CHAMPVA Health   |
|                        | Benefits Advisor if you have questions      |
|                        | about these programs.                       |
|                        |                                             |
|                        | **Suspended FEHB coverage to enroll in      |
|                        | TRICARE or CHAMPVA:** If you are an         |
|                        | annuitant or former spouse, you can suspend |
|                        | your FEHB coverage to enroll in one of      |
|                        | these programs, eliminating your FEHB       |
|                        | premium. (OPM does not contribute to any    |
|                        | applicable plan premiums.) For information  |
|                        | on suspending your FEHB enrollment, contact |
|                        | your retirement office. If you later want   |
|                        | to re-enroll in the FEHB Program, generally |
|                        | you may do so only at the next Open Season  |
|                        | unless you involuntarily lose coverage      |
|                        | under the program.                          |
+------------------------+---------------------------------------------+
| ##                     | We do not cover services that:              |
|  Workers' Compensation |                                             |
|                        | -   you need because of a workplace-related |
|                        |     illness or injury that the Office of    |
|                        |     Workers' Compensation Programs (OWCP)   |
|                        |     or a similar Federal or State agency    |
|                        |     determines they must provide; or        |
|                        |                                             |
|                        | -   OWCP or a similar agency pays for       |
|                        |     through a third-party injury settlement |
|                        |     or other similar proceeding that is     |
|                        |     based on a claim you filed under OWCP   |
|                        |     or similar laws.                        |
|                        |                                             |
|                        | Once OWCP or similar agency pays its        |
|                        | maximum benefits for your treatment, we     |
|                        | will cover your care. You must use our      |
|                        | providers.                                  |
+------------------------+---------------------------------------------+
| ## Medicaid            | When you have this Plan and Medicaid, we    |
|                        | pay first.                                  |
|                        |                                             |
|                        | **Suspended FEHB coverage to enroll in      |
|                        | Medicaid or a similar State-sponsored       |
|                        | program of medical assistance:** If you are |
|                        | an annuitant or former spouse, you can      |
|                        | suspend your FEHB coverage to enroll in one |
|                        | of these State programs, eliminating your   |
|                        | FEHB premium. For information on suspending |
|                        | your FEHB enrollment, contact your          |
|                        | retirement office. If you later want to     |
|                        | re-enroll in the FEHB Program, generally    |
|                        | you may do so only at the next Open Season  |
|                        | unless you involuntarily lose coverage      |
|                        | under the State program.                    |
+------------------------+---------------------------------------------+

+------------------------+---------------------------------------------+
| ## When other Gover    | We do not cover services and supplies when  |
| nment agencies are res | a local, State, or Federal Government       |
| ponsible for your care | agency directly or indirectly pays for      |
|                        | them.                                       |
+------------------------+---------------------------------------------+
| ## When others are re  | When you receive money to compensate you    |
| sponsible for injuries | for medical or hospital care for injuries   |
|                        | or illness caused by another person, you    |
|                        | must reimburse us for any expenses we paid. |
|                        | However, we will cover the cost of          |
|                        | treatment that exceeds the amount you       |
|                        | received in the settlement.                 |
|                        |                                             |
|                        | If you do not seek damages you must agree   |
|                        | to let us try. This is called subrogation.  |
|                        | If you need more information, contact us    |
|                        | for our subrogation procedures.             |
+------------------------+---------------------------------------------+

# Section 10. Definitions of terms we use in this brochure

+------------------------+---------------------------------------------+
| ## Calendar year       | January 1 through December 31 of the same   |
|                        | year. For new enrollees, the calendar year  |
|                        | begins on the effective date of their       |
|                        | enrollment and ends on December 31 of the   |
|                        | same year.                                  |
+------------------------+---------------------------------------------+
| **Coinsurance**        | Coinsurance is the percentage of our        |
|                        | allowance that you must pay for your care.  |
|                        | See page [14](#coinsurance).                |
+------------------------+---------------------------------------------+
| **Copayment**          | A copayment is a fixed amount of money you  |
|                        | pay when you receive covered services. See  |
|                        | page [14](#copayments).                     |
+------------------------+---------------------------------------------+
| **Covered services**   | Care we provide benefits for, as described  |
|                        | in this brochure.                           |
+------------------------+---------------------------------------------+
| **Custodial care**     | \(1\) Assistance with activities of daily   |
|                        | living, for example, walking, getting in    |
|                        | and out of bed, dressing, feeding,          |
|                        | toileting, and taking medicine. (2) Care    |
|                        | that can be performed safely and            |
|                        | effectively by people who, in order to      |
|                        | provide the care, do not require medical    |
|                        | licenses or certificates or the presence of |
|                        | a supervising licensed nurse. Custodial     |
|                        | care that lasts 90 days or more is          |
|                        | sometimes known as Long term care.          |
+------------------------+---------------------------------------------+
| **Deductible**         | A deductible is a fixed amount of covered   |
|                        | expenses you must incur for certain covered |
|                        | services and supplies before we start       |
|                        | paying benefits for those services. See     |
|                        | page [14](#deductible).                     |
+------------------------+---------------------------------------------+
| ## Dur                 | Durable medical equipment (DME) is          |
| able medical equipment | equipment that is intended for repeated     |
|                        | use, medically necessary, primarily and     |
|                        | customarily used to serve a medical         |
|                        | purpose, generally not useful to a person   |
|                        | who is not ill or injured, designed for     |
|                        | prolonged use, appropriate for use in the   |
|                        | home, and serves a specific therapeutic     |
|                        | purpose in the treatment of an illness or   |
|                        | injury.                                     |
+------------------------+---------------------------------------------+
| **Experimental or      | We carefully evaluate whether a particular  |
| investigational        | therapy is safe and effective or offers a   |
| services**             | reasonable degree of promise with respect   |
|                        | to improving health outcomes. The primary   |
|                        | source of evidence about health outcomes of |
|                        | any intervention is peer-reviewed medical   |
|                        | or dental literature. When the service or   |
|                        | supply, including a drug: (1) has not been  |
|                        | approved by the FDA; or (2) is the subject  |
|                        | of a new drug or new device application on  |
|                        | file with the FDA; or (3) is part of a      |
|                        | Phase I or Phase II clinical trial, as the  |
|                        | experimental or research arm of a Phase III |
|                        | clinical trial; or is intended to evaluate  |
|                        | the safety, toxicity, or efficacy of the    |
|                        | service; or (4) is available as the result  |
|                        | of a written protocol that evaluates the    |
|                        | service's safety, toxicity, or efficacy; or |
|                        | (5) is subject to the approval or review of |
|                        | an Institutional Review Board; or (6)       |
|                        | requires an informed consent that describes |
|                        | the service as experimental or              |
|                        | investigational; then this Plan considers   |
|                        | that service, supply, or drug to be         |
|                        | experimental, and not covered by the Plan.  |
+------------------------+---------------------------------------------+
| **Group health         | Health care benefits that are available as  |
| coverage**             | a result of your employment, or the         |
|                        | employment of your spouse, and that are     |
|                        | offered by an employer or through           |
|                        | membership in an employee organization.     |
|                        | Health care coverage may be insured or      |
|                        | indemnity coverage, self-insured or         |
|                        | self-funded coverage, or coverage through   |
|                        | health maintenance organizations or other   |
|                        | managed care plans. Health care coverage    |
|                        | purchased through membership in an          |
|                        | organization is also "group health          |
|                        | coverage."                                  |
+------------------------+---------------------------------------------+

