> **Kaiser Foundation**
>
> **Health Plan of the Northwest**
>
> [http://kaiserpermanente.org](http://kaiserpermanente.org/)
>
> ![](media/image1.png){width="1.8965277777777778in"
> height="0.5020833333333333in"} **2004**
>
> **A Health Maintenance Organization**
>
> ![](media/image2.bmp)
>
> **Serving:** *Portland and Salem, Oregon*
>
> *Vancouver and Longview, Washington*
>
> **Enrollment in this Plan is limited. You must live or work in our**
>
> **geographic service area to enroll. See page 9 for requirements.**
>
> ![](media/image3.jpeg){width="0.7298611111111111in"
> height="0.7298611111111111in"}
>
> **Enrollment codes for this Plan:**
>
> **571 High Option Self Only**
>
> **572 High Option Self and Family**
>
> **574 Standard Option Self Only**
>
> **575 Standard Option Self and Family**
>
> ![](media/image4.png)
>
> **RI 73-004**
>
> ![](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](http://www.opm.gov/insure)!
>
> 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. 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="1.195138888888889in"
> height="1.0354166666666667in"}
> ![](media/image9.png){width="1.1715277777777777in"
> height="0.9208333333333333in"}
>
> **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 manner
    described above.

-   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 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](#__RefHeading___Toc20908399)

Plain Language [5](#__RefHeading___Toc20908400)

Stop Health Care Fraud! [5](#__RefHeading___Toc20908401)

Preventing medical mistakes 6

Section 1. Facts about this HMO plan [8](#__RefHeading___Toc20908402)

How we pay providers [8](#__RefHeading___Toc20908403)

Your Rights [8](#__RefHeading___Toc20908404)

Service Area [9](#__RefHeading___Toc20908405)

Section 2. How we change for 2004 [10](#__RefHeading___Toc20908406)

Program-wide changes [10](#__RefHeading___Toc20908407)

Changes to this Plan [10](#__RefHeading___Toc20908408)

Section 3. How you get care [11](#__RefHeading___Toc20908409)

Identification cards [11](#__RefHeading___Toc20908410)

Where you get covered care [11](#__RefHeading___Toc20908411)

Plan providers [11](#__RefHeading___Toc20908412)

Plan facilities [11](#__RefHeading___Toc20908413)

What you must do to get covered care [11](#__RefHeading___Toc20908414)

Primary care [11](#__RefHeading___Toc20908415)

Specialty care [12](#__RefHeading___Toc20908416)

Hospital care [13](#__RefHeading___Toc20908417)

Circumstances beyond our control [13](#__RefHeading___Toc20908418)

Services requiring our prior approval [13](#__RefHeading___Toc20908419)

Section 4. Your costs for covered services
[14](#__RefHeading___Toc20908420)

Copayments [14](#__RefHeading___Toc20908421)

Deductible [14](#__RefHeading___Toc20908422)

Coinsurance [14](#__RefHeading___Toc20908423)

Fees when you fail to make your copayment
[14](#__RefHeading___Toc20908424)

Fees when you miss a medical appointment
[14](#__RefHeading___Toc20908425)

Your catastrophic protection out-of-pocket maximum for copayments and
coinsurance [14](#__RefHeading___Toc20908426)

Section 5. Benefits [15](#__RefHeading___Toc20908427)

Overview [15](#__RefHeading___Toc20908428)

\(a\) Medical services and supplies provided by physicians and other
health care professionals [16](#__RefHeading___Toc20908429)

\(b\) Surgical and anesthesia services provided by physicians and other
health care professionals [28](#__RefHeading___Toc20908430)

\(c\) Services provided by a hospital or other facility, and ambulance
services [33](#__RefHeading___Toc20908431)

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

\(e\) Mental health and substance abuse benefits
[40](#__RefHeading___Toc20908433)

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

\(g\) Special features [46](#__RefHeading___Toc20908435)

Flexible benefits option [46](#__RefHeading___Toc20908436)

24 hour nurse line [46](#__RefHeading___Toc20908437)

Services for deaf and hearing impaired [46](#__RefHeading___Toc20908438)

Language interpretation [46](#__RefHeading___Toc20908439)

High risk pregnancies [46](#__RefHeading___Toc20908440)

Centers of Excellence [47](#__RefHeading___Toc20908441)

Travel benefit [47](#__RefHeading___Toc20908442)

Services from other Kaiser Permanente Plans 48

Student coverage outside the service area 48

\(h\) Dental benefits [49](#__RefHeading___Toc20908444)

\(i\) Non-FEHB benefits available to Plan members
[53](#__RefHeading___Toc20908445)

Section 6. General exclusions \-- things we don\'t cover
[54](#__RefHeading___Toc20908446)

Section 7. Filing a claim for covered services
[55](#__RefHeading___Toc20908447)

Section 8. The disputed claims process [56](#__RefHeading___Toc20908451)

Section 9. Coordinating benefits with other coverage
[58](#__RefHeading___Toc20908452)

When you have other health coverage [58](#__RefHeading___Toc20908453)

What is Medicare? [58](#__RefHeading___Toc20908454)

Should I enroll in Medicare? 58

If you enroll in Medicare Part B 59

The Original Medicare Plan (Part A or Part B)
[59](#__RefHeading___Toc20908455)

Medicare+Choice [61](#__RefHeading___Toc20908456)

TRICARE and CHAMPVA [62](#__RefHeading___Toc20908459)

Workers' Compensation [62](#__RefHeading___Toc20908460)

Medicaid [62](#__RefHeading___Toc20908461)

When other Government agencies are responsible for your care
[62](#__RefHeading___Toc20908462)

When others are responsible for injuries
[62](#__RefHeading___Toc20908463)

Section 10. Definitions of terms we use in this brochure
[63](#__RefHeading___Toc20908464)

Section 11. FEHB facts [65](#__RefHeading___Toc20908465)

Coverage information 65

No pre-existing condition limitation [65](#__RefHeading___Toc20908466)

Where you can get information about enrolling in the FEHB Program
[65](#__RefHeading___Toc20908467)

Types of coverage available for you and your family
[65](#__RefHeading___Toc20908468)

Children's Equity Act [65](#__RefHeading___Toc20908469)

When benefits and premiums start [66](#__RefHeading___Toc20908470)

When you retire [66](#__RefHeading___Toc20908471)

When you lose benefits [66](#__RefHeading___Toc20908472)

When FEHB coverage ends [66](#__RefHeading___Toc20908473)

Spouse equity coverage [67](#__RefHeading___Toc20908474)

Temporary continuation of coverage (TCC)
[67](#__RefHeading___Toc20908475)

Converting to Individual Coverage [67](#__RefHeading___Toc20908476)

Getting a Certificate of Group Health Plan Coverage
[67](#__RefHeading___Toc20908477)

Two new Federal Programs complement FEHB benefits 69

The Federal Flexible Spending Account Program - FSAFEDS 69

The Federal Long Term Care Insurance Program 72

Index [74](#__RefHeading___Toc20908479)

Summary of benefits [75](#__RefHeading___Toc20908480)

Rates Back cover

  -----------------------------------------------------------------------
  Introduction[]{#__RefHeading___Toc20908399 .anchor}

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

This brochure describes the benefits of Kaiser Foundation Health Plan of
the Northwest under our contract (CS 1047) with the United States Office
of Personnel Management, as authorized by the Federal Employees Health
Benefits law. The address for Kaiser Foundation Health Plan of the
Northwest\'s administrative office is:

Kaiser Foundation Health Plan of the Northwest

500 N.E. Multnomah Street, Suite 100

Portland, Oregon 97232-2099

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. Rates are shown on the back cover of this brochure.

  -----------------------------------------------------------------------
  []{#__RefHeading___Toc20908400 .anchor}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 of the Northwest.

```{=html}
<!-- -->
```
-   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.

```{=html}
<!-- -->
```
-   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 the structure
of 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 Office of
Personnel Management, Insurance Services Program, Program Planning &
Evaluation Group, 1900 E Street NW, Washington, DC 20415-3650.

  -----------------------------------------------------------------------
  Stop Health Care Fraud\![]{#__RefHeading___Toc20908401 .anchor}

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

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:

```{=html}
<!-- -->
```
-   Call the provider and ask for an explanation. There may be an error.

-   If the provider does not resolve the matter, call us from Portland
    at 503/813-2000, or from other areas call 800/813-2000, or our TTY
    number at 800/735-2900 and explain the situation.

```{=html}
<!-- -->
```
-   If we do not resolve the issue:

+-----------------------------------------------------------------------+
| **CALL -- THE HEALTH CARE FRAUD HOTLINE**                             |
|                                                                       |
| **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:

```{=html}
<!-- -->
```
-   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).

```{=html}
<!-- -->
```
-   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.

```{=html}
<!-- -->
```
-   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.

  -----------------------------------------------------------------------
  Preventing 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, be it in person, by phone, or by mail.

-   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}
<!-- -->
```
-   [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**[]{#__RefHeading___Toc20908402
  .anchor}

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

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**[]{#__RefHeading___Toc20908403 .anchor}

The Northwest Permanente Medical Group provides patient care services
through a group capitation arrangement with Kaiser Foundation Health
Plan of the Northwest. Northwest Permanente physicians provide
approximately 98% of primary care services and more than 80% of
specialty services to members. The Medical Group receives a lump sum
incentive payment within a narrow range at the end of the year based on
financial performance of the Health Plan and the Medical Group against
budget. Compensation for physicians is designed to be competitive in
order to recruit and retain quality physicians. Physicians in the
Medical Group do not receive financial incentives linked to individual
utilization patterns. Instead, approximately ninety percent or more of
compensation received by individual physicians is salary; and the
remaining amount of variable compensation is based on clinical quality,
patient satisfaction and financial performance of the Medical Group and
the Health Plan.

**Your Rights**[]{#__RefHeading___Toc20908404 .anchor}

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 website
([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. Kaiser
Foundation Health Plan of the Northwest is a non-profit corporation.
Kaiser Permanente began offering medical services to workers and their
families at Grand Coulee Dam in northeastern Washington and later the
Kaiser shipyards in Portland, Oregon and Vancouver, Washington during
World War II. When the shipyards were closed in 1945, enrollment was
opened to the community. 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.

In 1995, Kaiser Permanente became the first HMO in Oregon and southwest
Washington to receive a three-year, full accreditation from the National
Committee for Quality Assurance (NCQA). We were again awarded
three-year, full accreditation in 1998. In 2001, we were awarded the
highest level of accreditation, known as \"Excellent Accreditation.\"
Excellent Accreditation status is awarded to plans whose service and
clinical quality meet or exceed NCQA's rigorous requirements for
consumer protection and quality improvement, and whose HEDIS (Health
Plan Employer Data and Information Set) results are in the highest range
of national performance.

All Kaiser Permanente and affiliated hospitals are accredited by the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

All applicants for employment with Northwest Permanente P.C., or
Permanente Dental Associates must meet rigorous Kaiser Permanente
credentialing standards. Once hired, they undergo periodic review by
peers and hospital boards to assure their credentials are up to date and
in order.

If you want more information about us, from Portland, call 503/813-2000,
or from other areas call 800/813-2000 or our TTY number at 800/735-2900,
or write to Kaiser Foundation Health Plan of the Northwest, 500 N.E.
Multnomah, Suite 100, Portland, OR 97232. You may also visit our website
at [http://kaiserpermanente.org](http://kaiserpermanente.org/).

**Service Area**[]{#__RefHeading___Toc20908405 .anchor}

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

These Oregon counties: Columbia, Multnomah, Polk, Yamhill

And these Oregon ZIP codes:

Benton County: 97330, 97331, 97333, 97339, 97370

Clackamas County: 97004, 97009, 97011, 97013, 97015, 97017, 97022-23,
97027, 97034-36, 97038, 97042, 97045, 97055, 97067-68, 97070, 97222,
97267-68

Linn County: 97321, 97322, 97335, 97355, 97358, 97360, 97374, 97389

Marion County: 97002, 97020, 97026, 97032, 97071, 97137, 97301-3,
97305-14, 97325, 97352, 97359, 97362, 97375, 97381, 97383-85, 97392

Washington County: 97005-8, 97062, 97075-78, 97106, 97109, 97113,
97116-17, 97119, 97123-25, 97133, 97140, 97144, 97223-25, 97229, 97281,
97291

These Washington counties: Clark County

And these Washington ZIP codes:

Cowlitz County: 98581, 98603, 98609, 98611, 98616, 98625-26, 98632,
98645, 98649, 98674

Lewis County: 98591, 98593, 98596

Wahkiakum County: 98612, 98647

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 47; and for
emergency care obtained from any non-Plan provider, as described on page
37. 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 your dependent goes to
college outside any Kaiser Permanente service area, they may qualify for
the student out-of-area coverage. See page 48. 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**[]{#__RefHeading___Toc20908406
  .anchor}

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

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**

[]{#__RefHeading___Toc20908407 .anchor}

-   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 pages 69-73.

-   We added information regarding Preventing medical mistakes. See page
    6.

-   We added information regarding enrolling in Medicare. See page 58.

-   We revised the Medicare Primary Payer Chart. See page 60.

**Changes to this Plan**[]{#__RefHeading___Toc20908408 .anchor}

Changes apply to both Standard and High Options unless otherwise noted.

-   Your share of the non-Postal premium will increase by 11.9% for Self
    Only or 12.0% for Self and Family under the High Option and will
    increase by 9.2% for Self Only or 9.2% for Self and Family under the
    Standard Option.

```{=html}
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```
-   We included self-referred chiropractic care to the list of excluded
    copayments and coinsurance from the annual out-of-pocket maximum.

```{=html}
<!-- -->
```
-   We cover multidisciplinary rehabilitation services to treat
    conditions, which in the judgment of a physician, are subject to
    significant improvement within 2 months per condition. The copayment
    per day for outpatient multidisciplinary rehabilitation is \$10 for
    high option and \$15 for standard option and there is no copayment
    for inpatient multidisciplinary rehabilitation services. The Federal
    Brochure has been silent on this benefit.

```{=html}
<!-- -->
```
-   We increased DME coverage to 80% when it is prescribed in
    conjunction with home health care that is in lieu of inpatient
    hospitalization.

-   We increased coverage for diabetic supplies such as external insulin
    pumps, infusion devices, glucose monitors, and diabetic foot care
    appliances for both standard and high option plans to 80% coverage.

-   We are changing how copayments are charged for certain contraceptive
    drugs and devices.

```{=html}
<!-- -->
```
-   We now provide certain non-emergency coverage up to \$1200 per year
    for eligible dependents of subscribers who are full time, registered
    college students (at least 12 credit hours per semester) attending a
    recognized accredited institution outside the Kaiser Permanente
    service areas.

  -----------------------------------------------------------------------
  []{#__RefHeading___Toc20908409 .anchor}**Section 3. How you get care**
  -----------------------------------------------------------------------

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

+----------------------+-----------------------------------------------+---+
| **Identification     | We will send you an identification (ID) card  |   |
| cards**[]{#__RefH    | when you enroll. You should carry your ID     |   |
| eading___Toc20908410 | card with you at all times. You must show it  |   |
| .anchor}             | whenever you receive services from a Plan     |   |
|                      | provider, or obtain 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 from Portland at 503/813-2000, or     |   |
|                      | from other areas call 800/813-2000 or our TTY |   |
|                      | number at 800/735-2900, or write to us at:    |   |
|                      | Membership Administration, Kaiser Permanente, |   |
|                      | P.O. Box 921008, Fort Worth, Texas            |   |
|                      | 96121-0008. You may also request replacement  |   |
|                      | cards through our website at                  |   |
|                      | [http://kaiserp                               |   |
|                      | ermanente.org](http://kaiserpermanente.org/). |   |
+----------------------+-----------------------------------------------+---+
|                      |                                               |   |
+----------------------+-----------------------------------------------+---+
| **Where you get      | You get care from \"Plan providers\" and      |   |
| covered              | \"Plan facilities.\" You will only pay        |   |
| care**[]{#__RefH     | copayments and/or coinsurance, and you will   |   |
| eading___Toc20908411 | not have to file claims.                      |   |
| .anchor}             |                                               |   |
+----------------------+-----------------------------------------------+---+
|                      |                                               |   |
+----------------------+-----------------------------------------------+---+
| > **Plan             | The Plan contracts with Northwest Permanente, |   |
| > p                  | P.C. to provide physician services. They      |   |
| roviders**[]{#__RefH | practice in medical offices located within    |   |
| eading___Toc20908412 | our service area. Permanente Dental           |   |
| > .anchor}           | Associates, an independent group of dentists, |   |
|                      | provides or arranges dental care for members  |   |
|                      | of the High Option plan.                      |   |
+----------------------+-----------------------------------------------+---+
|                      |                                               |   |
+----------------------+-----------------------------------------------+---+
|                      | We list Plan providers in the provider        |   |
|                      | directory, which we update periodically. The  |   |
|                      | list is also on our website.                  |   |
+----------------------+-----------------------------------------------+---+
|                      |                                               |   |
+----------------------+-----------------------------------------------+---+
| > **Plan             | Plan facilities are hospitals and other       |   |
| > fa                 | facilities in our service area that we        |   |
| cilities**[]{#__RefH | contract with to provide covered services to  |   |
| eading___Toc20908413 | our members. Medical Centers, Medical Offices |   |
| > .anchor}           | and Dental Offices are conveniently located   |   |
|                      | throughout Portland and Salem, Oregon and     |   |
|                      | Vancouver and Longview-Kelso, Washington. We  |   |
|                      | list these facilities and hospitals in the    |   |
|                      | provider directory, which we update           |   |
|                      | periodically. The list is also on our         |   |
|                      | website.                                      |   |
+----------------------+-----------------------------------------------+---+
|                      |                                               |   |
+----------------------+-----------------------------------------------+---+
|                      | 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 do   | It depends on the type of care you need.      |   |
| to get covered       | First, you and each family member must choose |   |
| care**[]{#__RefH     | a primary care physician. This decision is    |   |
| eading___Toc20908414 | important since your primary care physician   |   |
| .anchor}             | provides or arranges for most of your health  |   |
|                      | care. Our website has information about our   |   |
|                      | providers. Membership Services can help you   |   |
|                      | too, by telling you who is available and      |   |
|                      | sharing information about them. To choose or  |   |
|                      | change a primary care physician, call         |   |
|                      | Membership Services from Portland at          |   |
|                      | 503/813-2000, or from other areas call        |   |
|                      | 800/813-2000 or our TTY number at             |   |
|                      | 800/735-2900.                                 |   |
+----------------------+-----------------------------------------------+---+
|                      |                                               |   |
+----------------------+-----------------------------------------------+---+
| > **Primary          | Your primary care physician can be a          |   |
| > care**[]{#__RefH   | physician, nurse practitioner, or physician   |   |
| eading___Toc20908415 | assistant in family practice, internal        |   |
| > .anchor}           | medicine, or pediatrics. Your primary care    |   |
|                      | physician will provide most of your health    |   |
|                      | care, or give you a referral to see a         |   |
|                      | specialist.                                   |   |
|                      |                                               |   |
|                      | 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        | Your primary care physician will refer you to |   |
| > care**[]{#__RefH   | a specialist for needed care. When you        |   |
| eading___Toc20908416 | receive a referral from your primary care     |   |
| > .anchor}           | 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, a woman may see her      |   |
|                      | obstetrician/gynecologist without having to   |   |
|                      | obtain a referral. You may also receive       |   |
|                      | outpatient alcohol and drug treatment, cancer |   |
|                      | counseling, eye examinations, outpatient      |   |
|                      | mental health, chiropractic, occupational     |   |
|                      | health, and social work services 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.                                         |   |
|                      |                                               |   |
|                      | 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:                                           |   |
+----------------------+-----------------------------------------------+---+
|                      | ---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.                        |   |
+----------------------+-----------------------------------------------+---+
|                      |                                               |   |
+----------------------+-----------------------------------------------+---+
|                      | Note: Under certain circumstances and for a   |   |
|                      | limited period of time, we may continue to    |   |
|                      | pay for covered services provided by your     |   |
|                      | Kaiser Permanente physician or a physician    |   |
|                      | you have been referred to by your Kaiser      |   |
|                      | Permanente physician, when the physician\'s   |   |
|                      | contract with us has been terminated. This    |   |
|                      | extension of care is available for a period   |   |
|                      | up to 120 days from the date we notify you of |   |
|                      | the physician\'s termination, as long as you  |   |
|                      | are receiving an active course of medically   |   |
|                      | necessary treatment, and your treating        |   |
|                      | physician agrees that it is desirable to      |   |
|                      | maintain continuity of care. Additionally,    |   |
|                      | this extension of coverage is available if    |   |
|                      | you are in the second trimester of pregnancy, |   |
|                      | until the later of the following dates: the   |   |
|                      | 45th day after the baby\'s birth, or as long  |   |
|                      | as you are receiving active treatment, not to |   |
|                      | exceed 120 days from the date you receive     |   |
|                      | notice of the termination. To apply for this  |   |
|                      | continuity of care extension, you must submit |   |
|                      | a written request to us.                      |   |
+----------------------+-----------------------------------------------+---+
|                      |                                               |   |
+----------------------+-----------------------------------------------+---+
|                      | This continuity of care provision is          |   |
|                      | applicable only when your Kaiser Permanente   |   |
|                      | physician or referred physician agrees to     |   |
|                      | adhere to the reimbursement rate applicable   |   |
|                      | at the time of contract termination or an     |   |
|                      | equivalent rate, if the contractual rate was  |   |
|                      | not based on a fee-for-service basis.         |   |
+----------------------+-----------------------------------------------+---+
|                      |                                               |   |
+----------------------+-----------------------------------------------+---+
| > **Hospital         | Your Plan primary care physician or           |   |
| > care**[]{#__RefH   | specialist will make necessary hospital       |   |
| eading___Toc20908417 | arrangements and supervise your care. This    |   |
| > .anchor}           | 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       |   |
|                      | Membership Services department immediately    |   |
|                      | from Portland at 503/813-2000, or from other  |   |
|                      | areas call 800/813-2000 or our TTY number at  |   |
|                      | 800/735-2900. 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 92^nd^ day after you become a member of   |   |
|                      | this Plan;                                    |   |
|                      |                                               |   |
|                      | whichever happens first.                      |   |
|                      |                                               |   |
|                      | These provisions apply only to the benefits   |   |
|                      | 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    |   |
|                      | case, the hospitalized family member's        |   |
|                      | benefits under the new plan begin on the      |   |
|                      | effective date of enrollment.                 |   |
+----------------------+-----------------------------------------------+---+
|                      |                                               |   |
+----------------------+-----------------------------------------------+---+
| **Circumstances      | Under certain extraordinary circumstances,    |   |
| beyond our           | such as natural disasters, we may have to     |   |
| control**[]{#__RefH  | delay your services or we may be unable to    |   |
| eading___Toc20908418 | provide them. In that case, we will make all  |   |
| .anchor}             | reasonable efforts to provide you with the    |   |
|                      | necessary care.                               |   |
+----------------------+-----------------------------------------------+---+
|                      |                                               |   |
+----------------------+-----------------------------------------------+---+
| **Services requiring | Most care and service is not subject to       |   |
| our prior            | administrative prior authorization. Prior     |   |
| approval**[]{#__RefH | authorization is required for select services |   |
| eading___Toc20908419 | such as care at skilled nursing facilities,   |   |
| .anchor}             | home health and hospice services, referrals   |   |
|                      | to non-Kaiser Permanente physicians, and      |   |
|                      | transplants. Your primary care physician will |   |
|                      | give a referral for these services if they    |   |
|                      | are medically necessary.                      |   |
+----------------------+-----------------------------------------------+---+