+------------------------+---------------------------------------------+
| ## Medically necessary | All benefits need to be medically necessary |
|                        | in order for them to be covered benefits.   |
|                        | Generally, if your Plan physician provides  |
|                        | the service in accord with the terms of     |
|                        | this brochure, it will be considered        |
|                        | medically necessary. However, some services |
|                        | are reviewed in advance of your receiving   |
|                        | them to determine if they are medically     |
|                        | necessary. When we review a service to      |
|                        | determine if it is medically necessary, a   |
|                        | Plan physician will evaluate what would     |
|                        | happen to you if you do not receive the     |
|                        | service. If not receiving the service would |
|                        | adversely affect your health, it will be    |
|                        | considered medically necessary. The         |
|                        | services must be a medically appropriate    |
|                        | course of treatment for your condition. If  |
|                        | they are not medically necessary, we will   |
|                        | not cover the services. In case of          |
|                        | emergency services, the services that you   |
|                        | received will be evaluated to determine if  |
|                        | they were medically necessary.              |
+------------------------+---------------------------------------------+
| ## Our allowance       | The amount we use to determine your         |
|                        | coinsurance. When you receive services or   |
|                        | supplies from Plan providers, it is the     |
|                        | amount that we set for the services or      |
|                        | supplies if we were to charge for them.     |
|                        | When you receive services from non-Plan     |
|                        | providers, we determine the amount that we  |
|                        | believe is usual and customary for the      |
|                        | service or supply, and compare it to the    |
|                        | billed charges. Our payment is based upon   |
|                        | the reasonableness of the charges. If the   |
|                        | billed charges exceed what we believe is    |
|                        | reasonable, you may be responsible for the  |
|                        | excess over our allowance in addition to    |
|                        | your coinsurance.                           |
+------------------------+---------------------------------------------+
| ## Us/We               | Us and we refer to Kaiser Foundation Health |
|                        | Plan, Inc., Southern California Region.     |
+------------------------+---------------------------------------------+
| ## You                 | You refers to the enrollee and each covered |
|                        | family member.                              |
+------------------------+---------------------------------------------+

# Section 11. FEHB facts

+-----------------------+----------------------------------------------+
| ##                    |                                              |
|  Coverage information |                                              |
+-----------------------+----------------------------------------------+
| ## No pre-existing    | We will not refuse to cover the treatment of |
|  condition limitation | a condition that you had before you enrolled |
|                       | in this plan solely because you had the      |
|                       | condition before you enrolled.               |
+-----------------------+----------------------------------------------+
| ## Wh                 | See                                          |
| ere you can get infor | [www.opm.gov/insure](../www.opm.gov/insure). |
| mation about enrollin | Also, your employing or retirement office    |
| g in the FEHB Program | can answer your questions, and give you a    |
|                       | *Guide to Federal Employees Health Benefits  |
|                       | Plans*, brochures for other plans, and other |
|                       | materials you need to make an informed       |
|                       | decision about your FEHB coverage. These     |
|                       | materials tell you:                          |
|                       |                                              |
|                       | -   When you may change your enrollment;     |
|                       |                                              |
|                       | -   How you can cover your family members;   |
|                       |                                              |
|                       | -   What happens when you transfer to        |
|                       |     another Federal agency, go on leave      |
|                       |     without pay, enter military service, or  |
|                       |     retire;                                  |
|                       |                                              |
|                       | -   When your enrollment ends; and           |
|                       |                                              |
|                       | -   When the next open season for enrollment |
|                       |     begins.                                  |
|                       |                                              |
|                       | We don't determine who is eligible for       |
|                       | coverage and, in most cases, cannot change   |
|                       | your enrollment status without information   |
|                       | from your employing or retirement office.    |
+-----------------------+----------------------------------------------+
| ## Types of           | Self Only coverage is for you alone. Self    |
| coverage available fo | and Family coverage is for you, your spouse, |
| r you and your family | and your unmarried dependent children under  |
|                       | age 22, including any foster children or     |
|                       | stepchildren your employing or retirement    |
|                       | office authorizes coverage for. Under        |
|                       | certain circumstances, you may also continue |
|                       | coverage for a disabled child 22 years of    |
|                       | age or older who is incapable of             |
|                       | self-support.                                |
|                       |                                              |
|                       | If you have a Self Only enrollment, you may  |
|                       | change to a Self and Family enrollment if    |
|                       | you marry, give birth, or add a child to     |
|                       | your family. You may change your enrollment  |
|                       | 31days before to 60 days after that event.   |
|                       | The Self and Family enrollment begins on the |
|                       | first day of the pay period in which the     |
|                       | child is born or becomes an eligible family  |
|                       | member. When you change to Self and Family   |
|                       | because you marry, the change is effective   |
|                       | on the first day of the pay period that      |
|                       | begins after your employing office receives  |
|                       | your enrollment form; benefits will not be   |
|                       | available to your spouse until you marry.    |
|                       |                                              |
|                       | Your employing or retirement office will     |
|                       | **not** notify you when a family member is   |
|                       | no longer eligible to receive health         |
|                       | benefits, nor will we. Please tell us        |
|                       | immediately when you add or remove family    |
|                       | members from your coverage for any reason,   |
|                       | including divorce, or when your child under  |
|                       | age 22 marries or turns 22.                  |
|                       |                                              |
|                       | If you or one of your family members is      |
|                       | enrolled in one FEHB plan, that person may   |
|                       | not be enrolled in or covered as a family    |
|                       | member by another FEHB plan.                 |
+-----------------------+----------------------------------------------+
| ##                    | OPM has implemented the Federal Employees    |
| Children's Equity Act | Health Benefits Children's Equity Act of     |
|                       | 2000. This law mandates that you be enrolled |
|                       | for Self and Family coverage in the Federal  |
|                       | Employees Health Benefits (FEHB) Program, if |
|                       | you are an employee subject to a court or    |
|                       | administrative order requiring you to        |
|                       | provide health benefits for your child(ren). |
|                       |                                              |
|                       | If this law applies to you, you must enroll  |
|                       | for Self and Family coverage in a health     |
|                       | plan that provides full benefits in the area |
|                       | where your children live or provide          |
|                       | documentation to your employing office that  |
|                       | you have obtained other health benefits      |
|                       | coverage for your children. If you do not do |
|                       | so, your employing office will enroll you    |
|                       | involuntarily as follows:                    |
|                       |                                              |
|                       | -   If you have no FEHB coverage, your       |
|                       |     employing office will enroll you for     |
|                       |     Self and Family coverage in the Blue     |
|                       |     Cross and Blue Shield Service Benefit    |
|                       |     Plan's Basic Option,                     |
|                       |                                              |
|                       | -   If you have a Self Only enrollment in a  |
|                       |     fee-for-service plan or in an HMO that   |
|                       |     serves the area where your children      |
|                       |     live, your employing office will change  |
|                       |     your enrollment to Self and Family in    |
|                       |     the same option of the same plan; or     |
|                       |                                              |
|                       | -   If you are enrolled in an HMO that does  |
|                       |     not serve the area where the children    |
|                       |     live, your employing office will change  |
|                       |     your enrollment to Self and Family in    |
|                       |     the Blue Cross and Blue Shield Service   |
|                       |     Benefit Plan's Basic Option.             |
|                       |                                              |
|                       | As long as the court/administrative order is |
|                       | in effect, and you have at least one child   |
|                       | identified in the order who is still         |
|                       | eligible under the FEHB Program, you cannot  |
|                       | cancel your enrollment, change to Self Only, |
|                       | or change to a plan that doesn't serve the   |
|                       | area in which your children live, unless you |
|                       | provide documentation that you have other    |
|                       | coverage for the children. If the            |
|                       | court/administrative order is still in       |
|                       | effect when you retire, and you have at      |
|                       | least one child still eligible for FEHB      |
|                       | coverage, you must continue your FEHB        |
|                       | coverage into retirement (if eligible) and   |
|                       | cannot cancel your coverage, change to Self  |
|                       | Only, or change to a plan that doesn't serve |
|                       | the area in which your children live as long |
|                       | as the court/administrative order is in      |
|                       | effect. Contact your employing office for    |
|                       | further information.                         |
+-----------------------+----------------------------------------------+
| ## When benefi        | The benefits in this brochure are effective  |
| ts and premiums start | on January 1. If you joined this Plan during |
|                       | Open Season, your coverage begins on the     |
|                       | first day of your first pay period that      |
|                       | starts on or after January 1. If you changed |
|                       | plans or plan options during Open Season and |
|                       | you receive care between January 1 and the   |
|                       | effective date of coverage under your new    |
|                       | plan or option, your claims will be paid     |
|                       | according to the 2004 benefits of your old   |
|                       | plan or option. However, if your old plan    |
|                       | left the FEHB Program at the end of the      |
|                       | year, you are covered under that plan's 2003 |
|                       | benefits until the effective date of your    |
|                       | coverage with your new plan. Annuitants'     |
|                       | coverage and premiums begin on January 1. If |
|                       | you joined at any other time during the      |
|                       | year, your employing office will tell you    |
|                       | the effective date of coverage.              |
+-----------------------+----------------------------------------------+
| ## When you retire    | When you retire, you can usually stay in the |
|                       | FEHB Program. Generally, you must have been  |
|                       | enrolled in the FEHB Program for the last    |
|                       | five years of your Federal service. If you   |
|                       | do not meet this requirement, you may be     |
|                       | eligible for other forms of coverage, such   |
|                       | as temporary continuation of coverage (TCC). |
+-----------------------+----------------------------------------------+

[]{#__RefHeading___Toc52270467 .anchor}

+-----------------------+----------------------------------------------+
| ## W                  |                                              |
| hen you lose benefits |                                              |
+-----------------------+----------------------------------------------+
| ### Wh                | You will receive an additional 31 days of    |
| en FEHB coverage ends | coverage, for no additional premium, when:   |
|                       |                                              |
|                       | -   Your enrollment ends, unless you cancel  |
|                       |     your enrollment, or                      |
|                       |                                              |
|                       | -   You are a family member no longer        |
|                       |     eligible for coverage.                   |
|                       |                                              |
|                       | You may be eligible for spouse equity        |
|                       | coverage or Temporary Continuation of        |
|                       | Coverage (TCC), or a conversion policy (a    |
|                       | non-FEHB individual policy).                 |
+-----------------------+----------------------------------------------+
| ### S                 | If you are divorced from a Federal employee  |
| pouse equity coverage | or annuitant, you may not continue to get    |
|                       | benefits under your former spouse's          |
|                       | enrollment. This is the case even when the   |
|                       | court has ordered your former spouse to      |
|                       | supply health coverage to you. But, you may  |
|                       | be eligible for your own FEHB coverage under |
|                       | the spouse equity law or Temporary           |
|                       | Continuation of Coverage (TCC). If you are   |
|                       | recently divorced or are anticipating a      |
|                       | divorce, contact your ex-spouse's employing  |
|                       | or retirement office to get RI 70-5, the     |
|                       | *Guide to Federal Employees Health Benefits  |
|                       | Plans for Temporary Continuation of Coverage |
|                       | and Former Spouse Enrollees*, or other       |
|                       | information about your coverage choices. You |
|                       | can also download the guide from OPM's Web   |
|                       | site,                                        |
|                       | [www.opm.gov/insure](../www.opm.gov/insure). |
+-----------------------+----------------------------------------------+
| ##                    | If you leave Federal service, or if you lose |
| # Temporary continuat | coverage because you no longer qualify as a  |
| ion of coverage (TCC) | family member, you may be eligible for       |
|                       | Temporary Continuation of Coverage (TCC).    |
|                       | For example, you can receive TCC if you are  |
|                       | not able to continue your FEHB enrollment    |
|                       | after you retire, if you lose your job, if   |
|                       | you are a covered dependent child, and you   |
|                       | turn 22 or marry, etc.                       |
|                       |                                              |
|                       | You may not elect TCC if you are fired from  |
|                       | your Federal job due to gross misconduct.    |
|                       |                                              |
|                       | Enrolling in TCC. Get the RI 79-27, which    |
|                       | describes TCC, and the RI 70-5, the *Guide   |
|                       | to Federal Employees Health Benefits Plans   |
|                       | for Temporary Continuation of Coverage and   |
|                       | Former Spouse Enrollees*, from your          |
|                       | employing or retirement office or from       |
|                       | [www.opm.gov/insure](../www.opm.gov/insure). |
|                       | It explains what you have to do to enroll.   |
+-----------------------+----------------------------------------------+
| ### Converting t      | You may convert to a non-FEHB individual     |
| o individual coverage | policy if:                                   |
|                       |                                              |
|                       | -   Your coverage under TCC or the spouse    |
|                       |     equity law ends (if you canceled your    |
|                       |     coverage or did not pay your premium,    |
|                       |     you cannot convert);                     |
|                       |                                              |
|                       | -   You decided not to receive coverage      |
|                       |     under TCC or the spouse equity law; or   |
|                       |                                              |
|                       | -   You are not eligible for coverage under  |
|                       |     TCC or the spouse equity law.            |
|                       |                                              |
|                       | If you leave Federal service, your employing |
|                       | office will notify you of your right to      |
|                       | convert. You must apply in writing to us     |
|                       | within 31 days after you receive this        |
|                       | notice. However, if you are a family member  |
|                       | who is losing coverage, the employing or     |
|                       | retirement office will **not** notify you.   |
|                       | You must apply in writing to us within 31    |
|                       | days after you are no longer eligible for    |
|                       | coverage.                                    |
|                       |                                              |
|                       | Your benefits and rates will differ from     |
|                       | those under the FEHB Program; however, you   |
|                       | will not have to answer questions about your |
|                       | health, and we will not impose a waiting     |
|                       | period or limit your coverage due to         |
|                       | pre-existing conditions.                     |
+-----------------------+----------------------------------------------+