  -----------------------------------------------------------------------
  []{#__RefHeading___Toc20908420 .anchor}**Section 4. Your costs for
  covered services**
  -----------------------------------------------------------------------

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

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

+----------------------+-----------------------------------------------+
| > **Co               | A copayment is a fixed amount of money you    |
| payments**[]{#__RefH | pay to the provider, facility, pharmacy,      |
| eading___Toc20908421 | etc., when you receive services.              |
| > .anchor}           |                                               |
|                      | Example: When you see your primary care       |
|                      | physician, you pay a copayment of \$10 per    |
|                      | office visit if you are on the High Option    |
|                      | Plan and \$15 per office visit if you are on  |
|                      | the Standard Plan. When you go in the         |
|                      | hospital, you pay nothing under either        |
|                      | Option.                                       |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| > **De               | We do not have a deductible.                  |
| ductible**[]{#__RefH |                                               |
| eading___Toc20908422 |                                               |
| > .anchor}           |                                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| > **Coi              | Coinsurance is the percentage of our          |
| nsurance**[]{#__RefH | allowance that you must pay for certain       |
| eading___Toc20908423 | services you receive.                         |
| > .anchor}           |                                               |
|                      | Example: In our Plan, you pay 50% of our      |
|                      | allowance for infertility services.           |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| > **Fees when you    | If you do not pay your copayment at the time  |
| > fail to make your  | you receive services, we will bill you. You   |
| > c                  | will be required to pay a \$10 charge for     |
| opayment**[]{#__RefH | each bill sent for unpaid services.           |
| eading___Toc20908424 |                                               |
| > .anchor}           |                                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| > **Fees when you    | If you miss a medical appointment, we will    |
| > miss a medical     | charge you \$10, unless you notify us in      |
| > app                | advance.                                      |
| ointment**[]{#__RefH |                                               |
| eading___Toc20908425 |                                               |
| > .anchor}           |                                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Your catastrophic  | After your copayments and coinsurance total   |
| protection           | \$600 per person or \$1,200 per family        |
| out-of-pocket        | enrollment in any calendar year, you do not   |
| maximum for          | have to pay any more for covered services.    |
| copayments and       | However, copayments and coinsurances for the  |
| coi                  | following services do not count toward your   |
| nsurance**[]{#__RefH | catastrophic protection out-of-pocket         |
| eading___Toc20908426 | maximum. You must continue to pay copayments  |
| .anchor}             | for these services under both the High Option |
|                      | and Standard Option.                          |
+----------------------+-----------------------------------------------+
|                      | -   Outpatient prescription drugs             |
|                      |                                               |
|                      | -   Contraceptive devices                     |
|                      |                                               |
|                      | -   Dental services                           |
|                      |                                               |
|                      | -   Corrective appliances and artificial aids |
|                      |                                               |
|                      | -   The \$25 charges paid for follow-up or    |
|                      |     continuing care when you are traveling    |
|                      |     out of our service area                   |
|                      |                                               |
|                      | -   Long-term physical therapy and            |
|                      |     rehabilitation                            |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   Eyeglasses and contact lenses             |
|                      |                                               |
|                      | -   Health education services                 |
|                      |                                               |
|                      | -   Self-referred chiropractic care           |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
|                      | 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**[]{#__RefHeading___Toc20908427 .anchor} **\--  |
| Overview**[]{#__RefHeading___Toc20908428 .anchor}                     |
|                                                                       |
| ***(See page 10 for how our benefits changed this year and pages 75   |
| and 76 for benefit summaries.)***                                     |
+-----------------------------------------------------------------------+

**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 from
Portland at 503/813-2000, or from other areas call 800/813-2000 or our
TTY number at 800/735-2900 or at our website at
[http://kaiserpermanente.org](http://kaiserpermanente.org/)*.*

\(a\) Medical services and supplies provided by physicians and other
health care professionals 16-27

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

\(b\) Surgical and anesthesia services provided by physicians and other
health care professionals 28-32

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

\(c\) Services provided by a hospital or other facility, and ambulance
services 33-36

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

\(d\) Emergency services/accidents 37-39

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

\(e\) Mental health and substance abuse benefits 40-42

\(f\) Prescription drug benefits 43-45

\(g\) Special features 46-48

+-------------------------------+--------------------------------------+
| Flexible benefits option      | High risk pregnancies                |
|                               |                                      |
| 24 hour nurse line            | Centers of Excellence                |
|                               |                                      |
| Services for deaf and hearing | Travel benefit                       |
| impaired                      |                                      |
|                               | Services from other Kaiser           |
| Language interpretation       | Permanente Plans                     |
|                               |                                      |
|                               | Student coverage outside the service |
|                               | area                                 |
+-------------------------------+--------------------------------------+

\(h\) Dental benefits 49-52

\(i\) Non-FEHB benefits available to Plan members 53

Summary of benefits 75-76

+---+---+---------------------------+-------------------+-----------+---+---+
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| # |   |                           |                   |           |   |   |
| _ |   |                           |                   |           |   |   |
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| n |   |                           |                   |           |   |   |
| g |   |                           |                   |           |   |   |
| _ |   |                           |                   |           |   |   |
| _ |   |                           |                   |           |   |   |
| _ |   |                           |                   |           |   |   |
| T |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
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| 2 |   |                           |                   |           |   |   |
| 0 |   |                           |                   |           |   |   |
| 9 |   |                           |                   |           |   |   |
| 0 |   |                           |                   |           |   |   |
| 8 |   |                           |                   |           |   |   |
| 4 |   |                           |                   |           |   |   |
| 2 |   |                           |                   |           |   |   |
| 9 |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
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| a |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
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| } |   |                           |                   |           |   |   |
+---+---+---------------------------+-------------------+-----------+---+---+
|   | * | **Here are some important |                   |           | * |   |
|   | * | things to keep in mind    |                   |           | * |   |
|   | I | about these benefits:**   |                   |           | I |   |
|   | * |                           |                   |           | * |   |
|   | * | -   Please remember that  |                   |           | * |   |
|   |   |     all benefits are      |                   |           |   |   |
|   | * |     subject to the        |                   |           | * |   |
|   | * |     definitions,          |                   |           | * |   |
|   | M |     limitations, and      |                   |           | M |   |
|   | * |     exclusions in this    |                   |           | * |   |
|   | * |     brochure and we cover |                   |           | * |   |
|   |   |     them only when we     |                   |           |   |   |
|   | * |     determine they are    |                   |           | * |   |
|   | * |     medically necessary.  |                   |           | * |   |
|   | P |                           |                   |           | P |   |
|   | * | -   Plan physicians must  |                   |           | * |   |
|   | * |     provide or arrange    |                   |           | * |   |
|   |   |     your care.            |                   |           |   |   |
|   | * |                           |                   |           | * |   |
|   | * | -   We have no calendar   |                   |           | * |   |
|   | O |     year deductible.      |                   |           | O |   |
|   | * |                           |                   |           | * |   |
|   | * | ```{=html}                |                   |           | * |   |
|   |   | <!-- -->                  |                   |           |   |   |
|   | * | ```                       |                   |           | * |   |
|   | * | -   Be sure to read       |                   |           | * |   |
|   | R |     Section 4, *Your      |                   |           | R |   |
|   | * |     costs for covered     |                   |           | * |   |
|   | * |     services,* for        |                   |           | * |   |
|   |   |     valuable information  |                   |           |   |   |
|   | * |     about how cost        |                   |           | * |   |
|   | * |     sharing works. Also   |                   |           | * |   |
|   | T |     read Section 9 about  |                   |           | T |   |
|   | * |     coordinating benefits |                   |           | * |   |
|   | * |     with other coverage,  |                   |           | * |   |
|   |   |     including with        |                   |           |   |   |
|   | * |     Medicare.             |                   |           | * |   |
|   | * |                           |                   |           | * |   |
|   | A | -   Note: We waive the    |                   |           | A |   |
|   | * |     \$10 charge if you    |                   |           | * |   |
|   | * |     enroll in our         |                   |           | * |   |
|   |   |     Medicare+Choice Plan  |                   |           |   |   |
|   | * |     and assign your       |                   |           | * |   |
|   | * |     Medicare benefits to  |                   |           | * |   |
|   | N |     the Plan.             |                   |           | N |   |
|   | * |                           |                   |           | * |   |
|   | * |                           |                   |           | * |   |
|   |   |                           |                   |           |   |   |
|   | * |                           |                   |           | * |   |
|   | * |                           |                   |           | * |   |
|   | T |                           |                   |           | T |   |
|   | * |                           |                   |           | * |   |
|   | * |                           |                   |           | * |   |
+---+---+---------------------------+-------------------+-----------+---+---+
| > |   |                           | **You pay**       |           |   |   |
|   |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| B |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| f |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| D |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| p |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
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| o |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
+---+---+---------------------------+-------------------+-----------+---+---+
| # |   |                           | ######### You pay | ####      |   |   |
| # |   |                           |  -Standard Option | ##### You |   |   |
| # |   |                           |                   |  pay - Hi |   |   |
|   |   |                           |                   | gh Option |   |   |
| * |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| D |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
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| n |   |                           |                   |           |   |   |
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| t |   |                           |                   |           |   |   |
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| c |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
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| d |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
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| a |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
| m |   |                           |                   |           |   |   |
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| n |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| v |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
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| s |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
+---+---+---------------------------+-------------------+-----------+---+---+
| > |   |                           | > \$15 per office | > \$10    |   |   |
|   |   |                           | > visit           | > per     |   |   |
| P |   |                           |                   | > office  |   |   |
| r |   |                           |                   | > visit   |   |   |
| o |   |                           |                   |           |   |   |
| f |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
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| p |   |                           |                   |           |   |   |
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|   |   |                           |                   |           |   |   |
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+---+---+---------------------------+-------------------+-----------+---+---+
| # |   |                           | ######### You pay | ####      |   |   |
|   |   |                           |  -Standard Option | ##### You |   |   |
| L |   |                           |                   |  pay - Hi |   |   |
| a |   |                           |                   | gh Option |   |   |
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+---+---+---------------------------+-------------------+-----------+---+---+
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| ` |   |                           |                   |           |   |   |
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| c |   |                           |                   |           |   |   |
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| r |   |                           |                   |           |   |   |
| d |   |                           |                   |           |   |   |
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+---+---+---------------------------+-------------------+-----------+---+---+
| # |   |                           |                   |           |   |   |
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+---+---+---------------------------+-------------------+-----------+---+---+
| > |   |                           | > \$15 per office | > \$10    |   |   |
|   |   |                           | > visit           | > office  |   |   |
| R |   |                           |                   | > visit   |   |   |
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| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| y |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| u |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| l |   |                           |                   |           |   |   |
| l |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| . |   |                           |                   |           |   |   |
+---+---+---------------------------+-------------------+-----------+---+---+

Preventive care, adult \-- continued on next page

+--------------------------------+-------------------+----------------+
| ##### Preven                   | ######### You pay | ###            |
| tive care, adult *(continued)* |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > Routine immunizations and    | > Nothing         | #              |
| > boosters                     |                   | ###### Nothing |
+--------------------------------+-------------------+----------------+
| > Visits to receive injections | > \$5 per office  | ####### \$5 pe |
|                                | > visit           | r office visit |
+--------------------------------+-------------------+----------------+
| > Injectable travel            | > \$15 per office | #              |
| > immunizations                | > visit           | ###### \$10 pe |
| >                              |                   | r office visit |
| > Note: We cover oral travel   |                   |                |
| > immunizations under the      |                   |                |
| > prescription drug benefit.   |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | #####          |
|                                |                   | ## All charges |
| *Physical exams required for:* |                   |                |
|                                |                   |                |
| -   *Obtaining or continuing   |                   |                |
|     employment*                |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Insurance*                |                   |                |
|                                |                   |                |
| -   *Attending schools*        |                   |                |
+--------------------------------+-------------------+----------------+
| #                              |                   |                |
| #### Preventive care, children |                   |                |
+--------------------------------+-------------------+----------------+
| -   Childhood immunizations    | > Nothing         | > Nothing      |
|     recommended by the         |                   |                |
|     American Academy of        |                   |                |
|     Pediatrics                 |                   |                |
+--------------------------------+-------------------+----------------+
| -   Examinations, such as:     | > \$15 per office | > \$10 per     |
|                                | > visit           | > office visit |
| > ---Eye exams to determine    |                   |                |
| > the need for vision          |                   |                |
| > correction                   |                   |                |
| >                              |                   |                |
| > ---Ear exams to determine    |                   |                |
| > the need for hearing         |                   |                |
| > correction                   |                   |                |
| >                              |                   |                |
| > ---Examinations done on the  |                   |                |
| > day of immunizations         |                   |                |
|                                |                   |                |
| -   Well-child care charges    |                   |                |
|     for routine examinations,  |                   |                |
|     immunizations, and care    |                   |                |
+--------------------------------+-------------------+----------------+
| > Injectable travel            | > \$15 per office | #              |
| > immunizations                | > visit           | ###### \$10 pe |
| >                              |                   | r office visit |
| > Note: We cover oral travel   |                   |                |
| > immunizations under the      |                   |                |
| > prescription drug benefit.   |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | #####          |
|                                |                   | ## All charges |
| *Physical exams required for:* |                   |                |
|                                |                   |                |
| -   *Obtaining or continuing   |                   |                |
|     employment*                |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Insurance*                |                   |                |
|                                |                   |                |
| -   *Attending schools or      |                   |                |
|     camp*                      |                   |                |
+--------------------------------+-------------------+----------------+
| ######## Maternity care        | ######### You pay | ###            |
|                                |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > Complete maternity           | > \$15 per office | > \$10 per     |
| > (obstetrical) care, such as: | > visit           | > office visit |
|                                |                   |                |
| -   Prenatal care              |                   |                |
|                                |                   |                |
| -   Delivery                   |                   |                |
|                                |                   |                |
| -   Postnatal care             |                   |                |
|                                |                   |                |
| > 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. Your    |                   |                |
|     physician 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*   | > *All         |
|                                |                   | > charges*     |
| -   *Routine sonograms to      |                   |                |
|     determine fetal age, size, |                   |                |
|     or sex*                    |                   |                |
+--------------------------------+-------------------+----------------+
| ######## Family planning       |                   |                |
+--------------------------------+-------------------+----------------+
| -   Family planning services   | > \$15 per office | > \$10 per     |
|     including counseling       | > visit           | > office visit |
|                                |                   |                |
| -   Voluntary sterilization    |                   |                |
|     (See Surgical procedures   |                   |                |
|     Section 5(b))              |                   |                |
|                                |                   |                |
| -   Surgically implanted       |                   |                |
|     time-release               |                   |                |
|     contraceptives and         |                   |                |
|     intrauterine devices       |                   |                |
|     (IUDs)                     |                   |                |
|                                |                   |                |
| > Note: In addition to the     |                   |                |
| > office visit copayment for   |                   |                |
| > surgical procedures related  |                   |                |
| > to internally implanted      |                   |                |
| > time-release contraceptive   |                   |                |
| > drugs and contraceptive      |                   |                |
| > devices, we charge for the   |                   |                |
| > drug or device according to  |                   |                |
| > your Prescription Drug       |                   |                |
| > benefit. Other contraceptive |                   |                |
| > drugs and diaphragms are     |                   |                |
| > also covered under your      |                   |                |
| > Prescription Drug benefit.   |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Reversal of voluntary     |                   |                |
|     surgical sterilization*    |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Genetic counseling*       |                   |                |
+--------------------------------+-------------------+----------------+
| ######## Infertility services  | ######### You pay | ###            |
|                                |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > Diagnosis and treatment of   | > 50% of our      | 50% of our     |
| > involuntary infertility      | > allowance       | allowance      |
| > including artificial         |                   |                |
| > insemination limited to      |                   |                |
| > intrauterine insemination    |                   |                |
| > (IUI)                        |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
| >                              |                   | > charges*     |
| > *These exclusions apply to   |                   |                |
| > fertile as well as infertile |                   |                |
| > individuals or couples:*     |                   |                |
|                                |                   |                |
| -   *Intravaginal insemination |                   |                |
|     (IVI)*                     |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Intracervical             |                   |                |
|     insemination (ICI)*        |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Assisted reproductive     |                   |                |
|     technology (ART)           |                   |                |
|     procedures, such as:*      |                   |                |
|                                |                   |                |
| > ---*In vitro fertilization*  |                   |                |
| >                              |                   |                |
| > ---*Embryo transfer and      |                   |                |
| > gamete intrafallopian        |                   |                |
| > transfer (GIFT)*             |                   |                |
|                                |                   |                |
| -   *Services and supplies     |                   |                |
|     related to excluded ART    |                   |                |
|     procedures*                |                   |                |
|                                |                   |                |
| -   *Cost of donor sperm and   |                   |                |
|     donor eggs and services    |                   |                |
|     related to their           |                   |                |
|     procurement and storage*   |                   |                |
|                                |                   |                |
| -   *Drugs used in the         |                   |                |
|     diagnosis and treatment of |                   |                |
|     infertility*               |                   |                |
+--------------------------------+-------------------+----------------+
| > **Allergy care**             | #########         |                |
+--------------------------------+-------------------+----------------+
| > Testing and treatment        | > \$15 per office | > \$10 per     |
|                                | > visit           | > office visit |
+--------------------------------+-------------------+----------------+
| > Allergy injections           | > \$5 per office  | > \$5 per      |
|                                | > visit           | > office visit |
+--------------------------------+-------------------+----------------+
| > Allergy serum                | > Nothing         | > Nothing      |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Provocative food testing* |                   |                |
|                                |                   |                |
| -   *Sublingual allergy        |                   |                |
|     desensitization*           |                   |                |
+--------------------------------+-------------------+----------------+
| ######## Treatment therapies   | #########         | #########      |
+--------------------------------+-------------------+----------------+
| -   Chemotherapy and radiation | > \$15 per office | > \$10 per     |
|     therapy                    | > visit           | > office visit |
|                                |                   |                |
| > Note: We limit high dose     |                   |                |
| > chemotherapy in association  |                   |                |
| > with autologous bone marrow  |                   |                |
| > transplants to those         |                   |                |
| > transplants listed under     |                   |                |
| > Organ/Tissue Transplants on  |                   |                |
| > page 31.                     |                   |                |
|                                |                   |                |
| -   Respiratory and inhalation |                   |                |
|     therapy                    |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   Dialysis -- hemodialysis   |                   |                |
|     and peritoneal dialysis    |                   |                |
+--------------------------------+-------------------+----------------+

Treatment therapies -- continued on next page

+--------------------------------+-------------------+----------------+
| ######## Tre                   | ######### You pay | ###            |
| atment therapies *(continued)* |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > Note: We cover growth        | > Nothing         | > Nothing      |
| > hormone therapy (GHT) under  |                   |                |
| > the Prescription Drug        |                   |                |
| > benefit on page 43.          |                   |                |
|                                |                   |                |
| -   Intravenous (IV)/Infusion  |                   |                |
|     Therapy -- home IV and     |                   |                |
|     antibiotic therapy         |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Long-term rehabilitative  |                   |                |
|     therapy*                   |                   |                |
|                                |                   |                |
| -   *Chemotherapy supported by |                   |                |
|     a bone marrow transplant   |                   |                |
|     or with stem cell support, |                   |                |
|     for any diagnosis not      |                   |                |
|     listed as covered*         |                   |                |
|                                |                   |                |
| -   *Cognitive therapy*        |                   |                |
+--------------------------------+-------------------+----------------+
| > **Physical and occupational  |                   |                |
| > therapies**                  |                   |                |
+--------------------------------+-------------------+----------------+
| > Benefit is limited to the    | > \$15 per        | \$10 per       |
| > greater of 20 visits or 2    | > outpatient      | outpatient     |
| > months per condition for     | > visit           | visit          |
| > each therapy:                | >                 |                |
|                                | > Nothing for     | Nothing for    |
| -   Physical therapy by        | > inpatient       | inpatient      |
|     qualified physical         |                   |                |
|     therapists to restore      |                   |                |
|     bodily function when you   |                   |                |
|     have a total or partial    |                   |                |
|     loss of bodily function    |                   |                |
|     due to illness or injury   |                   |                |
|                                |                   |                |
| -   Occupational therapy is    |                   |                |
|     limited to services that   |                   |                |
|     assist the member to       |                   |                |
|     achieve and maintain       |                   |                |
|     self-care and improved     |                   |                |
|     functioning in other       |                   |                |
|     activities of daily living |                   |                |
|                                |                   |                |
| > Cardiac rehabilitation       |                   |                |
| > following a heart            |                   |                |
| > transplant, bypass surgery,  |                   |                |
| > or a myocardial infarction.  |                   |                |
+--------------------------------+-------------------+----------------+
| -   Multidisciplinary          | > \$15 per day    | > \$10 per day |
|     rehabilitation is provided | >                 | >              |
|     for up to two months per   | > Nothing         | > Nothing      |
|     condition. The two-month   |                   |                |
|     limit applies to all       |                   |                |
|     prescribed inpatient and   |                   |                |
|     outpatient                 |                   |                |
|     multidisciplinary          |                   |                |
|     rehabilitative services    |                   |                |
|     you may receive for the    |                   |                |
|     same condition, provided   |                   |                |
|     in an organized            |                   |                |
|     comprehensive              |                   |                |
|     multidisciplinary facility |                   |                |
|     or program.                |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   Outpatient                 |                   |                |
|     multidisciplinary          |                   |                |
|     rehabilitation             |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   Inpatient                  |                   |                |
|     multidisciplinary          |                   |                |
|     rehabilitation at hospital |                   |                |
|     or SNF facility when       |                   |                |
|     admitted from home         |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Long-term rehabilitative  |                   |                |
|     therapy*                   |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Exercise programs*        |                   |                |
+--------------------------------+-------------------+----------------+

+--------------------------------+-------------------+----------------+
| > **Speech therapy**           | ######### You pay | ###            |
|                                |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > Benefit is limited to the    | \$15 per          | > \$10 per     |
| > greater of 20 visits or 2    | outpatient visit  | > outpatient   |
| > months per condition for     |                   | > visit        |
| > each therapy:                | Nothing for       | >              |
|                                | inpatient         | > Nothing for  |
| -   Speech therapy by speech   |                   | > inpatient    |
|     pathologists when          |                   |                |
|     medically necessary        |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
| >                              |                   | > charges*     |
| > *Speech therapy that is not  |                   |                |
| > medically necessary such     |                   |                |
| > as:*                         |                   |                |
|                                |                   |                |
| -   *Therapy for educational   |                   |                |
|     placement or other         |                   |                |
|     educational purposes*      |                   |                |
|                                |                   |                |
| -   *Training or therapy to    |                   |                |
|     improve articulation in    |                   |                |
|     the absence of injury,     |                   |                |
|     illness, or medical        |                   |                |
|     condition affecting        |                   |                |
|     articulation*              |                   |                |
|                                |                   |                |
| -   *Therapy for tongue thrust |                   |                |
|     in the absence of          |                   |                |
|     swallowing problems*       |                   |                |
+--------------------------------+-------------------+----------------+
| > **Hearing services (testing, |                   |                |
| > treatment, and supplies)**   |                   |                |
+--------------------------------+-------------------+----------------+
| -   Ear and hearing            | > \$15 per office | \$10 per       |
|     examinations to determine  | > visit           | office visit   |
|     the need for hearing       |                   |                |
|     correction                 |                   |                |
|                                |                   |                |
| -   Hearing testing for        |                   |                |
|     children through age 17    |                   |                |
|     (see Preventive care,      |                   |                |
|     children)                  |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *All other hearing         |                   |                |
|     testing*                   |                   |                |
|                                |                   |                |
| -   *Hearing aids and          |                   |                |
|     supplies*                  |                   |                |
+--------------------------------+-------------------+----------------+
| > **Vision services (testing,  |                   |                |
| > treatment, and supplies)**   |                   |                |
+--------------------------------+-------------------+----------------+
| -   Diagnosis and treatment of | \$15 per office   | \$10 per       |
|     diseases of the eye        | visit             | office visit   |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   Eye refractions            |                   |                |
+--------------------------------+-------------------+----------------+
| -   Lenses, frames, industrial | > The cost of     | > The cost of  |
|     safety glasses and/or      | > lenses, frames, | > lenses,      |
|     medically necessary        | > industrial      | > frames,      |
|     contact lenses every 24    | > safety glasses, | > industrial   |
|     months                     | > and/or          | > safety       |
|                                | > medically       | > glasses,     |
| ```{=html}                     | > necessary       | > and/or       |
| <!-- -->                       | > contact lenses  | > medically    |
| ```                            | > less \$100      | > necessary    |
| -   Medically necessary        |                   | > contact      |
|     contact lenses for:        |                   | > lenses less  |
|                                |                   | > \$150        |
| > ---Extremely high degrees of |                   |                |
| > near or farsightedness       |                   |                |
| >                              |                   |                |
| > ---Distorted corneas which   |                   |                |
| > limit the best visual acuity |                   |                |
| > with glasses                 |                   |                |
| >                              |                   |                |
| > ---Visual error of the two   |                   |                |
| > eyes which are greatly       |                   |                |
| > different in power           |                   |                |
+--------------------------------+-------------------+----------------+

*Vision services (testing, treatment, and supplies) \-- continued on
next page*

+--------------------------------+-------------------+----------------+
| > **Vision services (testing,  | ######### You pay | ###            |
| > treatment, and supplies)**   |  -Standard Option | ###### You pay |
| > (*continued)*                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| -   You may select             | The cost of       | The cost of    |
|     non-medically necessary    | contact lenses    | contact lenses |
|     contact lenses instead of  | less \$100        | less \$150     |
|     lenses, frames, and/or     |                   |                |
|     industrial safety glasses. |                   |                |
+--------------------------------+-------------------+----------------+
| -   Eyeglasses and contact     | Nothing           | Nothing        |
|     lens(es) after cataract    |                   |                |
|     surgery with intraocular   |                   |                |
|     lens implant:              |                   |                |
|                                |                   |                |
| > Medically necessary          |                   |                |
| > intraocular lenses           |                   |                |
| >                              |                   |                |
| > One pair of eyeglasses       |                   |                |
| > (regular lenses and          |                   |                |
| > designated frames); or       |                   |                |
|                                |                   |                |
| One pair of contact lenses     |                   |                |
+--------------------------------+-------------------+----------------+
| -   Eyeglasses and contact     | Nothing           | Nothing        |
|     lens(es) after cataract    |                   |                |
|     surgery not involving      |                   |                |
|     intraocular lens implant:  |                   |                |
|                                |                   |                |
| > One pair of contact lenses   |                   |                |
| > and/or one pair of           |                   |                |
| > designated frames and        |                   |                |
| > regular lenses if both must  |                   |                |
| > be worn at the same time to  |                   |                |
| > provide a significant        |                   |                |
| > improvement in visual acuity |                   |                |
| > or binocular vision not      |                   |                |
| > obtainable with regular      |                   |                |
| > lenses or contact lens(es)   |                   |                |
| > alone                        |                   |                |
+--------------------------------+-------------------+----------------+
| > What you should know:        | \$60 for single   | \$60 for       |
| >                              | vision and        | single vision  |
| > Vision care benefits are     | cosmetic contact  | and cosmetic   |
| > provided to members when     | lenses;           | contact        |
| > prescribed by Plan           |                   | lenses;        |
| > physicians or optometrists   | \$90 for          |                |
| > and provided at Plan         | multifocal lenses | \$90 for       |
| > facilities and optical       |                   | multifocal     |
| > departments.                 |                   | lenses         |
| >                              |                   |                |
| > Your vision care benefits    |                   |                |
| > for lenses, frames,          |                   |                |
| > industrial safety glasses    |                   |                |
| > and/or medically necessary   |                   |                |
| > contact lenses renews every  |                   |                |
| > 24 months from the date you  |                   |                |
| > last received them.          |                   |                |
+--------------------------------+-------------------+----------------+
| > If a significant change in   |                   |                |
| > correction occurs in one or  |                   |                |
| > both eyes within 12 months   |                   |                |
| > of the initial exam, we      |                   |                |
| > cover lenses, industrial     |                   |                |
| > safety lenses or medically   |                   |                |
| > necessary contact lenses     |                   |                |
| > with the new correction at   |                   |                |
| > these maximum values.        |                   |                |
| > Replacement coverage is for  |                   |                |
| > the original product type    |                   |                |
| > (contacts or eyeglasses)     |                   |                |
| > only.                        |                   |                |
| >                              |                   |                |
| > If you have selected         |                   |                |
| > non-medically necessary      |                   |                |
| > contact lenses in lieu of    |                   |                |
| > lenses and frames, and/or    |                   |                |
| > industrial safety glasses,   |                   |                |
| > and a significant change in  |                   |                |
| > correction occurs in one or  |                   |                |
| > both eyes within 12 months   |                   |                |
| > of the initial exam, we will |                   |                |
| > cover replacement of         |                   |                |
| > non-medically necessary      |                   |                |
| > contact lenses at these      |                   |                |
| > maximum values. Replacement  |                   |                |
| > coverage is for the original |                   |                |
| > product type (contacts or    |                   |                |
| > eyeglasses) only.            |                   |                |
+--------------------------------+-------------------+----------------+

*Vision services (testing, treatment, and supplies) \-- continued on
next page*

+--------------------------------+-------------------+----------------+
| > **Vision services (testing,  | ######### You pay | ###            |
| > treatment, and supplies)**   |  -Standard Option | ###### You pay |
| > (*continued)*                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Repair or replacement of  |                   |                |
|     eyewear and accessories    |                   |                |
|     due to loss or damage*     |                   |                |
|                                |                   |                |
| -   *Contacts having no        |                   |                |
|     refractive value*          |                   |                |
|                                |                   |                |
| -   *Fitting and routine       |                   |                |
|     follow-up services for     |                   |                |
|     non-medically indicated    |                   |                |
|     contact lenses*            |                   |                |
|                                |                   |                |
| -   *Refractions for           |                   |                |
|     non-medically indicated    |                   |                |
|     contact lenses*            |                   |                |
|                                |                   |                |
| -   *Vision therapy            |                   |                |
|     (orthoptics or eye         |                   |                |
|     exercises)*                |                   |                |
|                                |                   |                |
| -   *Radial keratotomy,        |                   |                |
|     Photorefractive            |                   |                |
|     Keratectomy and other      |                   |                |
|     refractive surgery such as |                   |                |
|     Lasik surgery and          |                   |                |
|     evaluations for these      |                   |                |
|     procedures*                |                   |                |
|                                |                   |                |
| -   *Visual training*          |                   |                |
|                                |                   |                |
| -   *Low vision aids*          |                   |                |
+--------------------------------+-------------------+----------------+
| > **Foot Care**                |                   |                |
+--------------------------------+-------------------+----------------+
| > Routine foot care when you   | > \$15 per office | \$10 per       |
| > are under active treatment   | > visit           | office visit   |
| > for a metabolic or           |                   |                |
| > peripheral vascular disease, |                   |                |
| > such as diabetes             |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | *All charges*  |
|                                |                   |                |
| -   *Cutting, trimming or      |                   |                |
|     removal of corns,          |                   |                |
|     calluses, or the free edge |                   |                |
|     of toenails and similar    |                   |                |
|     routine treatment of       |                   |                |
|     conditions of the foot*    |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Treatment of weak,        |                   |                |
|     strained or flat feet or   |                   |                |
|     bunions or spurs; and of   |                   |                |
|     any instability, imbalance |                   |                |
|     or subluxation of the      |                   |                |
|     foot*                      |                   |                |
+--------------------------------+-------------------+----------------+
| > **Orthopedic and prosthetic  |                   |                |
| > devices**                    |                   |                |
+--------------------------------+-------------------+----------------+
| -   Internal prosthetic        | > Nothing         | > Nothing      |
|     devices, such as           |                   |                |
|     artificial joints,         |                   |                |
|     pacemakers, and surgically |                   |                |
|     implanted breast implant   |                   |                |
|     following mastectomy.      |                   |                |
|     Note: See Section 5(c) for |                   |                |
|     payment information and    |                   |                |
|     Section 5(b) for coverage  |                   |                |
|     of the surgery to insert   |                   |                |
|     the device.                |                   |                |
+--------------------------------+-------------------+----------------+
| -   Externally worn breast     | > 50% of our      | 50% of our     |
|     prostheses and surgical    | > allowance       | allowance      |
|     bras, including necessary  |                   |                |
|     replacements, following a  |                   |                |
|     mastectomy                 |                   |                |
|                                |                   |                |
| -   Corrective orthopedic      |                   |                |
|     appliances for nondental   |                   |                |
|     treatment of               |                   |                |
|     temporomandibular joint    |                   |                |
|     (TMJ) pain dysfunction     |                   |                |
|     syndrome                   |                   |                |
+--------------------------------+-------------------+----------------+

*Orthopedic and prosthetic devices \-- continued on next page*

+--------------------------------+-------------------+----------------+
| > **Orthopedic and prosthetic  | ######### You pay | ###            |
| > devices** *(continued)*      |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > Maxillo-facial prosthetic    | > 20% of our      | 20% of our     |
| > devices to restore or manage | > allowance       | allowance      |
| > head and facial structures   |                   |                |
| > that are defective           |                   |                |
+--------------------------------+-------------------+----------------+
| > When prescribed by a Plan    | > 50% of our      | 50% of our     |
| > physician, we cover          | > allowance       | allowance      |
| > orthopedic and other         |                   |                |
| > prosthetic devices not       |                   |                |
| > listed above, including      |                   |                |
| > repairs, adjustments or      |                   |                |
| > replacements other than      |                   |                |
| > those necessitated by misuse |                   |                |
| > or loss.                     |                   |                |
| >                              |                   |                |
| > Note: We cover only those    |                   |                |
| > standard items that are      |                   |                |
| > adequate to meet the medical |                   |                |
| > needs of the member.         |                   |                |
| >                              |                   |                |
| > Note: Orthopedic and other   |                   |                |
| > prosthetic devices are       |                   |                |
| > provided in accordance with  |                   |                |
| > the Plan\'s DME formulary    |                   |                |
| > and its guidelines.          |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Devices used primarily    |                   |                |
|     for cosmetic purposes that |                   |                |
|     are not necessary to       |                   |                |
|     control or eliminate       |                   |                |
|     infection, pain, or        |                   |                |
|     restore functions such as  |                   |                |
|     speech, swallowing, or     |                   |                |
|     chewing*                   |                   |                |
|                                |                   |                |
| -   *Artificial larynxes*      |                   |                |
|                                |                   |                |
| -   *Voice machines*           |                   |                |
|                                |                   |                |
| -   *Artificial hearts*        |                   |                |
|                                |                   |                |
| -   *Internally implanted      |                   |                |
|     insulin pumps*             |                   |                |
|                                |                   |                |
| -   *Dentures (except High     |                   |                |
|     Option)*                   |                   |                |
|                                |                   |                |
| -   *External and internally   |                   |                |
|     implanted hearing aids*    |                   |                |
|                                |                   |                |
| -   *Devices, equipment,       |                   |                |
|     supplies, and prosthetics  |                   |                |
|     related to the treatment   |                   |                |
|     of sexual dysfunction*     |                   |                |
|                                |                   |                |
| -   *Orthotic devices          |                   |                |
|     including corrective       |                   |                |
|     shoes*                     |                   |                |
|                                |                   |                |
| -   *Arch supports*            |                   |                |
|                                |                   |                |
| -   *Foot orthotics*           |                   |                |
|                                |                   |                |
| -   *Heel pads and heel cups*  |                   |                |
|                                |                   |                |
| -   *Lumbosacral supports*     |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Corsets, trusses, elastic |                   |                |
|     stockings, support hose,   |                   |                |
|     and other supportive       |                   |                |
|     devices*                   |                   |                |
+--------------------------------+-------------------+----------------+