[]{#__RefHeading___Toc52270472 .anchor}

+-----------------------+----------------------------------------------+
| ### Getting a         | The Health Insurance Portability and         |
|  Certificate of Group | Accountability Act of 1996 (HIPAA) is a      |
|  Health Plan Coverage | Federal law that offers limited Federal      |
|                       | protections for health coverage availability |
|                       | and continuity to people who lose employer   |
|                       | group coverage. If you leave the FEHB        |
|                       | Program, we will give you a Certificate of   |
|                       | Group Health Plan Coverage that indicates    |
|                       | how long you have been enrolled with us. You |
|                       | can use this certificate when getting health |
|                       | insurance or other health care coverage.     |
|                       | Your new plan must reduce or eliminate       |
|                       | waiting periods, limitations, or exclusions  |
|                       | for health related conditions based on the   |
|                       | information in the certificate, as long as   |
|                       | you enroll within 63 days of losing coverage |
|                       | under this Plan. If you have been enrolled   |
|                       | with us for less than 12 months, but were    |
|                       | previously enrolled in other FEHB plans, you |
|                       | may also request a certificate from those    |
|                       | plans. For more information, get OPM         |
|                       | pamphlet RI 79-27, Temporary Continuation of |
|                       | Coverage (TCC) under the FEHB Program. See   |
|                       | also the FEHB Web site                       |
|                       | (www.opm.gov/insure/health); refer to the    |
|                       | "TCC and HIPAA" frequently asked questions.  |
|                       | These highlight HIPAA rules, such as the     |
|                       | requirement that Federal employees must      |
|                       | exhaust any TCC eligibility as one condition |
|                       | for guaranteed access to individual health   |
|                       | coverage under HIPAA, and have information   |
|                       | about Federal and State agencies you can     |
|                       | contact for more information.                |
+-----------------------+----------------------------------------------+

  -----------------------------------------------------------------------
  []{#__RefHeading___Toc52270473 .anchor}Two new Federal Programs
  complement FEHB benefits

  -----------------------------------------------------------------------

**Important information** OPM wants to be sure you know about two new
Federal programs that complement the FEHB Program. First, the **Flexible
Spending Account (FSA) Program**, also known as **FSAFEDS,** lets you
set aside tax-free money to pay for health and dependent care expenses.
The result can be a discount of 20 to more than 40 percent on services
you routinely pay for out-of-pocket. Second, the **Federal Long Term
Care Insurance Program** **(FLTCIP)** covers long term care costs not
covered under the FEHB.

[]{#__RefHeading___Toc52270474 .anchor}The Federal Flexible Spending
Account Program -- *FSAFEDS*

+------------------------+---------------------------------------------+
| -   **What is an       | It is a tax-favored benefit that allows you |
|     FSA?**             | to set aside pre-tax money from your        |
|                        | paychecks to pay for a variety of eligible  |
|                        | expenses. *By using an FSA, you can reduce  |
|                        | your taxes while paying for services you    |
|                        | would have to pay for anyway, producing a   |
|                        | discount that can be over 40%!!*            |
+------------------------+---------------------------------------------+
| **Health Care          | There are two types of FSAs offered by the  |
| Flexible**             | FSAFEDS Program:                            |
|                        |                                             |
| ## Spending Account    | -   Covers eligible health care expenses    |
|                        |     not reimbursed by this Plan, or any     |
| **(HCFSA)**            |     other medical, dental, or vision care   |
|                        |     plan you or your dependents may have.   |
|                        |                                             |
|                        | -   Eligible dependents for this account    |
|                        |     include anyone you claim on your        |
|                        |     Federal income tax return as a          |
|                        |     qualified dependent under the U.S.      |
|                        |     Internal Revenue Service (IRS)          |
|                        |     definition and/or with whom you jointly |
|                        |     file your Federal income tax return,    |
|                        |     even if you don't have self and family  |
|                        |     health benefits coverage*.*             |
|                        |                                             |
|                        |     ***Note:*** The IRS has a broader       |
|                        |     definition of a "family member" than is |
|                        |     used under the FEHB Program to provide  |
|                        |     benefits by your FEHB Plan.             |
|                        |                                             |
|                        | -   The maximum amount that can be allotted |
|                        |     for the HCFSA is \$3,000 annually. The  |
|                        |     minimum amount is \$250 annually.       |
+------------------------+---------------------------------------------+
| **Dependent Care       | -   Covers eligible dependent care expenses |
| Flexible**             |     incurred so you can work, or if you are |
|                        |     married, so you and your spouse can     |
| **Spending Account     |     work, or your spouse can look for work  |
| (DCFSA)**              |     or attend school full-time.             |
|                        |                                             |
|                        | -   Eligible dependents for this account    |
|                        |     include anyone you claim on your        |
|                        |     Federal income tax return as a          |
|                        |     qualified IRS dependent and/or with     |
|                        |     whom you jointly file your Federal      |
|                        |     income tax return.                      |
|                        |                                             |
|                        | ```{=html}                                  |
|                        | <!-- -->                                    |
|                        | ```                                         |
|                        | -   The maximum that can be allotted for    |
|                        |     the DCFSA is \$5,000 annually. The      |
|                        |     minimum amount is \$250 annually. Note: |
|                        |     The IRS limits contributions to a       |
|                        |     Dependent Care FSA. For single          |
|                        |     taxpayers and taxpayers filing a joint  |
|                        |     return, the maximum is \$5,000 per      |
|                        |     year. For taxpayers who file their      |
|                        |     taxes separately with a spouse, the     |
|                        |     maximum is \$2,500 per year. The limit  |
|                        |     includes any child care subsidy you may |
|                        |     receive.                                |
+------------------------+---------------------------------------------+