+--------------------------------+-------------------+----------------+
| ######## D                     | ######### You pay | ###            |
| urable medical equipment (DME) |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > When prescribed by a Plan    | #                 | 50% of our     |
| > physician, we cover or       | # 50% of our allo | allowance      |
| > purchase, at our option,     | wance {#of-our-al |                |
| > durable medical equipment    | lowance .StyleK2} |                |
| > intended to be used          |                   |                |
| > repeatedly and in the home.  |                   |                |
| >                              |                   |                |
| > Necessary repairs,           |                   |                |
| > adjustments, and             |                   |                |
| > replacements other than      |                   |                |
| > those necessitated by misuse |                   |                |
| > or loss are also covered.    |                   |                |
+--------------------------------+-------------------+----------------+
| ######## When pre              | ######### 20%     | 20% of our     |
| scribed in conjunction with Ho |  of our allowance | allowance      |
| me Health care that is in lieu |                   |                |
|  of inpatient hospitalization. |                   |                |
+--------------------------------+-------------------+----------------+
| > Notes on DME benefits:       | #########         |                |
|                                |                   |                |
| -   We cover only those        |                   |                |
|     standard items that are    |                   |                |
|     adequate to meet the       |                   |                |
|     medical needs of the       |                   |                |
|     member.                    |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   DME-related supplies are   |                   |                |
|     provided in accordance     |                   |                |
|     with the Plan\'s DME       |                   |                |
|     formulary and its          |                   |                |
|     guidelines.                |                   |                |
|                                |                   |                |
| ######## DME-relate            |                   |                |
| d supplies for the treatment o |                   |                |
| f diabetes are covered under y |                   |                |
| our Prescription Drug benefit. |                   |                |
+--------------------------------+-------------------+----------------+
| ######## Home health services  | #########         |                |
+--------------------------------+-------------------+----------------+
| > If you are homebound and     | > Nothing         | > Nothing      |
| > reside in the service area:  |                   |                |
|                                |                   |                |
| -   You may receive home       |                   |                |
|     health services of nurses  |                   |                |
|     and health aides, physical |                   |                |
|     or occupational            |                   |                |
|     therapists, and speech and |                   |                |
|     language pathologists,     |                   |                |
|     when prescribed by your    |                   |                |
|     plan physician, who will   |                   |                |
|     periodically review the    |                   |                |
|     program for continuing     |                   |                |
|     appropriateness and need   |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   Services include oxygen    |                   |                |
|     therapy, intravenous       |                   |                |
|     therapy, and medications   |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Nursing care requested    |                   |                |
|     by, or for the convenience |                   |                |
|     of, the patient or the     |                   |                |
|     patient's family*          |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Home care primarily for   |                   |                |
|     personal assistance that   |                   |                |
|     does not include a medical |                   |                |
|     component and is not       |                   |                |
|     diagnostic, therapeutic,   |                   |                |
|     or rehabilitative*         |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Services outside our      |                   |                |
|     service area*              |                   |                |
+--------------------------------+-------------------+----------------+
| ######## Chiropractic          | ######### You pay | ###            |
|                                |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > Chiropractic services up to  | \$20 per office   | \$15 per       |
| > 20 visits per calendar year  | visit             | office visit   |
|                                |                   |                |
| -   Services include           |                   |                |
|     evaluation and management, |                   |                |
|     musculoskeletal            |                   |                |
|     treatments, physical       |                   |                |
|     therapy modalities such as |                   |                |
|     hot and cold packs, and    |                   |                |
|     X-rays                     |                   |                |
|                                |                   |                |
| ######## No                    |                   |                |
| te: You must choose the chirop |                   |                |
| ractor from our list of Partic |                   |                |
| ipating Chiropractors. Contact |                   |                |
|  us to get the list. You may s |                   |                |
| ee a chiropractor without refe |                   |                |
| rral from your Plan physician. |                   |                |
+--------------------------------+-------------------+----------------+
| ## Not covered:                | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Non-neuroskeletal         |                   |                |
|     disorders*                 |                   |                |
|                                |                   |                |
| -   *Vocational rehabilitation |                   |                |
|     services*                  |                   |                |
|                                |                   |                |
| -   *Laboratory services; MRI  |                   |                |
|     or other type of advanced  |                   |                |
|     diagnostic radiology*      |                   |                |
|                                |                   |                |
| ## Durable medical equipment o |                   |                |
| r supplies for use in the home |                   |                |
+--------------------------------+-------------------+----------------+
| #                              |                   |                |
| ####### Alternative treatments |                   |                |
+--------------------------------+-------------------+----------------+
| > No benefit                   | > *All charges*   | > *All         |
| >                              |                   | > charges*     |
| > Note: No coverage for any    |                   |                |
| > services such as             |                   |                |
| > acupuncture, naturopathic    |                   |                |
| > services, hypnotherapy.      |                   |                |
+--------------------------------+-------------------+----------------+
| ######## Ed                    | #########         |                |
| ucational classes and programs |                   |                |
+--------------------------------+-------------------+----------------+
| > No benefit                   | > *All charges*   | > *All         |
|                                |                   | > charges*     |
+--------------------------------+-------------------+----------------+

##  {#section-6 .StyleK2}

##  {#section-7 .StyleK2}

##  {#section-8 .StyleK2}

##  {#section-9 .StyleK2}

##  {#section-10 .StyleK2}

##  {#section-11 .StyleK2}

##  {#section-12 .StyleK2}

##  {#section-13 .StyleK2}

##  {#section-14 .StyleK2}

##  {#section-15 .StyleK2}

##  {#section-16 .StyleK2}

+---+---+---------------------------+-------------------+-----------+---+---+
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| S |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
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| o |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
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|   |   |                           |                   |           |   |   |
| 5 |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| ( |   |                           |                   |           |   |   |
| b |   |                           |                   |           |   |   |
| ) |   |                           |                   |           |   |   |
| . |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| S |   |                           |                   |           |   |   |
| u |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| g |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| l |   |                           |                   |           |   |   |
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| d |   |                           |                   |           |   |   |
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|   |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
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| s |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
| h |   |                           |                   |           |   |   |
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| s |   |                           |                   |           |   |   |
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| a |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| v |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| p |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| v |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| d |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| d |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| b |   |                           |                   |           |   |   |
| y |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| p |   |                           |                   |           |   |   |
| h |   |                           |                   |           |   |   |
| y |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| d |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
| h |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| h |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| l |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
| h |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| p |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| f |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| l |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| [ |   |                           |                   |           |   |   |
| ] |   |                           |                   |           |   |   |
| { |   |                           |                   |           |   |   |
| # |   |                           |                   |           |   |   |
| _ |   |                           |                   |           |   |   |
| _ |   |                           |                   |           |   |   |
| R |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| f |   |                           |                   |           |   |   |
| H |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| d |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| g |   |                           |                   |           |   |   |
| _ |   |                           |                   |           |   |   |
| _ |   |                           |                   |           |   |   |
| _ |   |                           |                   |           |   |   |
| T |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| 2 |   |                           |                   |           |   |   |
| 0 |   |                           |                   |           |   |   |
| 9 |   |                           |                   |           |   |   |
| 0 |   |                           |                   |           |   |   |
| 8 |   |                           |                   |           |   |   |
| 4 |   |                           |                   |           |   |   |
| 3 |   |                           |                   |           |   |   |
| 0 |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| . |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| h |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| } |   |                           |                   |           |   |   |
+---+---+---------------------------+-------------------+-----------+---+---+
|   | * | > **Here are some         |                   |           | * |   |
|   | * | > important things to     |                   |           | * |   |
|   | I | > keep in mind about      |                   |           | I |   |
|   | * | > these benefits:**       |                   |           | * |   |
|   | * |                           |                   |           | * |   |
|   |   | -   Please remember that  |                   |           |   |   |
|   | * |     all benefits are      |                   |           | * |   |
|   | * |     subject to the        |                   |           | * |   |
|   | M |     definitions,          |                   |           | M |   |
|   | * |     limitations, and      |                   |           | * |   |
|   | * |     exclusions in this    |                   |           | * |   |
|   |   |     brochure and we cover |                   |           |   |   |
|   | * |     them only when we     |                   |           | * |   |
|   | * |     determine they are    |                   |           | * |   |
|   | P |     medically necessary.  |                   |           | P |   |
|   | * |                           |                   |           | * |   |
|   | * | -   Plan physicians must  |                   |           | * |   |
|   |   |     provide or arrange    |                   |           |   |   |
|   | * |     your care.            |                   |           | * |   |
|   | * |                           |                   |           | * |   |
|   | O | -   We have no calendar   |                   |           | O |   |
|   | * |     year deductible.      |                   |           | * |   |
|   | * |                           |                   |           | * |   |
|   |   | -   Be sure to read       |                   |           |   |   |
|   | * |     Section 4, *Your      |                   |           | * |   |
|   | * |     costs for covered     |                   |           | * |   |
|   | R |     services*, for        |                   |           | R |   |
|   | * |     valuable information  |                   |           | * |   |
|   | * |     about how cost        |                   |           | * |   |
|   |   |     sharing works. Also   |                   |           |   |   |
|   | * |     read Section 9 about  |                   |           | * |   |
|   | * |     coordinating benefits |                   |           | * |   |
|   | T |     with other coverage,  |                   |           | T |   |
|   | * |     including with        |                   |           | * |   |
|   | * |     Medicare.             |                   |           | * |   |
|   |   |                           |                   |           |   |   |
|   | * | ```{=html}                |                   |           | * |   |
|   | * | <!-- -->                  |                   |           | * |   |
|   | A | ```                       |                   |           | A |   |
|   | * | -   The amounts listed    |                   |           | * |   |
|   | * |     below are for the     |                   |           | * |   |
|   |   |     charges billed by a   |                   |           |   |   |
|   | * |     physician or other    |                   |           | * |   |
|   | * |     health care           |                   |           | * |   |
|   | N |     professional for your |                   |           | N |   |
|   | * |     surgical care. Look   |                   |           | * |   |
|   | * |     in Section 5(c) for   |                   |           | * |   |
|   |   |     charges associated    |                   |           |   |   |
|   | * |     with the facility     |                   |           | * |   |
|   | * |     (i.e. hospital,       |                   |           | * |   |
|   | T |     surgical center,      |                   |           | T |   |
|   | * |     etc.).                |                   |           | * |   |
|   | * |                           |                   |           | * |   |
|   |   | -   YouR PHYSICIAN must   |                   |           |   |   |
|   |   |     get pre-authorization |                   |           |   |   |
|   |   |     for some surgical     |                   |           |   |   |
|   |   |     procedures. please    |                   |           |   |   |
|   |   |     refer to the          |                   |           |   |   |
|   |   |     pre-authorization     |                   |           |   |   |
|   |   |     shown in Section 3 to |                   |           |   |   |
|   |   |     be sure which         |                   |           |   |   |
|   |   |     services and          |                   |           |   |   |
|   |   |     surgeries require     |                   |           |   |   |
|   |   |     pre-authorization.    |                   |           |   |   |
+---+---+---------------------------+-------------------+-----------+---+---+
| > |   |                           | **You pay**       |           |   |   |
|   |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| B |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| f |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| D |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| p |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
+---+---+---------------------------+-------------------+-----------+---+---+
| > |   |                           | ######### You pay | ####      |   |   |
|   |   |                           |  -Standard Option | ##### You |   |   |
| * |   |                           |                   |  pay - Hi |   |   |
| * |   |                           |                   | gh Option |   |   |
| S |   |                           |                   |           |   |   |
| u |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| g |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| l |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| p |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| d |   |                           |                   |           |   |   |
| u |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
+---+---+---------------------------+-------------------+-----------+---+---+
| > |   |                           | > \$15 per office | > \$10    |   |   |
|   |   |                           | > visit for       | > per     |   |   |
| A |   |                           | > outpatient      | > office  |   |   |
| > |   |                           | > services        | > visit   |   |   |
|   |   |                           | >                 | > for     |   |   |
| c |   |                           | > Nothing for     | > o       |   |   |
| o |   |                           | > inpatient       | utpatient |   |   |
| m |   |                           | > services        | >         |   |   |
| p |   |                           |                   |  services |   |   |
| r |   |                           |                   | >         |   |   |
| e |   |                           |                   | > Nothing |   |   |
| h |   |                           |                   | > for     |   |   |
| e |   |                           |                   | >         |   |   |
| n |   |                           |                   | inpatient |   |   |
| s |   |                           |                   | >         |   |   |
| i |   |                           |                   |  services |   |   |
| v |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| g |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| f |   |                           |                   |           |   |   |
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|   |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| v |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| , |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| u |   |                           |                   |           |   |   |
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|   |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| : |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
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| c |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| d |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| v |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| f |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| v |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| g |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| f |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| m |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
+---+---+---------------------------+-------------------+-----------+---+---+

*Surgical procedures \-- continued on next page*

+--------------------------------+-------------------+----------------+
| > **Surgical procedures**      | ######### You pay | ###            |
| > *(continued)*                |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| -   Voluntary sterilization    | > \$15 per office | > \$10 per     |
|     (e.g., Tubal ligation,     | > visit for       | > office visit |
|     Vasectomy)                 | > outpatient      | > for          |
|                                | > services        | > outpatient   |
| -   Surgically implanted       | >                 | > services     |
|     time-release               | > Nothing for     | >              |
|     contraceptives and         | > inpatient       | > Nothing for  |
|     intrauterine devices       | > services        | > inpatient    |
|     (IUDs)                     |                   | > services     |
|                                |                   |                |
| -   Other implanted            |                   |                |
|     time-release drugs         |                   |                |
|                                |                   |                |
| > Note: In addition to the     |                   |                |
| > office visit copayment, we   |                   |                |
| > charge the prescription drug |                   |                |
| > copayment for the drug or    |                   |                |
| > device.                      |                   |                |
|                                |                   |                |
| -   Treatment of burns         |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Reversal of voluntary     |                   |                |
|     sterilization*             |                   |                |
+--------------------------------+-------------------+----------------+
| > **Reconstructive surgery**   |                   |                |
+--------------------------------+-------------------+----------------+
| -   Surgery to correct a       | > \$15 per office | > \$10 per     |
|     functional defect          | > visit for       | > office visit |
|                                | > outpatient      | > for          |
| ```{=html}                     | > services        | > outpatient   |
| <!-- -->                       | >                 | > services     |
| ```                            | > Nothing for     | >              |
| -   Surgery to correct a       | > inpatient       | > Nothing for  |
|     condition caused by injury | > services        | > inpatient    |
|     or illness if:             |                   | > services     |
|                                |                   |                |
| > the condition produced a     |                   |                |
| > major effect on the member's |                   |                |
| > appearance; and              |                   |                |
| >                              |                   |                |
| > the condition can reasonably |                   |                |
| > be expected to be corrected  |                   |                |
| > by such surgery.             |                   |                |
|                                |                   |                |
| -   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,         |                   |                |
|     birthmarks, webbed         |                   |                |
|     fingers, and webbed toes.  |                   |                |
+--------------------------------+-------------------+----------------+
| -   All stages of breast       | > Nothing         | > Nothing      |
|     reconstruction surgery     |                   |                |
|     following a mastectomy,    |                   |                |
|     such as:                   |                   |                |
|                                |                   |                |
| > 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 covered at no   |                   |                |
| > charge (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.         |                   |                |
+--------------------------------+-------------------+----------------+

*Reconstructive surgery \-- continued on next page*

+--------------------------------+-------------------+----------------+
| > **Reconstructive surgery**   | ######### You pay | ###            |
| > *(continued)*                |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Cosmetic surgery -- any   |                   |                |
|     surgical procedure (or any |                   |                |
|     portion of a procedure)    |                   |                |
|     performed primarily to     |                   |                |
|     improve physical           |                   |                |
|     appearance through change  |                   |                |
|     in bodily form*            |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Surgeries related to sex  |                   |                |
|     transformation*            |                   |                |
+--------------------------------+-------------------+----------------+
| > **Oral and maxillofacial     |                   | #########      |
| > surgery**                    |                   |                |
+--------------------------------+-------------------+----------------+
| > Oral surgical procedures,    | > \$15 per office | > \$10 per     |
| > limited to:                  | > visit for       | > office visit |
|                                | > outpatient      | > for          |
| -   Reduction of fractures of  | > services        | > outpatient   |
|     the jaws or facial bones   | >                 | > services     |
|                                | > Nothing for     | >              |
| -   Surgical correction of     | > inpatient       | > Nothing for  |
|     cleft lip, cleft palate,   | > services        | > inpatient    |
|     or severe functional       |                   | > services     |
|     malocclusion               |                   |                |
|                                |                   |                |
| -   Removal of stones from     |                   |                |
|     salivary ducts             |                   |                |
|                                |                   |                |
| -   Excision of leukoplakia or |                   |                |
|     malignancies               |                   |                |
|                                |                   |                |
| -   Excision of cysts and      |                   |                |
|     incision of abscesses when |                   |                |
|     done as independent        |                   |                |
|     procedures                 |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   Other surgical procedures  |                   |                |
|     that do not involve the    |                   |                |
|     teeth or their supporting  |                   |                |
|     structures                 |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Oral implants and         |                   |                |
|     transplants*               |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Procedures that involve   |                   |                |
|     the teeth or their         |                   |                |
|     supporting structures      |                   |                |
|     (such as the periodontal   |                   |                |
|     membrane, gingiva, and     |                   |                |
|     alveolar bone)*            |                   |                |
+--------------------------------+-------------------+----------------+

+--------------------------------+-------------------+----------------+
| > **Organ/tissue transplants** | ######### You pay | ###            |
|                                |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > Limited to:                  | > \$15 per office | > \$10 per     |
|                                | > visit for       | > office visit |
| -   Cornea                     | > outpatient      | > for          |
|                                | > services        | > outpatient   |
| -   Heart                      | >                 | > services     |
|                                | > Nothing for     | >              |
| -   Heart/Lung                 | > inpatient       | > Nothing for  |
|                                | > services        | > inpatient    |
| -   Kidney                     |                   | > services     |
|                                |                   |                |
| -   Kidney/Pancreas            |                   |                |
|                                |                   |                |
| -   Liver                      |                   |                |
|                                |                   |                |
| -   Lung: Single -- Double     |                   |                |
|                                |                   |                |
| -   Pancreas                   |                   |                |
|                                |                   |                |
| -   Stem cell                  |                   |                |
|                                |                   |                |
| -   Autologous tandem          |                   |                |
|                                |                   |                |
| -   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                   |                   |                |
|                                |                   |                |
| > Note: We cover related       |                   |                |
| > medical and hospital         |                   |                |
| > expenses of the donor when   |                   |                |
| > we cover your transplant.    |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Donor screening tests and |                   |                |
|     donor search expenses,     |                   |                |
|     except those performed for |                   |                |
|     the actual donor*          |                   |                |
|                                |                   |                |
| -   *Implants of non-human or  |                   |                |
|     artificial organs*         |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Transplants not listed as |                   |                |
|     covered*                   |                   |                |
+--------------------------------+-------------------+----------------+

+--------------------------------+-------------------+----------------+
| **Anesthesia**                 | ######### You pay | ###            |
|                                |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > Professional services        | > Nothing         | > Nothing      |
| > provided in:                 |                   |                |
|                                |                   |                |
| -   Hospital (inpatient)       |                   |                |
|                                |                   |                |
| -   Hospital outpatient        |                   |                |
|     department                 |                   |                |
|                                |                   |                |
| -   Ambulatory surgical center |                   |                |
|                                |                   |                |
| -   Office                     |                   |                |
+--------------------------------+-------------------+----------------+

+---+---+---------------------------+-------------------+--------+---+---+
| > |   |                           |                   |        |   |   |
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| [ |   |                           |                   |        |   |   |
| ] |   |                           |                   |        |   |   |
| { |   |                           |                   |        |   |   |
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| 8 |   |                           |                   |        |   |   |
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| 3 |   |                           |                   |        |   |   |
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| > |   |                           |                   |        |   |   |
|   |   |                           |                   |        |   |   |
| . |   |                           |                   |        |   |   |
| a |   |                           |                   |        |   |   |
| n |   |                           |                   |        |   |   |
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| r |   |                           |                   |        |   |   |
| } |   |                           |                   |        |   |   |
+---+---+---------------------------+-------------------+--------+---+---+
|   | * | > **Here are some         |                   |        | * |   |
|   | * | > important things to     |                   |        | * |   |
|   | I | > keep in mind about      |                   |        | I |   |
|   | * | > these benefits:**       |                   |        | * |   |
|   | * |                           |                   |        | * |   |
|   |   | -   Please remember that  |                   |        |   |   |
|   | * |     all benefits are      |                   |        | * |   |
|   | * |     subject to the        |                   |        | * |   |
|   | M |     definitions,          |                   |        | M |   |
|   | * |     limitations, and      |                   |        | * |   |
|   | * |     exclusions in this    |                   |        | * |   |
|   |   |     brochure and we cover |                   |        |   |   |
|   | * |     them only when we     |                   |        | * |   |
|   | * |     determine they are    |                   |        | * |   |
|   | P |     medically necessary.  |                   |        | P |   |
|   | * |                           |                   |        | * |   |
|   | * | -   Plan physicians must  |                   |        | * |   |
|   |   |     provide or arrange    |                   |        |   |   |
|   | * |     your care and you     |                   |        | * |   |
|   | * |     must be hospitalized  |                   |        | * |   |
|   | O |     in a Plan facility.   |                   |        | O |   |
|   | * |                           |                   |        | * |   |
|   | * | -   We have no calendar   |                   |        | * |   |
|   |   |     year deductible.      |                   |        |   |   |
|   | * |                           |                   |        | * |   |
|   | * | -   Be sure to read       |                   |        | * |   |
|   | R |     Section 4, *Your      |                   |        | R |   |
|   | * |     costs for covered     |                   |        | * |   |
|   | * |     services*, for        |                   |        | * |   |
|   |   |     valuable information  |                   |        |   |   |
|   | * |     about how cost        |                   |        | * |   |
|   | * |     sharing works. Also   |                   |        | * |   |
|   | T |     read Section 9 about  |                   |        | T |   |
|   | * |     coordinating benefits |                   |        | * |   |
|   | * |     with other coverage,  |                   |        | * |   |
|   |   |     including with        |                   |        |   |   |
|   | * |     Medicare.             |                   |        | * |   |
|   | * |                           |                   |        | * |   |
|   | A | ```{=html}                |                   |        | A |   |
|   | * | <!-- -->                  |                   |        | * |   |
|   | * | ```                       |                   |        | * |   |
|   |   | -   The amounts listed    |                   |        |   |   |
|   | * |     below are for the     |                   |        | * |   |
|   | * |     charges billed by the |                   |        | * |   |
|   | N |     facility (i.e.,       |                   |        | N |   |
|   | * |     hospital or surgical  |                   |        | * |   |
|   | * |     center) or ambulance  |                   |        | * |   |
|   |   |     service for your      |                   |        |   |   |
|   | * |     surgery or care. Any  |                   |        | * |   |
|   | * |     costs associated with |                   |        | * |   |
|   | T |     the professional      |                   |        | T |   |
|   | * |     charge (i.e.,         |                   |        | * |   |
|   | * |     physicians, etc.) are |                   |        | * |   |
|   |   |     covered in Section    |                   |        |   |   |
|   |   |     5(a) or (b).          |                   |        |   |   |
+---+---+---------------------------+-------------------+--------+---+---+
| > |   |                           | **You pay**       |        |   |   |
|   |   |                           |                   |        |   |   |
| * |   |                           |                   |        |   |   |
| * |   |                           |                   |        |   |   |
| B |   |                           |                   |        |   |   |
| e |   |                           |                   |        |   |   |
| n |   |                           |                   |        |   |   |
| e |   |                           |                   |        |   |   |
| f |   |                           |                   |        |   |   |
| i |   |                           |                   |        |   |   |
| t |   |                           |                   |        |   |   |
| > |   |                           |                   |        |   |   |
|   |   |                           |                   |        |   |   |
| D |   |                           |                   |        |   |   |
| e |   |                           |                   |        |   |   |
| s |   |                           |                   |        |   |   |
| c |   |                           |                   |        |   |   |
| r |   |                           |                   |        |   |   |
| i |   |                           |                   |        |   |   |
| p |   |                           |                   |        |   |   |
| t |   |                           |                   |        |   |   |
| i |   |                           |                   |        |   |   |
| o |   |                           |                   |        |   |   |
| n |   |                           |                   |        |   |   |
| * |   |                           |                   |        |   |   |
| * |   |                           |                   |        |   |   |
+---+---+---------------------------+-------------------+--------+---+---+
| # |   |                           | ######### You pay | #      |   |   |
| # |   |                           |  -Standard Option | ###### |   |   |
| # |   |                           |                   | ## You |   |   |
| # |   |                           |                   |  pay - |   |   |
| # |   |                           |                   |  High  |   |   |
| # |   |                           |                   | Option |   |   |
| # |   |                           |                   |        |   |   |
| # |   |                           |                   |        |   |   |
|   |   |                           |                   |        |   |   |
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| t |   |                           |                   |        |   |   |
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| n |   |                           |                   |        |   |   |
| t |   |                           |                   |        |   |   |
|   |   |                           |                   |        |   |   |
| h |   |                           |                   |        |   |   |
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| s |   |                           |                   |        |   |   |
| p |   |                           |                   |        |   |   |
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| t |   |                           |                   |        |   |   |
| a |   |                           |                   |        |   |   |
| l |   |                           |                   |        |   |   |
+---+---+---------------------------+-------------------+--------+---+---+
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| t |   |                           |                   |        |   |   |
| e |   |                           |                   |        |   |   |
| . |   |                           |                   |        |   |   |
+---+---+---------------------------+-------------------+--------+---+---+

Inpatient hospital \-- continued on next page

+--------------------------------+-------------------+----------------+
| ######## In                    | ######### You pay | ###            |
| patient hospital *(continued)* |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| #### Other hospital s          | > Nothing         | > Nothing      |
| ervices and supplies, such 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      |                   |                |
|                                |                   |                |
| -   Pre-surgical testing       |                   |                |
|                                |                   |                |
| -   Costs associated with      |                   |                |
|     blood donated by you for a |                   |                |
|     scheduled covered surgery  |                   |                |
|                                |                   |                |
| -   Dressings, splints, casts, |                   |                |
|     and sterile tray services  |                   |                |
|                                |                   |                |
| -   Medical supplies and       |                   |                |
|     equipment, including       |                   |                |
|     oxygen                     |                   |                |
|                                |                   |                |
| -   Anesthetics, including     |                   |                |
|     nurse anesthetist services |                   |                |
|                                |                   |                |
| -   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*   | > *All         |
|                                |                   | > charges*     |
| -   *Custodial care*           |                   |                |
|                                |                   |                |
| -   *Non-covered facilities*   |                   |                |
|                                |                   |                |
| -   *Personal comfort items,   |                   |                |
|     such as telephone,         |                   |                |
|     television, barber         |                   |                |
|     services, guest meals and  |                   |                |
|     beds*                      |                   |                |
|                                |                   |                |
| -   *Private nursing care*     |                   |                |
|                                |                   |                |
| -   *Cord blood procurement    |                   |                |
|     and storage for possible   |                   |                |
|     future need or for a       |                   |                |
|     yet-to-be determined       |                   |                |
|     member recipient*          |                   |                |
|                                |                   |                |
| -   *Any inpatient dental      |                   |                |
|     procedures*                |                   |                |
+--------------------------------+-------------------+----------------+
| #### **Outpatient hospital o   | ######### You pay | ###            |
| r ambulatory surgical center** |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| -   Operating, recovery, and   | > Nothing         | > Nothing      |
|     other treatment rooms      |                   |                |
|                                |                   |                |
| -   Prescribed drugs and       |                   |                |
|     medicines                  |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   Diagnostic laboratory      |                   |                |
|     tests, X-rays, and         |                   |                |
|     pathology services         |                   |                |
|                                |                   |                |
| -   Administration of blood,   |                   |                |
|     and blood products         |                   |                |
|                                |                   |                |
| -   Blood and blood plasma     |                   |                |
|                                |                   |                |
| -   Costs associated with      |                   |                |
|     blood donated by you for a |                   |                |
|     scheduled covered surgery  |                   |                |
|                                |                   |                |
| -   Dressings, casts, and      |                   |                |
|     sterile tray services      |                   |                |
|                                |                   |                |
| -   Medical supplies           |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   Anesthetics and anesthesia |                   |                |
|     service                    |                   |                |
|                                |                   |                |
| > Note: Your regular           |                   |                |
| > prescription drug copayment  |                   |                |
| > will apply for prescriptions |                   |                |
| > purchased at Plan            |                   |                |
| > pharmacies.                  |                   |                |
+--------------------------------+-------------------+----------------+
| ## *Not cover                  | > *All charges*   | > *All         |
| ed:* {#not-covered-1 .StyleK2} |                   | > charges*     |
|                                |                   |                |
| ## *                           |                   |                |
| Collection, processing, and st |                   |                |
| orage of blood donated by dono |                   |                |
| rs designated by you or a fami |                   |                |
| ly member* {#collection-proces |                   |                |
| sing-and-storage-of-blood-dona |                   |                |
| ted-by-donors-designated-by-yo |                   |                |
| u-or-a-family-member .StyleK2} |                   |                |
|                                |                   |                |
| ## *Cord blood procu           |                   |                |
| rement and storage for possibl |                   |                |
| e future need of for a yet-to- |                   |                |
| be determined member recipient |                   |                |
| * {#cord-blood-procurement-and |                   |                |
| -storage-for-possible-future-n |                   |                |
| eed-of-for-a-yet-to-be-determi |                   |                |
| ned-member-recipient .StyleK2} |                   |                |
+--------------------------------+-------------------+----------------+
| ########                       |                   |                |
|  Skilled nursing care benefits |                   |                |
+--------------------------------+-------------------+----------------+
| > Up to 100 days per calendar  | > Nothing         | Nothing        |
| > year when full-time skilled  |                   |                |
| > nursing care is necessary    |                   |                |
| > and confinement in a skilled |                   |                |
| > nursing facility is          |                   |                |
| > medically appropriate. We    |                   |                |
| > cover the following:         |                   |                |
|                                |                   |                |
| -   Room, 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*   | *All charges*  |
|                                |                   |                |
| -   *Custodial care*           |                   |                |
|                                |                   |                |
| -   *Care in an intermediate   |                   |                |
|     care facility*             |                   |                |
|                                |                   |                |
| -   *Personal comfort items    |                   |                |
|     such as telephone or       |                   |                |
|     television*                |                   |                |
+--------------------------------+-------------------+----------------+
| #### **Hospice care**          | ######### You pay | ###            |
|                                |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > Supportive and palliative    | > Nothing         | > Nothing      |
| > care for a 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 six 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.    |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Private duty nursing      |                   |                |
|     (independent nursing)*     |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Homemaker services*       |                   |                |
+--------------------------------+-------------------+----------------+
| ######## Ambulance             |                   |                |
+--------------------------------+-------------------+----------------+
| -   Local professional         | > \$75 per        | > \$75 per     |
|     ambulance service when     | > transport       | > transport    |
|     medically appropriate      |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Transports that we        |                   |                |
|     determine are not          |                   |                |
|     medically necessary*       |                   |                |
+--------------------------------+-------------------+----------------+

+---+---+-----------------------------------------------------------+---+---+
| # |   |                                                           |   |   |
| # |   |                                                           |   |   |
| # |   |                                                           |   |   |
| # |   |                                                           |   |   |
| # |   |                                                           |   |   |
|   |   |                                                           |   |   |
| S |   |                                                           |   |   |
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| n |   |                                                           |   |   |
|   |   |                                                           |   |   |
| 5 |   |                                                           |   |   |
|   |   |                                                           |   |   |
| ( |   |                                                           |   |   |
| d |   |                                                           |   |   |
| ) |   |                                                           |   |   |
| . |   |                                                           |   |   |
|   |   |                                                           |   |   |
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| m |   |                                                           |   |   |
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| r |   |                                                           |   |   |
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| n |   |                                                           |   |   |
| c |   |                                                           |   |   |
| y |   |                                                           |   |   |
|   |   |                                                           |   |   |
| s |   |                                                           |   |   |
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| r |   |                                                           |   |   |
| v |   |                                                           |   |   |
| i |   |                                                           |   |   |
| c |   |                                                           |   |   |
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| s |   |                                                           |   |   |
| / |   |                                                           |   |   |
| a |   |                                                           |   |   |
| c |   |                                                           |   |   |
| c |   |                                                           |   |   |
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| d |   |                                                           |   |   |
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| n |   |                                                           |   |   |
| t |   |                                                           |   |   |
| s |   |                                                           |   |   |
+---+---+-----------------------------------------------------------+---+---+
|   | * | > **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 coverage, including with          | * |   |
|   | P |     Medicare.                                             | P |   |
|   | * |                                                           | * |   |
|   | * | #####                                                     | * |   |
|   |   |                                                           |   |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   | O |                                                           | O |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   |   |                                                           |   |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   | R |                                                           | R |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   |   |                                                           |   |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   | T |                                                           | T |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   |   |                                                           |   |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   | A |                                                           | A |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   |   |                                                           |   |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
|   | N |                                                           | N |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
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|   | * |                                                           | * |   |
|   | T |                                                           | T |   |
|   | * |                                                           | * |   |
|   | * |                                                           | * |   |
+---+---+-----------------------------------------------------------+---+---+
| > |   |                                                           |   |   |
|   |   |                                                           |   |   |
| * |   |                                                           |   |   |
| * |   |                                                           |   |   |
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| . |   |                                                           |   |   |
+---+---+-----------------------------------------------------------+---+---+

*Emergency within our service area \-- begins on next page*

+--------------------------------+-------------------+----------------+
| > **Benefit Description**      | **You pay**       |                |
+--------------------------------+-------------------+----------------+
| > **Emergency within our       | ######### You pay | ###            |
| > service area**               |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > Emergency care as an         |                   |                |
| > outpatient or inpatient at a |                   |                |
| > hospital, including          |                   |                |
| > physicians\' services        |                   |                |
+--------------------------------+-------------------+----------------+
| -   At a physician\'s office   | > \$15 per visit  | > \$10 per     |
|                                |                   | > visit        |
+--------------------------------+-------------------+----------------+
| -   At a Plan urgent care      | > \$15 per visit  | > \$10 per     |
|     center                     |                   | > visit        |
+--------------------------------+-------------------+----------------+
| -   In a Plan hospital         | > \$75 per visit  | > \$75 per     |
|     emergency room             |                   | > visit        |
+--------------------------------+-------------------+----------------+
| > Notes:                       |                   |                |
|                                |                   |                |
| -   We waive your copayment if |                   |                |
|     you are directly admitted  |                   |                |
|     to a Plan hospital from    |                   |                |
|     the emergency room.        |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   If you are transferred     |                   |                |
|     from emergency department  |                   |                |
|     care to an observation     |                   |                |
|     bed, there is no           |                   |                |
|     additional copayment.      |                   |                |
|                                |                   |                |
| -   If you are directly        |                   |                |
|     admitted as an inpatient   |                   |                |
|     after being seen in an     |                   |                |
|     emergency department or    |                   |                |
|     from an observation bed,   |                   |                |
|     your emergency visit       |                   |                |
|     copayment will be waived   |                   |                |
|     and your inpatient copay   |                   |                |
|     will apply.                |                   |                |
+--------------------------------+-------------------+----------------+
| > Emergency care in a non-Plan | > \$75 per visit  | > \$75 per     |
| > hospital emergency room or   |                   | > visit        |
| > urgent care center           |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Elective care or          |                   |                |
|     non-emergency care*        |                   |                |
+--------------------------------+-------------------+----------------+
| ######## Emer                  |                   |                |
| gency outside our service area |                   |                |
+--------------------------------+-------------------+----------------+
| > Emergency care as an         |                   |                |
| > outpatient or inpatient at a |                   |                |
| > hospital, including          |                   |                |
| > physicians\' services        |                   |                |
+--------------------------------+-------------------+----------------+
| -   At a physician\'s office   | > \$15 per visit  | > \$10 per     |
|                                |                   | > visit        |
+--------------------------------+-------------------+----------------+
| -   At an urgent care center   | > \$15 per visit  | > \$10 per     |
|                                |                   | > visit        |
+--------------------------------+-------------------+----------------+
| -   In a hospital emergency    | > \$75 per visit  | > \$75 per     |
|     room                       |                   | > visit        |
+--------------------------------+-------------------+----------------+
| -   In a Kaiser Foundation     | > The amount you  | > The amount   |
|     hospital in another Kaiser | > would be        | > you would be |
|     Foundation Health Plan     | > charged if you  | > charged if   |
|     service area               | > were a member   | > you were a   |
|                                | > in that service | > member in    |
|                                | > area            | > that service |
|                                |                   | > area         |
+--------------------------------+-------------------+----------------+