+------------------------+---------------------------------------------+
| -   **Enroll during    | You **must make an election** to enroll in  |
|     Open Season**      | an FSA during the                           |
|                        |                                             |
|                        | FEHB Open Season. Even if you enrolled      |
|                        | during the initial Open Season for 2003,    |
|                        | you must make a new election to continue    |
|                        | participating in 2004. Enrollment is easy!  |
|                        |                                             |
|                        | -   Enroll online anytime during Open       |
|                        |     Season (November 10 through December    |
|                        |     8, 2003) at                             |
|                        |     [**w                                    |
|                        | ww.fsafeds.com**](http://www.fsafeds.com/). |
|                        |                                             |
|                        | ```{=html}                                  |
|                        | <!-- -->                                    |
|                        | ```                                         |
|                        | -   Call the toll-free number               |
|                        |     **1-877-FSAFEDS (372-3337)** Monday     |
|                        |     through Friday, from 9 a.m. until 9     |
|                        |     p.m. Eastern time and a FSAFEDS Benefit |
|                        |     Counselor will help you enroll.         |
+------------------------+---------------------------------------------+
| > **What is SHPS?**    | SHPS is a third-party administrator hired   |
|                        | by OPM to manage the FSAFEDS Program. SHPS  |
|                        | is the largest FSA administrator in the     |
|                        | nation and will be responsible for          |
|                        | enrollment, claims processing, customer     |
|                        | service, and day-to-day operations of       |
|                        | FSAFEDS.                                    |
+------------------------+---------------------------------------------+
| > **Who is eligible to | If you are a Federal employee eligible for  |
| > enroll?**            | FEHB--even if you're not enrolled in        |
|                        | FEHB--you can choose to participate in      |
|                        | either, or both, of the flexible spending   |
|                        | accounts. If you are not eligible for FEHB, |
|                        | you are not eligible to enroll for a Health |
|                        | Care FSA. However, almost all Federal       |
|                        | employees are eligible to enroll for the    |
|                        | Dependent Care FSA. The only exception is   |
|                        | intermittent (also called when actually     |
|                        | employed \[WAE\]) employees expected to     |
|                        | work less than 180 days during the year.    |
|                        |                                             |
|                        | ***Note:*** FSAFEDS is the FSA Program      |
|                        | established for all Executive Branch        |
|                        | employees and Legislative Branch employees  |
|                        | whose employers signed on. Under IRS law,   |
|                        | FSAs are not available to annuitants. In    |
|                        | addition, the U.S. Postal Service and the   |
|                        | Judicial Branch, among others, are Federal  |
|                        | agencies that have their own plans with     |
|                        | slightly different rules, but the           |
|                        | advantages of having an FSA are the same no |
|                        | matter what agency you work for.            |
+------------------------+---------------------------------------------+
| -   **How much should  | Plan carefully when deciding how much to    |
|     I contribute to my | contribute to an FSA. Because of the tax    |
|     FSA?**             | benefits of an FSA, the IRS places strict   |
|                        | guidelines on them. You need to estimate    |
|                        | how much you want to allocate to an FSA     |
|                        | because current IRS regulations require you |
|                        | forfeit any funds remaining in your         |
|                        | account(s) at the end of the FSA plan year. |
|                        | This is referred to as the                  |
|                        | "use-it-or-lose-it" rule. You will have     |
|                        | until April 29, 2004 to submit claims for   |
|                        | your eligible expenses incurred during 2003 |
|                        | if you enrolled in FSAFEDS when it was      |
|                        | initially offered. You will have until      |
|                        | April 30, 2005 to submit claims for your    |
|                        | eligible expenses incurred from January 1   |
|                        | through December 31, 2004 if you elect      |
|                        | FSAFEDS during this Open Season.            |
|                        |                                             |
|                        | The **FSAFEDS Calculator** at               |
|                        | [**                                         |
|                        | www.fsafeds.com**](http://www.fsafeds.com/) |
|                        | will help you plan your FSA allocations and |
|                        | provide an estimate of your tax savings     |
|                        | based on your individual situation.         |
+------------------------+---------------------------------------------+
| -   **What can my      | Every FEHB health plan includes             |
|     HCFSA pay for?**   | cost-sharing features, such as deductibles  |
|                        | you must meet before the Plan provides      |
|                        | benefits, coinsurance or copayments that    |
|                        | you pay when you and the Plan share costs,  |
|                        | and medical services and supplies that are  |
|                        | not covered by the Plan and for which you   |
|                        | must pay. These out-of-pocket costs are     |
|                        | summarized on page                          |
|                        | [14](#                                      |
|                        | section-4.-your-costs-for-covered-services) |
|                        | and detailed throughout this brochure. Your |
|                        | HCFSA will reimburse you for such costs     |
|                        | when they are for tax deductible medical    |
|                        | care for you and your dependents that is    |
|                        | NOT covered by this FEHB Plan or any other  |
|                        | coverage that you have.                     |
|                        |                                             |
|                        | Under this Plan, typical out-of-pocket      |
|                        | expenses include: office visit copayments,  |
|                        | prescription drug copayments, and durable   |
|                        | medical equipment coinsurance.              |
|                        |                                             |
|                        | The IRS governs expenses reimbursable by a  |
|                        | HCFSA. See Publication 502 for a            |
|                        | comprehensive list of tax-deductible        |
|                        | medical expenses. *Note: While you will see |
|                        | insurance premiums listed in Publication    |
|                        | 502, they are NOT a reimbursable expense    |
|                        | for FSA purposes*. Publication 502 can be   |
|                        | found on the IRS Web site at                |
|                        | [                                           |
|                        | **http://www.irs.gov/pub/irs-pdf/p502.pdf** |
|                        | ](http://www.irs.gov/pub/irs-pdf/p502.pdf). |
|                        | If you do not see your service or expense   |
|                        | listed in Publication 502, please call a    |
|                        | FSAFEDS Benefit Counselor at                |
|                        | **1-877-FSAFEDS (372-3337)**, who will be   |
|                        | able to answer your specific questions.     |
+------------------------+---------------------------------------------+
| > **Tax savings with   | An FSA lets you allot money for eligible    |
| > an FSA**             | expenses ***before*** your agency deducts   |
|                        | taxes from your paycheck. This means the    |
|                        | amount of income that your taxes are based  |
|                        | on will be lower, so your tax liability     |
|                        | will also be lower. Without an FSA, you     |
|                        | would still pay for these expenses, but you |
|                        | would do so using money remaining in your   |
|                        | paycheck after Federal (and often state and |
|                        | local) taxes are deducted. The following    |
|                        | chart illustrates a typical tax savings     |
|                        | example:                                    |
+------------------------+---------------------------------------------+