*Emergency outside our service area \-- continues on next page*

+--------------------------------+-------------------+----------------+
| ######## Emergency outside     | **You pay         | **You pay -    |
| our service area *(continued)* | -Standard         | High Option**  |
|                                | Option**          |                |
+--------------------------------+-------------------+----------------+
| > Notes:                       |                   |                |
|                                |                   |                |
| -   We waive your copayment if |                   |                |
|     you are directly admitted  |                   |                |
|     to a hospital from ER.     |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   If you are transferred     |                   |                |
|     from emergency department  |                   |                |
|     care to an observation     |                   |                |
|     bed, there is no           |                   |                |
|     additional copayment.      |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   If you are directly        |                   |                |
|     admitted as an inpatient   |                   |                |
|     after being seen in an     |                   |                |
|     emergency department or    |                   |                |
|     from an observation bed,   |                   |                |
|     your emergency visit       |                   |                |
|     copayment will be waived   |                   |                |
|     and your inpatient copay   |                   |                |
|     will apply.                |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   See the Travel Benefit for |                   |                |
|     coverage of continuing or  |                   |                |
|     follow-up care.            |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Elective care or          |                   |                |
|     non-emergency care*        |                   |                |
|                                |                   |                |
| -   *Emergency care provided   |                   |                |
|     outside the service area   |                   |                |
|     if the need for care could |                   |                |
|     have been foreseen before  |                   |                |
|     leaving the service area*  |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Medical and hospital      |                   |                |
|     costs resulting from a     |                   |                |
|     normal full-term delivery  |                   |                |
|     of a baby outside the      |                   |                |
|     service area*              |                   |                |
+--------------------------------+-------------------+----------------+
| > **Ambulance**                | #########         | #########      |
+--------------------------------+-------------------+----------------+
| > Professional ambulance       | > \$75 per        | > \$75 per     |
| > service, including air       | > transport       | > transport    |
| > ambulance, when medically    |                   |                |
| > appropriate. See Section     |                   |                |
| > 5(c) for non-emergency       |                   |                |
| > service.                     |                   |                |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Transports we determine   |                   |                |
|     are not medically          |                   |                |
|     necessary*                 |                   |                |
+--------------------------------+-------------------+----------------+

+---+---+---------------------------+-------------------+-----------+---+---+
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| S |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| 5 |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| ( |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| ) |   |                           |                   |           |   |   |
| . |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| M |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| l |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| h |   |                           |                   |           |   |   |
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| ] |   |                           |                   |           |   |   |
| { |   |                           |                   |           |   |   |
| # |   |                           |                   |           |   |   |
| _ |   |                           |                   |           |   |   |
| _ |   |                           |                   |           |   |   |
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| T |   |                           |                   |           |   |   |
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| c |   |                           |                   |           |   |   |
| 2 |   |                           |                   |           |   |   |
| 0 |   |                           |                   |           |   |   |
| 9 |   |                           |                   |           |   |   |
| 0 |   |                           |                   |           |   |   |
| 8 |   |                           |                   |           |   |   |
| 4 |   |                           |                   |           |   |   |
| 3 |   |                           |                   |           |   |   |
| 3 |   |                           |                   |           |   |   |
| > |   |                           |                   |           |   |   |
|   |   |                           |                   |           |   |   |
| . |   |                           |                   |           |   |   |
| a |   |                           |                   |           |   |   |
| n |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| h |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| } |   |                           |                   |           |   |   |
+---+---+---------------------------+-------------------+-----------+---+---+
|   | * | > When you get our        |                   |           | * | # |
|   | * | > approval for services   |                   |           | * | # |
|   | I | > and follow a treatment  |                   |           | I | # |
|   | * | > plan we approve,        |                   |           | * | # |
|   | * | > cost-sharing and        |                   |           | * | # |
|   |   | > limitations for Plan    |                   |           |   |   |
|   | * | > mental health and       |                   |           | * |   |
|   | * | > substance abuse         |                   |           | * |   |
|   | M | > benefits will be no     |                   |           | M |   |
|   | * | > greater than for        |                   |           | * |   |
|   | * | > similar benefits for    |                   |           | * |   |
|   |   | > other illnesses and     |                   |           |   |   |
|   | * | > conditions.             |                   |           | * |   |
|   | * | >                         |                   |           | * |   |
|   | P | > **Here are some         |                   |           | P |   |
|   | * | > important things to     |                   |           | * |   |
|   | * | > keep in mind about      |                   |           | * |   |
|   |   | > these benefits:**       |                   |           |   |   |
|   | * |                           |                   |           | * |   |
|   | * | -   Please remember that  |                   |           | * |   |
|   | O |     all benefits are      |                   |           | O |   |
|   | * |     subject to the        |                   |           | * |   |
|   | * |     definitions,          |                   |           | * |   |
|   |   |     limitations, and      |                   |           |   |   |
|   | * |     exclusions in this    |                   |           | * |   |
|   | * |     brochure and we cover |                   |           | * |   |
|   | R |     them only when we     |                   |           | R |   |
|   | * |     determine they are    |                   |           | * |   |
|   | * |     clinically            |                   |           | * |   |
|   |   |     appropriate to treat  |                   |           |   |   |
|   | * |     your condition.       |                   |           | * |   |
|   | * |                           |                   |           | * |   |
|   | T | ```{=html}                |                   |           | T |   |
|   | * | <!-- -->                  |                   |           | * |   |
|   | * | ```                       |                   |           | * |   |
|   |   | -   Plan physicians must  |                   |           |   |   |
|   | * |     provide or arrange    |                   |           | * |   |
|   | * |     your care.            |                   |           | * |   |
|   | A |                           |                   |           | A |   |
|   | * | ```{=html}                |                   |           | * |   |
|   | * | <!-- -->                  |                   |           | * |   |
|   |   | ```                       |                   |           |   |   |
|   | * | -   We have no calendar   |                   |           | * |   |
|   | * |     year deductible.      |                   |           | * |   |
|   | N |                           |                   |           | N |   |
|   | * | ##### Be sure to          |                   |           | * |   |
|   | * |  read Section 4, *Your co |                   |           | * |   |
|   |   | sts for covered services, |                   |           |   |   |
|   | * | * for valuable informatio |                   |           | * |   |
|   | * | n about how cost sharing  |                   |           | * |   |
|   | T | works. Also read Section  |                   |           | T |   |
|   | * | 9 about coordinating bene |                   |           | * |   |
|   | * | fits with other coverage, |                   |           | * |   |
|   |   |  including with Medicare. |                   |           |   |   |
+---+---+---------------------------+-------------------+-----------+---+---+
| * |   |                           | **You pay**       |           |   |   |
| * |   |                           |                   |           |   |   |
| B |   |                           |                   |           |   |   |
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| n |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| f |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
| D |   |                           |                   |           |   |   |
| e |   |                           |                   |           |   |   |
| s |   |                           |                   |           |   |   |
| c |   |                           |                   |           |   |   |
| r |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
| p |   |                           |                   |           |   |   |
| t |   |                           |                   |           |   |   |
| i |   |                           |                   |           |   |   |
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| n |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
+---+---+---------------------------+-------------------+-----------+---+---+
| > |   |                           | ######### You pay | ####      |   |   |
|   |   |                           |  -Standard Option | ##### You |   |   |
| * |   |                           |                   |  pay - Hi |   |   |
| * |   |                           |                   | gh Option |   |   |
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|   |   |                           |                   |           |   |   |
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| * |   |                           |                   |           |   |   |
| * |   |                           |                   |           |   |   |
+---+---+---------------------------+-------------------+-----------+---+---+
| > |   |                           | > Your cost       | > Your    |   |   |
|   |   |                           | > sharing         | > cost    |   |   |
| W |   |                           | >                 | > sharing |   |   |
| e |   |                           |  responsibilities | > respons |   |   |
| > |   |                           | > are no greater  | ibilities |   |   |
|   |   |                           | > than for other  | > are no  |   |   |
| c |   |                           | > illnesses or    | > greater |   |   |
| o |   |                           | > conditions      | > than    |   |   |
| v |   |                           |                   | > for     |   |   |
| e |   |                           |                   | > other   |   |   |
| r |   |                           |                   | >         |   |   |
| > |   |                           |                   | illnesses |   |   |
|   |   |                           |                   | > or      |   |   |
| a |   |                           |                   | > c       |   |   |
| l |   |                           |                   | onditions |   |   |
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|   |   |                           |                   |           |   |   |
| o |   |                           |                   |           |   |   |
| f |   |                           |                   |           |   |   |
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|   |   |                           |                   |           |   |   |
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| r |   |                           |                   |           |   |   |
| . |   |                           |                   |           |   |   |
+---+---+---------------------------+-------------------+-----------+---+---+

*Mental health and substance abuse benefits \-- continued on next page*

+--------------------------------+-------------------+----------------+
| > **Mental health and          | ######### You pay | ###            |
| > substance abuse benefits**   |  -Standard Option | ###### You pay |
| > *(continued)*                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| ## Diagnosis and               | > \$15 per        | > \$10 per     |
|  treatment of psychiatric diso | > individual      | > individual   |
| rders, mental illness or disor | > therapy office  | > therapy      |
| ders of children, adolescents, | > visit           | > office visit |
|  and adults. Services include: | >                 | >              |
|                                | > \$7 per group   | > \$5 per      |
| -   Diagnostic evaluation      | > therapy office  | > group        |
|                                | > visit           | > therapy      |
| -   Treatment services         |                   | > office visit |
|     (including individual and  |                   |                |
|     group therapy visits)      |                   |                |
|                                |                   |                |
| -   Crisis intervention and    |                   |                |
|     stabilization for acute    |                   |                |
|     episodes                   |                   |                |
|                                |                   |                |
| -   Psychological testing      |                   |                |
|     necessary to determine the |                   |                |
|     appropriate psychiatric    |                   |                |
|     treatment                  |                   |                |
|                                |                   |                |
| -   Medication evaluation and  |                   |                |
|     management                 |                   |                |
|                                |                   |                |
| > Diagnosis and treatment of   |                   |                |
| > chemical dependency.         |                   |                |
| > Services include:            |                   |                |
|                                |                   |                |
| # Detoxification (medical ma   |                   |                |
| nagement of withdrawal from th |                   |                |
| e substance) {#detoxification- |                   |                |
| medical-management-of-withdraw |                   |                |
| al-from-the-substance .StyleK} |                   |                |
|                                |                   |                |
| -   Treatment and counseling   |                   |                |
|     (including individual and  |                   |                |
|     group therapy visits)      |                   |                |
|                                |                   |                |
| > Notes:                       |                   |                |
|                                |                   |                |
| -   Your mental health or      |                   |                |
|     substance abuse provider   |                   |                |
|     will develop a treatment   |                   |                |
|     plan to assist you in      |                   |                |
|     improving or maintaining   |                   |                |
|     your condition and         |                   |                |
|     functional level, or to    |                   |                |
|     prevent relapse.           |                   |                |
|                                |                   |                |
| ## You may                     |                   |                |
| see a Plan outpatient mental h |                   |                |
| ealth or chemical dependency p |                   |                |
| rovider without a referral fro |                   |                |
| m your primary care physician. |                   |                |
+--------------------------------+-------------------+----------------+
| -   Inpatient psychiatric care | > Nothing         | > Nothing      |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   Inpatient care             |                   |                |
|                                |                   |                |
| -   Residential treatment      |                   |                |
|                                |                   |                |
| ## Note:                       |                   |                |
|  All inpatient admissions and  |                   |                |
| hospital alternative services  |                   |                |
| treatment programs require pre |                   |                |
| -approval by a Plan physician. |                   |                |
+--------------------------------+-------------------+----------------+
| -   Intensive outpatient       | > \$50 per day up | > \$50 per day |
|     psychiatric treatment      | > to a maximum of | > up to a      |
|     programs                   | > \$250 per       | > maximum of   |
|                                | > episode or      | > \$250 per    |
| > Note: These services must be | > course of       | > episode or   |
| > pre-approved by a Plan       | > treatment       | > course of    |
| > physician.                   |                   | > treatment    |
+--------------------------------+-------------------+----------------+

*Mental health and substance abuse benefits \-- continued on next page*

+--------------------------------+-------------------+----------------+
| > **Mental health and          | ######### You pay | ###            |
| > substance abuse benefits**   |  -Standard Option | ###### You pay |
| > *(continued)*                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | > *All         |
|                                |                   | > charges*     |
| -   *Care that is not          |                   |                |
|     clinically appropriate for |                   |                |
|     the treatment of your      |                   |                |
|     condition*                 |                   |                |
|                                |                   |                |
| -   *Services we have not      |                   |                |
|     approved*                  |                   |                |
|                                |                   |                |
| -   *Intelligence, IQ,         |                   |                |
|     aptitude ability, 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*       |                   |                |
|                                |                   |                |
| -   *Marital, family, or       |                   |                |
|     educational services*      |                   |                |
|                                |                   |                |
| -   *Services rendered or      |                   |                |
|     billed by a school or a    |                   |                |
|     member of its staff*       |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Services provided under a |                   |                |
|     federal, state, or local   |                   |                |
|     government program*        |                   |                |
|                                |                   |                |
| ## Psychoanal                  |                   |                |
| ysis or psychotherapy credited |                   |                |
|  toward earning a degree or fu |                   |                |
| rtherance of education or trai |                   |                |
| ning regardless of diagnosis o |                   |                |
| r symptoms that may be present |                   |                |
+--------------------------------+-------------------+----------------+

**Limitation** We may limit your benefits if you do not obtain a
treatment plan.

+---+---+----------------------------------------------------------+---+---+
| # |   |                                                          |   |   |
|   |   |                                                          |   |   |
| S |   |                                                          |   |   |
| e |   |                                                          |   |   |
| c |   |                                                          |   |   |
| t |   |                                                          |   |   |
| i |   |                                                          |   |   |
| o |   |                                                          |   |   |
| n |   |                                                          |   |   |
|   |   |                                                          |   |   |
| 5 |   |                                                          |   |   |
|   |   |                                                          |   |   |
| ( |   |                                                          |   |   |
| f |   |                                                          |   |   |
| ) |   |                                                          |   |   |
| . |   |                                                          |   |   |
|   |   |                                                          |   |   |
| P |   |                                                          |   |   |
| r |   |                                                          |   |   |
| e |   |                                                          |   |   |
| s |   |                                                          |   |   |
| c |   |                                                          |   |   |
| r |   |                                                          |   |   |
| i |   |                                                          |   |   |
| p |   |                                                          |   |   |
| t |   |                                                          |   |   |
| i |   |                                                          |   |   |
| o |   |                                                          |   |   |
| n |   |                                                          |   |   |
|   |   |                                                          |   |   |
| d |   |                                                          |   |   |
| r |   |                                                          |   |   |
| u |   |                                                          |   |   |
| g |   |                                                          |   |   |
|   |   |                                                          |   |   |
| b |   |                                                          |   |   |
| e |   |                                                          |   |   |
| n |   |                                                          |   |   |
| e |   |                                                          |   |   |
| f |   |                                                          |   |   |
| i |   |                                                          |   |   |
| t |   |                                                          |   |   |
| s |   |                                                          |   |   |
+---+---+----------------------------------------------------------+---+---+
|   | * | **Here are some important things to keep in mind about   | * |   |
|   | * | these benefits:**                                        | * |   |
|   | I |                                                          | I |   |
|   | * | -   We cover prescribed drugs and medications, as        | * |   |
|   | * |     described in the chart beginning on the next page.   | * |   |
|   |   |                                                          |   |   |
|   | * | -   Please remember that all benefits are subject to the | * |   |
|   | * |     definitions, limitations, and exclusions in this     | * |   |
|   | M |     brochure and we cover them only when we determine    | M |   |
|   | * |     they are medically necessary.                        | * |   |
|   | * |                                                          | * |   |
|   |   | -   We have no calendar year deductible.                 |   |   |
|   | * |                                                          | * |   |
|   | * | ```{=html}                                               | * |   |
|   | P | <!-- -->                                                 | P |   |
|   | * | ```                                                      | * |   |
|   | * | -   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 coverage, including | * |   |
|   | O |     with Medicare.                                       | O |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   |   |                                                          |   |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   | R |                                                          | R |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   |   |                                                          |   |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   | T |                                                          | T |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   |   |                                                          |   |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   | A |                                                          | A |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   |   |                                                          |   |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   | N |                                                          | N |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   |   |                                                          |   |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
|   | T |                                                          | T |   |
|   | * |                                                          | * |   |
|   | * |                                                          | * |   |
+---+---+----------------------------------------------------------+---+---+
|   | * |                                                          |   |   |
|   | * |                                                          |   |   |
|   | T |                                                          |   |   |
|   | h |                                                          |   |   |
|   | e |                                                          |   |   |
|   | r |                                                          |   |   |
|   | e |                                                          |   |   |
|   | a |                                                          |   |   |
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|   | r |                                                          |   |   |
|   | e |                                                          |   |   |
|   | s |                                                          |   |   |
|   | y |                                                          |   |   |
|   | o |                                                          |   |   |
|   | u |                                                          |   |   |
|   | s |                                                          |   |   |
|   | h |                                                          |   |   |
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+---+---+----------------------------------------------------------+---+---+

*Covered medications and supplies \-- begin on next page*

+--------------------------------+---+-------------------+---+----------------+
| **Benefit Description**        |   | **You pay**       |   |                |
+--------------------------------+---+-------------------+---+----------------+
| > **Covered medications and    |   | ######### You pay |   | ###            |
| > supplies**                   |   |  -Standard Option |   | ###### You pay |
|                                |   |                   |   |  - High Option |
+--------------------------------+---+-------------------+---+----------------+
| > We cover the following       | \ |                   | \ |                |
| > medications and supplies     | $ |                   | $ |                |
| > prescribed by a Plan         | 1 |                   | 1 |                |
| > physician and obtained from  | 5 |                   | 0 |                |
| > a Plan pharmacy or through   | p |                   | p |                |
| > our mail order program:      | e |                   | e |                |
|                                | r |                   | r |                |
| -   Drugs for which a          | p |                   | p |                |
|     > prescription is required | r |                   | r |                |
|     > by law                   | e |                   | e |                |
|                                | s |                   | s |                |
| ```{=html}                     | c |                   | c |                |
| <!-- -->                       | r |                   | r |                |
| ```                            | i |                   | i |                |
| -   Insulin                    | p |                   | p |                |
|                                | t |                   | t |                |
| ```{=html}                     | i |                   | i |                |
| <!-- -->                       | o |                   | o |                |
| ```                            | n |                   | n |                |
| -   Glucose test strips        | o |                   | o |                |
|                                | r |                   | r |                |
| -   Disposable needles and     | r |                   | r |                |
|     syringes for               | e |                   | e |                |
|     administration of covered  | f |                   | f |                |
|     prescribed medications     | i |                   | i |                |
|                                | l |                   | l |                |
| > Note: The cost of any        | l |                   | l |                |
| > needles and syringes (not    | f |                   | f |                |
| > for insulin) may be less     | o |                   | o |                |
| > than your copayment. If this | r |                   | r |                |
| > is the case, you are         | g |                   | g |                |
| > required to pay the cost of  | e |                   | e |                |
| > the needles and syringes.    | n |                   | n |                |
|                                | e |                   | e |                |
| -   Smoking cessation drugs    | r |                   | r |                |
|     and medication, including  | i |                   | i |                |
|     prescribed nicotine gum    | c |                   | c |                |
|     and patches, when used in  | d |                   | d |                |
|     conjunction with smoking   | r |                   | r |                |
|     cessation programs         | u |                   | u |                |
|                                | g |                   | g |                |
| ```{=html}                     | s |                   | s |                |
| <!-- -->                       | o |                   | o |                |
| ```                            | r |                   | r |                |
| -   Chemotherapy               | d |                   | d |                |
|                                | e |                   | e |                |
| ```{=html}                     | v |                   | v |                |
| <!-- -->                       | i |                   | i |                |
| ```                            | c |                   | c |                |
| -   Drugs for foreign travel   | e |                   | e |                |
|                                | s |                   | s |                |
| ```{=html}                     |   |                   |   |                |
| <!-- -->                       | \ |                   | \ |                |
| ```                            | $ |                   | $ |                |
| -   Certain over-the-counter   | 3 |                   | 2 |                |
|     medications prescribed by  | 0 |                   | 0 |                |
|     a Plan physician and       | p |                   | p |                |
|     listed on the Plan\'s      | e |                   | e |                |
|     formulary as the most      | r |                   | r |                |
|     appropriate treatment for  | p |                   | p |                |
|     a particular condition     | r |                   | r |                |
|                                | e |                   | e |                |
| -   Contraceptive drugs and    | s |                   | s |                |
|     devices:                   | c |                   | c |                |
|                                | r |                   | r |                |
| -   Diaphragms and cervical    | i |                   | i |                |
|     caps                       | p |                   | p |                |
|                                | t |                   | t |                |
| -   Intrauterine devices       | i |                   | i |                |
|     (IUDs)                     | o |                   | o |                |
|                                | n |                   | n |                |
| -   Injectable contraceptive   | o |                   | o |                |
|     drugs                      | r |                   | r |                |
|                                | r |                   | r |                |
| -   Implanted time-release     | e |                   | e |                |
|     contraceptive drug         | f |                   | f |                |
|                                | i |                   | i |                |
| -   Oral contraceptive drugs   | l |                   | l |                |
|                                | l |                   | l |                |
| -   Other implanted            | f |                   | f |                |
|     time-release drugs         | o |                   | o |                |
|                                | r |                   | r |                |
|                                | b |                   | b |                |
|                                | r |                   | r |                |
|                                | a |                   | a |                |
|                                | n |                   | n |                |
|                                | d |                   | d |                |
|                                | - |                   | - |                |
|                                | n |                   | n |                |
|                                | a |                   | a |                |
|                                | m |                   | m |                |
|                                | e |                   | e |                |
|                                | d |                   | d |                |
|                                | r |                   | r |                |
|                                | u |                   | u |                |
|                                | g |                   | g |                |
|                                | s |                   | s |                |
|                                | o |                   | o |                |
|                                | r |                   | r |                |
|                                | d |                   | d |                |
|                                | e |                   | e |                |
|                                | v |                   | v |                |
|                                | i |                   | i |                |
|                                | c |                   | c |                |
|                                | e |                   | e |                |
|                                | s |                   | s |                |
+--------------------------------+---+-------------------+---+----------------+

*Covered medications and supplies \-- continued on next page*

+--------------------------------+---+-------------------+---+----------------+
| > **Covered medications and    | # |                   | # |                |
| > supplies** *(continued)*     | # |                   | # |                |
|                                | # |                   | # |                |
|                                | # |                   | # |                |
|                                | # |                   | # |                |
|                                | # |                   | # |                |
|                                | # |                   | # |                |
|                                | # |                   | # |                |
|                                | # |                   | # |                |
|                                |   |                   |   |                |
|                                | Y |                   | Y |                |
|                                | o |                   | o |                |
|                                | u |                   | u |                |
|                                |   |                   |   |                |
|                                | p |                   | p |                |
|                                | a |                   | a |                |
|                                | y |                   | y |                |
|                                |   |                   |   |                |
|                                | - |                   | - |                |
|                                | S |                   |   |                |
|                                | t |                   | H |                |
|                                | a |                   | i |                |
|                                | n |                   | g |                |
|                                | d |                   | h |                |
|                                | a |                   |   |                |
|                                | r |                   | O |                |
|                                | d |                   | p |                |
|                                |   |                   | t |                |
|                                | O |                   | i |                |
|                                | p |                   | o |                |
|                                | t |                   | n |                |
|                                | i |                   |   |                |
|                                | o |                   |   |                |
|                                | n |                   |   |                |
+--------------------------------+---+-------------------+---+----------------+
| -   Drugs to treat sexual      | 5 |                   | 5 |                |
|     dysfunction                | 0 |                   | 0 |                |
|                                | % |                   | % |                |
| > Note: These drugs have       | o |                   | o |                |
| > dispensing limitations.      | f |                   | f |                |
| > Contact the Plan for         | o |                   | o |                |
| > details.                     | u |                   | u |                |
|                                | r |                   | r |                |
|                                | a |                   | a |                |
|                                | l |                   | l |                |
|                                | l |                   | l |                |
|                                | o |                   | o |                |
|                                | w |                   | w |                |
|                                | a |                   | a |                |
|                                | n |                   | n |                |
|                                | c |                   | c |                |
|                                | e |                   | e |                |
+--------------------------------+---+-------------------+---+----------------+
| > Diabetic supplies such as    | 2 |                   | 2 |                |
| > external insulin pumps,      | 0 |                   | 0 |                |
| > infusion devices, lancets,   | % |                   | % |                |
| > glucose monitors, and        | o |                   | o |                |
| > diabetic foot care           | f |                   | f |                |
| > appliances                   | o |                   | o |                |
|                                | u |                   | u |                |
|                                | r |                   | r |                |
|                                | a |                   | a |                |
|                                | l |                   | l |                |
|                                | l |                   | l |                |
|                                | o |                   | o |                |
|                                | w |                   | w |                |
|                                | a |                   | a |                |
|                                | n |                   | n |                |
|                                | c |                   | c |                |
|                                | e |                   | e |                |
+--------------------------------+---+-------------------+---+----------------+
| -   Amino acid modified        | N |                   | N |                |
|     products used in the       | o |                   | o |                |
|     treatment of inborn errors | t |                   | t |                |
|     of amino acid metabolism   | h |                   | h |                |
|     (PKU)                      | i |                   | i |                |
|                                | n |                   | n |                |
| ```{=html}                     | g |                   | g |                |
| <!-- -->                       |   |                   |   |                |
| ```                            |   |                   |   |                |
| -   Immunosuppressive drugs    |   |                   |   |                |
|     required after a           |   |                   |   |                |
|     transplant                 |   |                   |   |                |
|                                |   |                   |   |                |
| ```{=html}                     |   |                   |   |                |
| <!-- -->                       |   |                   |   |                |
| ```                            |   |                   |   |                |
| -   Intravenous fluids and     |   |                   |   |                |
|     medication for home        |   |                   |   |                |
+--------------------------------+---+-------------------+---+----------------+
| > *Not covered:*               |   | > *All charges*   |   | > *All         |
|                                |   |                   |   | > charges*     |
| -   *Drugs available without a |   |                   |   |                |
|     prescription or for which  |   |                   |   |                |
|     there is a nonprescription |   |                   |   |                |
|     equivalent available,      |   |                   |   |                |
|     except those listed on the |   |                   |   |                |
|     Plan\'s formulary and      |   |                   |   |                |
|     prescribed by a Plan       |   |                   |   |                |
|     physician*                 |   |                   |   |                |
|                                |   |                   |   |                |
| -   *Drugs obtained at a       |   |                   |   |                |
|     non-Plan pharmacy except   |   |                   |   |                |
|     for out-of-area            |   |                   |   |                |
|     emergencies*               |   |                   |   |                |
|                                |   |                   |   |                |
| -   *Vitamins and nutritional  |   |                   |   |                |
|     supplements that can be    |   |                   |   |                |
|     purchased without a        |   |                   |   |                |
|     prescription*              |   |                   |   |                |
|                                |   |                   |   |                |
| -   *Medical supplies such as  |   |                   |   |                |
|     dressings and antiseptics* |   |                   |   |                |
|                                |   |                   |   |                |
| -   *Drugs for cosmetic        |   |                   |   |                |
|     purposes*                  |   |                   |   |                |
|                                |   |                   |   |                |
| -   *Drugs to enhance athletic |   |                   |   |                |
|     performance*               |   |                   |   |                |
|                                |   |                   |   |                |
| -   *Drugs used in the         |   |                   |   |                |
|     diagnosis and treatment of |   |                   |   |                |
|     infertility*               |   |                   |   |                |
|                                |   |                   |   |                |
| -   *Drugs related to          |   |                   |   |                |
|     non-covered services*      |   |                   |   |                |
|                                |   |                   |   |                |
| -   *Drugs used for weight     |   |                   |   |                |
|     management*                |   |                   |   |                |
|                                |   |                   |   |                |
| -   *Any packaging other than  |   |                   |   |                |
|     the dispensing pharmacy's  |   |                   |   |                |
|     standard packaging*        |   |                   |   |                |
|                                |   |                   |   |                |
| -   *Replacement of lost,      |   |                   |   |                |
|     stolen, or damaged drugs   |   |                   |   |                |
|     and accessories*           |   |                   |   |                |
+--------------------------------+---+-------------------+---+----------------+

+------------------+---------------------------------------------------+
| > Section 5 (g). |                                                   |
| > Special        |                                                   |
| > featur         |                                                   |
| es[]{#__RefHeadi |                                                   |
| ng___Toc20908435 |                                                   |
| > .anchor}       |                                                   |
+------------------+---------------------------------------------------+
| > **Feature**    | > **Description**                                 |
+------------------+---------------------------------------------------+
| > **Flexible     | > Under the flexible benefits option, we          |
| > benefits       | > determine the most effective way to provide     |
| > option         | > services.                                       |
| **[]{#__RefHeadi |                                                   |
| ng___Toc20908436 | -   We may identify medically appropriate         |
| > .anchor}       |     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.                  |
+------------------+---------------------------------------------------+
| > **24 hour      | > For any of your health concerns, 24 hours a     |
| > nurse          | > day, 7 days a week, you may call from Portland  |
| > line           | > at 503/813-2000, or from other areas call       |
| **[]{#__RefHeadi | > 800/813-2000 or our TTY number at 800/735-2900, |
| ng___Toc20908437 | > and talk with a registered nurse who will       |
| > .anchor}       | > discuss treatment options and answer your       |
|                  | > health questions.                               |
+------------------+---------------------------------------------------+
| > **Services for | > We provide TTY/text telephone number at         |
| > deaf and       | > 800/735-2900. Sign language services are also   |
| > hearing        | > available.                                      |
| > impaired       |                                                   |
| **[]{#__RefHeadi |                                                   |
| ng___Toc20908438 |                                                   |
| > .anchor}       |                                                   |
+------------------+---------------------------------------------------+
| > **Language     | > Interpreters are available to assist            |
| > interpretation | > non-English speaking members. Please see the    |
| **[]{#__RefHeadi | > listing in your Medical Directory.              |
| ng___Toc20908439 |                                                   |
| > .anchor}       |                                                   |
+------------------+---------------------------------------------------+
| > **High risk    | > Starring Healthy Babies was born August 1995 in |
| > pregnancies    | > response to the need for a comprehensive        |
| **[]{#__RefHeadi | > program to prevent pre-term birth. Our program  |
| ng___Toc20908440 | > works with you to:                              |
| > .anchor}       |                                                   |
|                  | -   Increase the gestational age of newborns and  |
|                  |     decrease our premature birth rate though      |
|                  |     prevention and education.                     |
|                  |                                                   |
|                  | -   Decrease the length of stay our infants       |
|                  |     require in the Neonatal Intensive Care Unit   |
|                  |     due to premature birth.                       |
|                  |                                                   |
|                  | -   Decrease the amount of time our high-risk     |
|                  |     mothers need to spend in the hospital during  |
|                  |     their pregnancies by helping with their care  |
|                  |     at home.                                      |
|                  |                                                   |
|                  | > All pregnant Kaiser Permanente members are      |
|                  | > screened at their prenatal appointments or at   |
|                  | > an urgent hospital visit. We enroll those       |
|                  | > identified as being high risk for pre-term      |
|                  | > labor and assign them to their own case         |
|                  | > manager.                                        |
+------------------+---------------------------------------------------+

+----------------------+-----------------------------------------------+
| > **Feature**        | > **Description**                             |
+----------------------+-----------------------------------------------+
| > **Centers of       | > The Centers of Excellence program began in  |
| > Ex                 | > Fall 1987. As new technologies proliferate  |
| cellence**[]{#__RefH | > and become the standard of care, Kaiser     |
| eading___Toc20908441 | > Permanente refers members to contracted     |
| > .anchor}           | > \"centers of excellence\" for certain       |
|                      | > specialized medical procedures.             |
|                      | >                                             |
|                      | > We have developed a network of Centers of   |
|                      | > Excellence for organ transplantation, which |
|                      | > consists of medical facilities that have    |
|                      | > met stringent criteria for quality care in  |
|                      | > specific procedures. A national clinical    |
|                      | > and administrative team has developed       |
|                      | > guidelines for site selection, site visit   |
|                      | > protocol, volume and survival criteria for  |
|                      | > evaluation and selection of facilities. The |
|                      | > institutions have a record of positive      |
|                      | > outcomes and exceptional standards of       |
|                      | > quality.                                    |
+----------------------+-----------------------------------------------+
| > **Travel           | > Kaiser Permanente's travel benefits for     |
| >                    | > Federal employees provide you with          |
|  benefit**[]{#__RefH | > outpatient follow-up or continuing medical  |
| eading___Toc20908442 | > care when you are temporarily outside your  |
| > .anchor}           | > home service area by more than 100 miles    |
|                      | > and 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 or        |
|                      |     continuing care office visit. This amount |
|                      |     will be deducted from the payment we make |
|                      |     to you.                                   |
|                      |                                               |
|                      | -   Your benefit is limited to \$1200 each    |
|                      |     calendar year**.**                        |
|                      |                                               |
|                      | -   For more information about this benefit   |
|                      |     call 800/813-2000.                        |
|                      |                                               |
|                      | -   File claims as shown on page 55.          |
|                      |                                               |
|                      | > *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*                    |
+----------------------+-----------------------------------------------+

+----------------------+-----------------------------------------------+
| > **Feature**        | > **Description**                             |
+----------------------+-----------------------------------------------+
| > **Services from    | > When you visit the service area of another  |
| > other Kaiser       | > Kaiser Permanente plan, you are entitled to |
| > Permanente Plans** | > receive virtually all the benefits          |
|                      | > described in this brochure (including our   |
|                      | > mail order prescription program) at any     |
|                      | > Kaiser Permanente medical office or medical |
|                      | > center. You will have to pay the copayments |
|                      | > or other charges imposed by the Plan you    |
|                      | > are visiting, with the exception of mail    |
|                      | > order prescriptions which are administered  |
|                      | > by your home Plan. If the Plan you are      |
|                      | > visiting has a benefit that differs 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 this Plan.                               |
|                      | >                                             |
|                      | > If you are seeking routine, non-emergent,   |
|                      | > or non-urgent services, you should call the |
|                      | > Kaiser Permanente Membership 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. 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 Membership Services at    |
|                      | > 503/813-2000 or 800/813-2000.               |
+----------------------+-----------------------------------------------+
| > **Student Coverage | > We provide a limited benefit to dependents  |
| > Outside the        | > of eligible subscribers who are full time   |
| > Service Area**     | > registered college students (at least 12    |
|                      | > credit hours per semester) attending a      |
|                      | > recognized accredited institution outside   |
|                      | > Kaiser Permanente's service areas and       |
|                      | > within the United States. These benefits    |
|                      | > are in addition to your emergency and       |
|                      | > travel benefits.                            |
|                      |                                               |
|                      | -   You are covered for routine, continuing   |
|                      |     and follow-up medical care                |
|                      |                                               |
|                      | -   You pay 20% of the usual and customary    |
|                      |     charges.                                  |
|                      |                                               |
|                      | -   Your benefit is limited to \$1,200 each   |
|                      |     calendar year.                            |
|                      |                                               |
|                      | -   You must certify your dependent\'s        |
|                      |     student status annually.                  |
|                      |                                               |
|                      | -   For more information about this benefit,  |
|                      |     call 800/813-2000.                        |
|                      |                                               |
|                      | -   File claims as shown on page 55.          |
|                      |                                               |
|                      | > *The following are not included in your     |
|                      | > out-of-area student coverage benefit:*      |
|                      |                                               |
|                      | -   *Transplants*                             |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   *Dental (High Option)*                    |
+----------------------+-----------------------------------------------+