  ------------------------------------- ------------- -------------------
  **Annual Tax Savings Example**        **With FSA**  **Without FSA**

  If your taxable income is:            \$50,000      \$50,000

  And you deposit this amount into an   \$ 2,000      -\$0-
  FSA:                                                

  Your taxable income is now:           \$48,000      \$50,000

  Subtract Federal & Social Security    \$13,807      \$14,383
  taxes:                                              

  If you spend after-tax dollars for    -\$0-         \$ 2,000
  expenses:                                           

  Your real spendable income is:        \$34,193      \$33,617

  **Your tax savings:**                 **\$576**     **- \$0-**
  ------------------------------------- ------------- -------------------

+------------------------+---------------------------------------------+
|                        | **Note:** This example is intended to       |
|                        | demonstrate a typical tax savings based on  |
|                        | 27% Federal and 7.65% FICA taxes. Actual    |
|                        | savings will vary based upon in which       |
|                        | retirement system you are enrolled (CSRS or |
|                        | FERS), as well as your individual tax       |
|                        | situation. In this example, the individual  |
|                        | received \$2,000 in services for \$1,424, a |
|                        | discount of almost 36%! You may also wish   |
|                        | to consult a tax professional for more      |
|                        | information on the tax implications of an   |
|                        | FSA.                                        |
+------------------------+---------------------------------------------+
| -   **Tax credits and  | You *cannot* claim expenses on your Federal |
|     deductions**       | income tax return if you receive            |
|                        | reimbursement for them from your HCFSA or   |
|                        | DCFSA. Below are some guidelines that may   |
|                        | help you decide whether to participate in   |
|                        | FSAFEDS.                                    |
+------------------------+---------------------------------------------+
| **Health care          | The HCFSA is tax-free from the first        |
| expenses**             | dollar. In addition, you may be reimbursed  |
|                        | from the HCFSA at any time during the year  |
|                        | for expenses up to the annual amount you've |
|                        | elected to contribute.                      |
+------------------------+---------------------------------------------+
|                        | Only health care expenses exceeding 7.5% of |
|                        | your adjusted gross income are eligible to  |
|                        | be deducted on your Federal income tax      |
|                        | return. Using the example listed in the     |
|                        | above chart, only health care expenses      |
|                        | exceeding \$3,750 (7.5% of \$50,000) would  |
|                        | be eligible to be deducted on your Federal  |
|                        | income tax return. In addition, money set   |
|                        | aside through an HCFSA is also exempt from  |
|                        | FICA taxes. This exemption is not available |
|                        | on your Federal income tax return.          |
+------------------------+---------------------------------------------+
| **Dependent care       | The DCFSA generally allows many families to |
| expenses**             | save more than they would with the Federal  |
|                        | tax credit for dependent care expenses.     |
|                        | Note that you may only be reimbursed from   |
|                        | the DCFSA up to your current account        |
|                        | balance. If you file a claim for more than  |
|                        | your current balance, it will be held until |
|                        | additional payroll allotments have been     |
|                        | added to your account.                      |
|                        |                                             |
|                        | Visit                                       |
|                        | [www.fsafeds.com](http://www.fsafeds.com/)  |
|                        | and download the Dependent Care Tax Credit  |
|                        | Worksheet from the Quick Links box to help  |
|                        | you determine what is best for your         |
|                        | situation. You may also wish to consult a   |
|                        | tax professional for more details.          |
+------------------------+---------------------------------------------+
| -   **Does it cost me  | Probably not. While there is an             |
|     anything to        | administrative fee of \$4.00 per month for  |
|     participate in     | an HCFSA and 1.5% of the annual election    |
|     FSAFEDS?**         | for a DCFSA, most agencies have elected to  |
|                        | pay these fees out of their share of        |
|                        | employment tax savings. To be sure, check   |
|                        | the FSAFEDS.com Web site or call            |
|                        | **1-877-FSAFEDS (372-3337)**. Also,         |
|                        | remember that participating in FSAFEDS can  |
|                        | cost you money if don't spend your entire   |
|                        | account balance by the end of the plan year |
|                        | and wind up forfeiting your end-of-year     |
|                        | account balance, per the IRS                |
|                        | "use-it-or-lose-it" rule.                   |
+------------------------+---------------------------------------------+
| -   **Contact us**     | To find out more or to enroll, please visit |
|                        | the FSAFEDS Web site at                     |
|                        | [[www.fsafeds.                              |
|                        | com]{.underline}](http://www.fsafeds.com/), |
|                        | or contact SHPS by email or by phone. SHPS  |
|                        | Benefit Counselors are available from 9:00  |
|                        | a.m. until 9:00 p.m. Eastern time, Monday   |
|                        | through Friday.                             |
|                        |                                             |
|                        | -   E-mail:                                 |
|                        |     [**f                                    |
|                        | safeds@shps.net**](mailto:fsafeds@shps.net) |
|                        |                                             |
|                        | -   Telephone: **1-877-FSAFEDS (372-3337)** |
|                        |                                             |
|                        | -   **TTY: 1-800-952-0450** (for hearing    |
|                        |     impaired individuals that would like to |
|                        |     utilize a text messaging service)       |
+------------------------+---------------------------------------------+

[]{#__RefHeading___Toc52270475 .anchor}The Federal Long Term Care
Insurance Program

**It's important protection** Here's why you should consider enrolling
in the Federal Long Term Care Insurance Program:

-   **FEHB plans do not cover the cost of long term care.** Also called
    "custodial care," long term care is help you receive when you need
    assistance performing activities of daily living--such as bathing or
    dressing yourself. This need can strike anyone at any age and the
    cost of care can be substantial.

-   **The Federal Long Term Care Insurance Program can help protect you
    from the potentially high cost of long term care**. This coverage
    gives you control over the type of care you receive and where you
    receive it. It can also help you remain independent, so you won't
    have to worry about being a burden to your loved ones.

-   **It's to your advantage to apply sooner rather than later**. Long
    term care insurance is something you must apply for, and pass a
    medical screening (called underwriting) in order to be enrolled.
    Certain medical conditions will prevent some people from being
    approved for coverage. By applying while you're in good health, you
    could avoid the risk of having a change in health disqualify you
    from obtaining coverage. Also, the younger you are when you apply,
    the lower your premiums.

-   **You don't have to wait for an Open Season to apply**. The Federal
    Long Term Care Insurance Program accepts applications from eligible
    persons at any time. You will have to complete a full underwriting
    application, which asks a number of questions about your health.
    However, if you are a new or newly eligible employee, you (and your
    spouse, if applicable) have a limited opportunity to apply using the
    abbreviated underwriting application, which asks fewer questions. If
    you marry, your new spouse will also have a limited opportunity to
    apply using abbreviated underwriting. Qualified relatives are also
    eligible to apply with full underwriting.

+------------------------+---------------------------------------------+
| **To find out more and | Call **1-800-LTC-FEDS (1-800-582-3337) (TTY |
| to request**           | 1-800-843-3557)** or visit                  |
|                        | [**w                                        |
| **an application**     | ww.ltcfeds.com**](http://www.ltcfeds.com/). |
+------------------------+---------------------------------------------+

# Index

**24** hour nurse line, 15, 43, 68

**A**ccidental injury, 27

Alternative treatment, 15, 24

Ambulance, 15, 30, 32, 36

Anesthesia, 15, 26, 31

Autologous bone marrow transplant, 20

**B**iopsies, 26

Blood and blood plasma, 17, 23, 31

Breast cancer screening, 29

**C**asts, 31

Centers of excellence, 15, 44, 68

Changes for 2004, 10

Chemotherapy, 20

Chiropractic, 24

Cholesterol tests, 17

Coinsurance, 8, 11, 14, 48, 54, 55, 58

Colorectal cancer screening, 17

Congenital anomalies, 26, 27

Contraceptive devices and drugs, 19, 26, 27

Covered providers, 8, 11, 12, 39, 51, 55, 58

Crutches, 23

**D**eaf and hearing impaired service, 15, 43, 68

Deductible, 14, 57

Dental care, 31, 45, 46, 47, 57

Diagnostic services, 15, 17, 20, 24, 37, 38

Disputed claims review, 3, 4, 42, 46, 49, 50

Donor expenses (transplants), 15, 20, 28, 29

Dressings, 41

Durable medical equipment (DME), 15, 22, 23, 43, 57

**E**ducational classes and programs, 15, 25

Effective date of enrollment, 11, 57, 60

Emergency, 8, 9, 11, 24, 33, 34, 35, 39, 42, 43, 48, 58

Experimental or investigational, 57

Eyeglasses, 21

**F**amily planning, 15, 19

Fecal occult blood test, 17

Flexible benefits option, 15, 42, 68

**G**eneral Exclusions, 47

**H**earing services, 15, 21

Home health services, 15, 24, 43

Hospice care, 15, 32

Hospital, 8, 13, 15, 16, 18, 22, 26, 27, 29, 30, 31, 32, 33, 35, 38, 43,
45, 48, 52, 56, 68

Immunizations, 8, 17, 18, 40

Infertility, 14, 19

Inpatient Hospital Benefits, 45

Insulin, 40

**L**aboratory and pathological services, 11, 31

**M**ail Order Prescription Drugs, 9, 39, 40, 42

Mammograms, 17

Maternity Benefits, 18, 31

Medicaid, 55

Medically necessary, 16, 17, 18, 20, 21, 23, 26, 30, 31, 32, 33, 34, 36,
37, 38, 39, 45, 47, 57, 58

Medicare, 16, 22, 26, 30, 33, 37, 39, 45, 48, 51, 52, 53, 54, 55

Mental Conditions/Substance Abuse Benefits, 15, 37, 38

**N**ewborn care, 16, 18

Non-FEHB Benefits, 3, 15, 46

Nurse

24 hour nurse line, 15, 43, 69

Licensed Practical Nurse, 24

Nurse Anesthetist, 31

Nurse Practitioner, 11

Registered Nurse, 24, 43

Nursery charges, 18

**O**bstetrical care, 18, 31

Occupational therapy, 15, 20

Ocular injury, 15, 21, 54

Oral and maxillofacial surgery, 15, 28

Orthopedic devices, 22

Ostomy and catheter supplies, 43

Out-of-pocket expenses, 14, 46, 68

Oxygen, 23, 24, 31

**P**ap test, 17

Physical examination, 8

Physical therapy, 11, 20

Precertification, 50

Prescription drugs, 39

Preventive care

Adult, 15, 17, 18

Children, 15, 18

Prior approval, 13, 50

Prostate cancer screening, 17

Prosthetic devices, 14, 15, 22, 27

Psychotherapy, 38

**R**adiation therapy, 20

Renal dialysis, 20, 43, 51

Room and board, 30

**S**econd surgical opinion, 16

Services from other Kaiser Permanente Plans, 15, 42, 68

Skilled nursing facility care, 13, 15, 16, 22, 32

Smoking cessation, 25

Speech therapy, 15, 21

Splints, 31

Sterilization procedures, 19, 26, 27

Subrogation, 56

Substance abuse, 12, 15, 37, 38, 68

Surgery, 15, 19, 26, 27

Anesthesia, 15, 26, 31

Outpatient, 15, 26, 30, 31

Reconstructive, 15, 26, 27

Syringes, 40

**T**emporary continuation of coverage, 61

Transplants, 20, 29, 44, 51

Travel benefit, 8, 43, 48

Treatment therapies, 15, 20

TRICARE & CHAMPVA, 55

**V**ision services, 15, 21, 54

**W**ell-child care, 18

Wheelchairs, 23

Workers' Compensation, 55

**X**-rays, 17, 31, 54

# Summary of benefits

#  for Kaiser Foundation Health Plan, Inc., Southern California Region--2004

-   **Do not rely on this chart alone.** All benefits are provided in
    full unless indicated and are subject to the definitions,
    limitations, and exclusions in this brochure. On this page we
    summarize specific expenses we cover; for more detail, look inside.

-   If you want to enroll or change your enrollment in this Plan, be
    sure to put the correct enrollment code from the cover on your
    enrollment form.

-   We only cover services provided or arranged by Plan physicians,
    except in emergencies.

+----------------------------------------+--------------------+--------+
| **Benefits**                           | **You Pay**        | ###### |
|                                        |                    | # Page |
+----------------------------------------+--------------------+--------+
| Medical services provided by           | \$10 per office    | [16](# |
| physicians:                            | visit              | Benefi |
|                                        |                    | tDiagn |
| -   Diagnostic and treatment services  |                    | ostic) |
|     provided in the office             |                    |        |
+----------------------------------------+--------------------+--------+
| Services provided by a hospital:       | Nothing            | [31](  |
|                                        |                    | #Benef |
| -   Inpatient                          | Nothing            | itInpa |
|                                        |                    | tient) |
| -   Outpatient                         |                    |        |
|                                        |                    | [32](# |
|                                        |                    | Benefi |
|                                        |                    | tOutpa |
|                                        |                    | tient) |
+----------------------------------------+--------------------+--------+
| Emergency benefits:                    | \$50 per visit     | [36    |
|                                        |                    | ](#Ben |
| -   In-area                            | \$50 per visit     | efitEm |
|                                        |                    | ergIn) |
| -   Out-of-area                        |                    |        |
|                                        |                    | [36]   |
|                                        |                    | (#Bene |
|                                        |                    | fitEme |
|                                        |                    | rgOut) |
+----------------------------------------+--------------------+--------+
| Mental health and substance abuse      | Regular            | [3     |
| treatment                              | cost-sharing       | 8](#Be |
|                                        |                    | nefitM |
|                                        |                    | ental) |
+----------------------------------------+--------------------+--------+
| Prescription drugs                     | \$10 per           | [41]   |
|                                        | prescription for   | (#Bene |
|                                        | generic drugs;     | fitRx) |
|                                        | \$25 per           |        |
|                                        | prescription for   |        |
|                                        | brand-name drugs;  |        |
|                                        | all charges if you |        |
|                                        | request a          |        |
|                                        | brand-name drug in |        |
|                                        | place of a generic |        |
|                                        | drug               |        |
+----------------------------------------+--------------------+--------+
| Dental Care                            | No benefit         | [4     |
|                                        |                    | 7](#Be |
|                                        |                    | nefitD |
|                                        |                    | ental) |
+----------------------------------------+--------------------+--------+
| Vision Care                            | Refractions; \$10  | [      |
|                                        | per office visit   | 21](#V |
|                                        |                    | ISION) |
+----------------------------------------+--------------------+--------+
| Special features: Flexible benefits    |                    | [      |
| option; Services from other Kaiser     |                    | 44](#f |
| Permanente Plans; Travel benefit;\     |                    | lexibl |
| 24 hour nurse line; Services for deaf  |                    | e-bene |
| and hearing impaired; Centers of       |                    | fits-o |
| excellence                             |                    | ption) |
+----------------------------------------+--------------------+--------+
| Protection against catastrophic costs  | Nothing after      | [14]   |
| (your catastrophic protection          | \$1,500/Self Only  | (#your |
| out-of-pocket maximum)                 | or \$3,000/Family  | -catas |
|                                        | enrollment per     | trophi |
|                                        | year               | c-prot |
|                                        |                    | ection |
|                                        | Some costs do not  | -out-o |
|                                        | count toward this  | f-pock |
|                                        | protection         | et-max |
|                                        |                    | imum-f |
|                                        |                    | or-cop |
|                                        |                    | ayment |
|                                        |                    | s-and- |
|                                        |                    | coinsu |
|                                        |                    | rance) |
+----------------------------------------+--------------------+--------+

Notes

Notes

# 2004 Rate Information for Kaiser Foundation Health Plan, Inc., Southern California Region

**Non-Postal rates** apply to most non-Postal enrollees. If you are in a
special enrollment category, refer to the FEHB Guide for that category
or contact the agency that maintains your health benefits enrollment.

**Postal rates** apply to career Postal Service employees. Most
employees should refer to the FEHB Guide for United States Postal
Service Employees, RI 70-2. Different postal rates apply and a special
FEHB guide is published for Postal Service Inspectors and Office of
Inspector General (OIG) employees (see RI 70-2IN).

> Postal rates do not apply to non-career postal employees, postal
> retirees, or associate members of any postal employee organization who
> are not career postal employees. Refer to the applicable FEHB Guide.

+-------------+----+------+------+------+------+------+------------+
|             |    | **No |      |      |      | **Po |            |
|             |    | n-Po |      |      |      | stal |            |
|             |    | stal |      |      |      | P    |            |
|             |    | P    |      |      |      | remi |            |
|             |    | remi |      |      |      | um** |            |
|             |    | um** |      |      |      |      |            |
+-------------+----+------+------+------+------+------+------------+
|             |    | **Bi |      | **M  |      | **Bi |            |
|             |    | week |      | onth |      | week |            |
|             |    | ly** |      | ly** |      | ly** |            |
+-------------+----+------+------+------+------+------+------------+
| **Type of   | ** | *    | **Yo | *    | **Yo | **US | **Your**   |
| E           | Co | *Gov | ur** | *Gov | ur** | PS** |            |
| nrollment** | de | 't** |      | 't** |      |      | **Share**  |
|             | ** |      | *    |      | *    | *    |            |
|             |    | *    | *Sha | *    | *Sha | *Sha |            |
|             |    | *Sha | re** | *Sha | re** | re** |            |
|             |    | re** |      | re** |      |      |            |
+-------------+----+------+------+------+------+------+------------+

  -------------- --------- -------------- ------------- -------------- -------------- -------------- -------------
  **Self Only**  **621**   **\$111.16**   **\$37.05**   **\$240.84**   **\$80.28**    **\$131.54**   **\$16.67**

  **Self and     **622**   **\$256.91**   **\$85.63**   **\$556.63**   **\$185.54**   **\$304.00**   **\$38.54**
  Family**                                                                                           
  -------------- --------- -------------- ------------- -------------- -------------- -------------- -------------

[]{#rate_info .anchor}