+---+---+---------------------------+-------------------+----------+---+---+---+
| > |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
| S |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| c |   |                           |                   |          |   |   |   |
| t |   |                           |                   |          |   |   |   |
| i |   |                           |                   |          |   |   |   |
| o |   |                           |                   |          |   |   |   |
| n |   |                           |                   |          |   |   |   |
| > |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
| 5 |   |                           |                   |          |   |   |   |
| > |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
| ( |   |                           |                   |          |   |   |   |
| h |   |                           |                   |          |   |   |   |
| ) |   |                           |                   |          |   |   |   |
| . |   |                           |                   |          |   |   |   |
| > |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
| D |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| n |   |                           |                   |          |   |   |   |
| t |   |                           |                   |          |   |   |   |
| a |   |                           |                   |          |   |   |   |
| l |   |                           |                   |          |   |   |   |
| > |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
| b |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| n |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| f |   |                           |                   |          |   |   |   |
| i |   |                           |                   |          |   |   |   |
| t |   |                           |                   |          |   |   |   |
| s |   |                           |                   |          |   |   |   |
| [ |   |                           |                   |          |   |   |   |
| ] |   |                           |                   |          |   |   |   |
| { |   |                           |                   |          |   |   |   |
| # |   |                           |                   |          |   |   |   |
| _ |   |                           |                   |          |   |   |   |
| _ |   |                           |                   |          |   |   |   |
| R |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| f |   |                           |                   |          |   |   |   |
| H |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| a |   |                           |                   |          |   |   |   |
| d |   |                           |                   |          |   |   |   |
| i |   |                           |                   |          |   |   |   |
| n |   |                           |                   |          |   |   |   |
| g |   |                           |                   |          |   |   |   |
| _ |   |                           |                   |          |   |   |   |
| _ |   |                           |                   |          |   |   |   |
| _ |   |                           |                   |          |   |   |   |
| T |   |                           |                   |          |   |   |   |
| o |   |                           |                   |          |   |   |   |
| c |   |                           |                   |          |   |   |   |
| 2 |   |                           |                   |          |   |   |   |
| 0 |   |                           |                   |          |   |   |   |
| 9 |   |                           |                   |          |   |   |   |
| 0 |   |                           |                   |          |   |   |   |
| 8 |   |                           |                   |          |   |   |   |
| 4 |   |                           |                   |          |   |   |   |
| 4 |   |                           |                   |          |   |   |   |
| 4 |   |                           |                   |          |   |   |   |
| > |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
| . |   |                           |                   |          |   |   |   |
| a |   |                           |                   |          |   |   |   |
| n |   |                           |                   |          |   |   |   |
| c |   |                           |                   |          |   |   |   |
| h |   |                           |                   |          |   |   |   |
| o |   |                           |                   |          |   |   |   |
| r |   |                           |                   |          |   |   |   |
| } |   |                           |                   |          |   |   |   |
+---+---+---------------------------+-------------------+----------+---+---+---+
|   | * | > **Here are some         |                   |          | * |   |   |
|   | * | > important things to     |                   |          | * |   |   |
|   | I | > keep in mind about      |                   |          | I |   |   |
|   | * | > these benefits:**       |                   |          | * |   |   |
|   | * |                           |                   |          | * |   |   |
|   |   | -   Please remember that  |                   |          |   |   |   |
|   | * |     all benefits are      |                   |          | * |   |   |
|   | * |     subject to the        |                   |          | * |   |   |
|   | M |     definitions,          |                   |          | M |   |   |
|   | * |     limitations, and      |                   |          | * |   |   |
|   | * |     exclusions in this    |                   |          | * |   |   |
|   |   |     brochure and we cover |                   |          |   |   |   |
|   | * |     them only when we     |                   |          | * |   |   |
|   | * |     determine they are    |                   |          | * |   |   |
|   | P |     medically necessary.  |                   |          | P |   |   |
|   | * |                           |                   |          | * |   |   |
|   | * | -   Plan dentists must    |                   |          | * |   |   |
|   |   |     provide or arrange    |                   |          |   |   |   |
|   | * |     your care.            |                   |          | * |   |   |
|   | * |                           |                   |          | * |   |   |
|   | O | -   We cover              |                   |          | O |   |   |
|   | * |     hospitalization for   |                   |          | * |   |   |
|   | * |     dental procedures at  |                   |          | * |   |   |
|   |   |     a Plan hospital we    |                   |          |   |   |   |
|   | * |     designate subject to  |                   |          | * |   |   |
|   | * |     pre-authorization     |                   |          | * |   |   |
|   | R |     only when a           |                   |          | R |   |   |
|   | * |     non-dental physical   |                   |          | * |   |   |
|   | * |     impairment exists     |                   |          | * |   |   |
|   |   |     which makes           |                   |          |   |   |   |
|   | * |     hospitalization       |                   |          | * |   |   |
|   | * |     necessary to          |                   |          | * |   |   |
|   | T |     safeguard the health  |                   |          | T |   |   |
|   | * |     of the patient. See   |                   |          | * |   |   |
|   | * |     Section 5(c) for      |                   |          | * |   |   |
|   |   |     inpatient hospital    |                   |          |   |   |   |
|   | * |     benefits. We do not   |                   |          | * |   |   |
|   | * |     cover the dental      |                   |          | * |   |   |
|   | A |     procedure except as   |                   |          | A |   |   |
|   | * |     described below.      |                   |          | * |   |   |
|   | * |                           |                   |          | * |   |   |
|   |   | -   We have no calendar   |                   |          |   |   |   |
|   | * |     year deductible.      |                   |          | * |   |   |
|   | * |                           |                   |          | * |   |   |
|   | N | -   Be sure to read       |                   |          | N |   |   |
|   | * |     Section 4, *Your      |                   |          | * |   |   |
|   | * |     costs for covered     |                   |          | * |   |   |
|   |   |     services,* for        |                   |          |   |   |   |
|   | * |     valuable information  |                   |          | * |   |   |
|   | * |     about how cost        |                   |          | * |   |   |
|   | T |     sharing works. Also   |                   |          | T |   |   |
|   | * |     read Section 9 about  |                   |          | * |   |   |
|   | * |     coordinating benefits |                   |          | * |   |   |
|   |   |     with other coverage,  |                   |          |   |   |   |
|   |   |     including with        |                   |          |   |   |   |
|   |   |     Medicare.             |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   | > Note: You will have to  |                   |          |   |   |   |
|   |   | > pay \$10 for each       |                   |          |   |   |   |
|   |   | > missed appointment,     |                   |          |   |   |   |
|   |   | > unless you notify the   |                   |          |   |   |   |
|   |   | > dental office in        |                   |          |   |   |   |
|   |   | > advance.                |                   |          |   |   |   |
+---+---+---------------------------+-------------------+----------+---+---+---+
| * |   |                           |                   |          |   |   |   |
| * |   |                           |                   |          |   |   |   |
| D |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| n |   |                           |                   |          |   |   |   |
| t |   |                           |                   |          |   |   |   |
| a |   |                           |                   |          |   |   |   |
| l |   |                           |                   |          |   |   |   |
| B |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| n |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| f |   |                           |                   |          |   |   |   |
| i |   |                           |                   |          |   |   |   |
| t |   |                           |                   |          |   |   |   |
| s |   |                           |                   |          |   |   |   |
| * |   |                           |                   |          |   |   |   |
| * |   |                           |                   |          |   |   |   |
+---+---+---------------------------+-------------------+----------+---+---+---+
| # |   |                           | ######### You pay | #######  |   |   |   |
| # |   |                           |  -Standard Option | ## You p |   |   |   |
| # |   |                           |                   | ay - Hig |   |   |   |
|   |   |                           |                   | h Option |   |   |   |
| * |   |                           |                   |          |   |   |   |
| * |   |                           |                   |          |   |   |   |
| S |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| r |   |                           |                   |          |   |   |   |
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| e |   |                           |                   |          |   |   |   |
| * |   |                           |                   |          |   |   |   |
| * |   |                           |                   |          |   |   |   |
+---+---+---------------------------+-------------------+----------+---+---+---+
| > |   |                           | > No benefit      | See      |   |   |   |
|   |   |                           |                   | below    |   |   |   |
| M |   |                           |                   |          |   |   |   |
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| h |   |                           |                   |          |   |   |   |
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| n |   |                           |                   |          |   |   |   |
| y |   |                           |                   |          |   |   |   |
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|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
| t |   |                           |                   |          |   |   |   |
| w |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| l |   |                           |                   |          |   |   |   |
| v |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| - |   |                           |                   |          |   |   |   |
| m |   |                           |                   |          |   |   |   |
| o |   |                           |                   |          |   |   |   |
| n |   |                           |                   |          |   |   |   |
| t |   |                           |                   |          |   |   |   |
| h |   |                           |                   |          |   |   |   |
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|   |   |                           |                   |          |   |   |   |
| p |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| r |   |                           |                   |          |   |   |   |
| i |   |                           |                   |          |   |   |   |
| o |   |                           |                   |          |   |   |   |
| d |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
| - |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
| P |   |                           |                   |          |   |   |   |
| r |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| s |   |                           |                   |          |   |   |   |
| c |   |                           |                   |          |   |   |   |
| r |   |                           |                   |          |   |   |   |
| i |   |                           |                   |          |   |   |   |
| b |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| d |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
| s |   |                           |                   |          |   |   |   |
| p |   |                           |                   |          |   |   |   |
| a |   |                           |                   |          |   |   |   |
| c |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
| m |   |                           |                   |          |   |   |   |
| a |   |                           |                   |          |   |   |   |
| i |   |                           |                   |          |   |   |   |
| n |   |                           |                   |          |   |   |   |
| t |   |                           |                   |          |   |   |   |
| a |   |                           |                   |          |   |   |   |
| i |   |                           |                   |          |   |   |   |
| n |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| r |   |                           |                   |          |   |   |   |
| s |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
| a |   |                           |                   |          |   |   |   |
| n |   |                           |                   |          |   |   |   |
| d |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
| h |   |                           |                   |          |   |   |   |
| a |   |                           |                   |          |   |   |   |
| b |   |                           |                   |          |   |   |   |
| i |   |                           |                   |          |   |   |   |
| t |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
|   |   |                           |                   |          |   |   |   |
| a |   |                           |                   |          |   |   |   |
| p |   |                           |                   |          |   |   |   |
| p |   |                           |                   |          |   |   |   |
| l |   |                           |                   |          |   |   |   |
| i |   |                           |                   |          |   |   |   |
| a |   |                           |                   |          |   |   |   |
| n |   |                           |                   |          |   |   |   |
| c |   |                           |                   |          |   |   |   |
| e |   |                           |                   |          |   |   |   |
| s |   |                           |                   |          |   |   |   |
+---+---+---------------------------+-------------------+----------+---+---+---+

*Dental benefits \-- continued on next page*

+--------------------------------+-------------------+----------------+
| **Dental Benefits**            |                   |                |
| *(continued)*                  |                   |                |
+--------------------------------+-------------------+----------------+
| ### **Service**                | ######### You pay | ###            |
|                                |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > Basic Restorative Services   | > *All charges*   | \$10 per       |
| > including basic restorative  |                   | office visit   |
| > services resulting from      |                   | plus 50% of    |
| > accidental injury as         |                   | our allowance  |
| > follows:                     |                   |                |
|                                |                   |                |
| -   Amalgam (silver)           |                   |                |
|     restorations in posterior  |                   |                |
|     teeth and anterior teeth   |                   |                |
|                                |                   |                |
| -   Synthetic (plastic, resin  |                   |                |
|     and glass ionomer)         |                   |                |
|     restorations in all        |                   |                |
|     primary teeth, anterior    |                   |                |
|     teeth and one-surface      |                   |                |
|     restorations of posterior  |                   |                |
|     permanent teeth            |                   |                |
|                                |                   |                |
| -   Stainless steel or plastic |                   |                |
|     crowns when amalgam or     |                   |                |
|     synthetic restorative      |                   |                |
|     materials are not          |                   |                |
|     professionally appropriate |                   |                |
|                                |                   |                |
| -   If a member requests a     |                   |                |
|     procedure or material in   |                   |                |
|     excess of that recommended |                   |                |
|     by a Plan dentist, the     |                   |                |
|     desired procedure or       |                   |                |
|     material may be provided   |                   |                |
|     upon payment of charges    |                   |                |
|     that reflect the           |                   |                |
|     additional value of        |                   |                |
|     providing the procedure or |                   |                |
|     material, only if a Plan   |                   |                |
|     dentist agrees to perform  |                   |                |
|     the service                |                   |                |
|                                |                   |                |
| > Major Restorative Services   |                   |                |
| > as follows:                  |                   |                |
|                                |                   |                |
| -   Placement of crowns,       |                   |                |
|     inlays, bridge pontics, or |                   |                |
|     other cast metal           |                   |                |
|     restoration when           |                   |                |
|     prescribed by a Plan       |                   |                |
|     dentist                    |                   |                |
|                                |                   |                |
| -   If a member requests a     |                   |                |
|     procedure or material in   |                   |                |
|     excess of that recommended |                   |                |
|     by a Plan dentist, the     |                   |                |
|     desired procedure or       |                   |                |
|     material may be provided   |                   |                |
|     upon payment of charges    |                   |                |
|     that reflect the           |                   |                |
|     additional value of        |                   |                |
|     providing the procedure or |                   |                |
|     material, only if a Plan   |                   |                |
|     dentist agrees to perform  |                   |                |
|     the service                |                   |                |
|                                |                   |                |
| > Note: We do not cover repair |                   |                |
| > or replacement of existing   |                   |                |
| > cast crowns, inlays, bridge  |                   |                |
| > pontics, or other cast metal |                   |                |
| > restorations less than five  |                   |                |
| > years after the date of the  |                   |                |
| > most recent placement or     |                   |                |
| > replacement.                 |                   |                |
+--------------------------------+-------------------+----------------+
| > Oral Surgery Services as     |                   |                |
| > follows:                     |                   |                |
|                                |                   |                |
| -   Diagnosis, evaluation,     |                   |                |
|     consultation, and          |                   |                |
|     treatment for removal of   |                   |                |
|     teeth (including local     |                   |                |
|     anesthesia)                |                   |                |
|                                |                   |                |
| -   Minor surgical preparation |                   |                |
|     of mouth for insertion of  |                   |                |
|     dentures                   |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   Surgical treatment         |                   |                |
|     normally performed by a    |                   |                |
|     dentist for minor          |                   |                |
|     pathological conditions    |                   |                |
+--------------------------------+-------------------+----------------+

*Dental benefits \-- continued on next page*

+--------------------------------+-------------------+----------------+
| **Dental Benefits**            |                   |                |
| *(continued)*                  |                   |                |
+--------------------------------+-------------------+----------------+
| ### **Service**                | ######### You pay | ###            |
|                                |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > Periodontal Services as      | > *All charges*   | \$10 per       |
| > follows:                     |                   | office visit   |
|                                |                   | plus 50% of    |
| -   Diagnosis, evaluation,     |                   | our allowance  |
|     consultation, and          |                   |                |
|     treatment for diseases of  |                   |                |
|     tissues supporting the     |                   |                |
|     teeth including all        |                   |                |
|     follow-up cleaning visits  |                   |                |
+--------------------------------+-------------------+----------------+
| > Endodontic Services as       |                   |                |
| > follows:                     |                   |                |
|                                |                   |                |
| -   Diagnosis, evaluation,     |                   |                |
|     consultation, and          |                   |                |
|     treatment for root canal   |                   |                |
|     therapy                    |                   |                |
+--------------------------------+-------------------+----------------+
| > Removable Prosthetic         |                   |                |
| > Appliances and Services as   |                   |                |
| > follows:                     |                   |                |
|                                |                   |                |
| -   Diagnosis, evaluation,     |                   |                |
|     consultation, and          |                   |                |
|     treatment for removable    |                   |                |
|     prosthetic appliances,     |                   |                |
|     including full or partial  |                   |                |
|     dentures, relines, and     |                   |                |
|     rebases                    |                   |                |
|                                |                   |                |
| > Note: If the removable       |                   |                |
| > appliance cannot be          |                   |                |
| > satisfactorily repaired or   |                   |                |
| > adjusted, then we cover a    |                   |                |
| > new prosthetic appliance as  |                   |                |
| > long as the existing         |                   |                |
| > appliance is more than 5     |                   |                |
| > years old.                   |                   |                |
+--------------------------------+-------------------+----------------+
| > Emergency or Urgent Care     | > *All charges*   | > \$25 per     |
| >                              |                   | > office visit |
| > Note: This copayment applies |                   |                |
| > for emergency or urgent      |                   |                |
| > dental care received from a  |                   |                |
| > Plan dentist at Plan dental  |                   |                |
| > offices.                     |                   |                |
| >                              |                   |                |
| > Note: All other applicable   |                   |                |
| > copayments apply.            |                   |                |
+--------------------------------+-------------------+----------------+
| > Out-of-Area Emergency Care   | > *All charges*   | > All charges  |
| >                              |                   | > exceeding    |
| > Note: The Plan pays up to    |                   | > \$100        |
| > \$100 for emergency care for |                   |                |
| > relief of pain, acute        |                   |                |
| > infection, or hemorrhage, or |                   |                |
| > necessary treatment          |                   |                |
| > (including local anesthesia  |                   |                |
| > and pre-medication) due to   |                   |                |
| > injury.                      |                   |                |
+--------------------------------+-------------------+----------------+
| > Prescription Drugs           |                   |                |
| >                              |                   |                |
| > Covered under Prescription   |                   |                |
| > Drug benefits                |                   |                |
+--------------------------------+-------------------+----------------+
| > Nitrous Oxide                | *All charges*     | \$15 per       |
| >                              |                   | occurrence     |
| > Adults and children over 12  | *All charges*     |                |
| > years of age                 |                   | Nothing        |
| >                              |                   |                |
| > Children 12 years of age and |                   |                |
| > under                        |                   |                |
+--------------------------------+-------------------+----------------+
| > Nightguards                  | *All charges*     | 10% of our     |
|                                |                   | allowance      |
+--------------------------------+-------------------+----------------+

*Dental benefits \-- continued on next page*

+--------------------------------+-------------------+----------------+
| **Dental Benefits**            |                   |                |
| *(continued)*                  |                   |                |
+--------------------------------+-------------------+----------------+
| ### **Service**                | ######### You pay | ###            |
|                                |  -Standard Option | ###### You pay |
|                                |                   |  - High Option |
+--------------------------------+-------------------+----------------+
| > *Not covered:*               | > *All charges*   | *All charges*  |
|                                |                   |                |
| -   *Orthodontics*             |                   |                |
|                                |                   |                |
| -   *Dental treatment for      |                   |                |
|     problems of the jaw joint, |                   |                |
|     including                  |                   |                |
|     temporomandibular joint    |                   |                |
|     syndrome/ craniomandibular |                   |                |
|     disorders; or other        |                   |                |
|     conditions of the joint    |                   |                |
|     linking the jaw bone and   |                   |                |
|     skull, and of the complex  |                   |                |
|     of muscles, nerves, and    |                   |                |
|     other tissues related to   |                   |                |
|     that joint*                |                   |                |
|                                |                   |                |
| -   *Dental implants,          |                   |                |
|     including bone             |                   |                |
|     augmentation and the fixed |                   |                |
|     or removable prosthetic    |                   |                |
|     devices attached to or     |                   |                |
|     covering the implants; and |                   |                |
|     all services and materials |                   |                |
|     relating to the placement  |                   |                |
|     or removal of implants     |                   |                |
|     including, but not limited |                   |                |
|     to, diagnostic             |                   |                |
|     consultations,             |                   |                |
|     impressions, oral surgery, |                   |                |
|     and removal of implants    |                   |                |
|     for cleaning; and dental   |                   |                |
|     services related to        |                   |                |
|     post-operative conditions  |                   |                |
|     or complications arising   |                   |                |
|     from implants*             |                   |                |
|                                |                   |                |
| -   *Restorative or            |                   |                |
|     reconstructive services    |                   |                |
|     for congenital or          |                   |                |
|     developmental              |                   |                |
|     malformations*             |                   |                |
|                                |                   |                |
| -   *Full mouth                |                   |                |
|     reconstructions. This      |                   |                |
|     includes appliances,       |                   |                |
|     restoration, and           |                   |                |
|     procedures needed to alter |                   |                |
|     vertical dimension or      |                   |                |
|     occlusion, or in           |                   |                |
|     conjunction with           |                   |                |
|     alteration of vertical     |                   |                |
|     dimension or occlusion or  |                   |                |
|     for the purpose of         |                   |                |
|     splinting teeth or         |                   |                |
|     correcting attrition or    |                   |                |
|     abrasion.*                 |                   |                |
|                                |                   |                |
| -   *Cosmetic dental services, |                   |                |
|     including replacement of   |                   |                |
|     cosmetic dental            |                   |                |
|     restoration*               |                   |                |
|                                |                   |                |
| -   *Restoration replacement.  |                   |                |
|     Clinically acceptable      |                   |                |
|     restorations or material   |                   |                |
|     will not be removed or     |                   |                |
|     replaced with alternative  |                   |                |
|     materials unless a         |                   |                |
|     pathological condition of  |                   |                |
|     the teeth exists*          |                   |                |
|                                |                   |                |
| -   *IV sedation*              |                   |                |
|                                |                   |                |
| -   *Genetic testing*          |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Replacement of            |                   |                |
|     pre-fabricated, non-cast   |                   |                |
|     crowns, including non-cast |                   |                |
|     stainless steel crowns,    |                   |                |
|     which have not been placed |                   |                |
|     by a Kaiser Permanente     |                   |                |
|     dentist*                   |                   |                |
|                                |                   |                |
| ```{=html}                     |                   |                |
| <!-- -->                       |                   |                |
| ```                            |                   |                |
| -   *Replacement of any        |                   |                |
|     permanent removable        |                   |                |
|     appliances with new        |                   |                |
|     permanent removable or     |                   |                |
|     fixed prosthetic           |                   |                |
|     appliances within 5 years  |                   |                |
|     of the date the member     |                   |                |
|     receives the appliance     |                   |                |
|     regardless of where the    |                   |                |
|     appliance was obtained*    |                   |                |
|                                |                   |                |
| -   *Replacement of any        |                   |                |
|     nightguards within 5 years |                   |                |
|     of the date the member     |                   |                |
|     receives the appliance     |                   |                |
|     even if prescribed by a    |                   |                |
|     dentist outside the Plan*  |                   |                |
+--------------------------------+-------------------+----------------+

+-----------------------------------------------------------------------+
| > **Section 5 (i). Non-FEHB benefits available to Plan                |
| > members**[]{#__RefHeading___Toc20908445 .anchor}                    |
+-----------------------------------------------------------------------+

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.

**[Classes to change your lifestyle and keep you healthy]{.underline}**

At Kaiser Permanente, we actively encourage you to share responsibility
for your health care. Choices you make every day, about what you eat and
drink, whether you exercise or smoke, how you handle stress, or whether
you wear a seat belt, are tied directly to your health. They affect your
chances of having a stroke or a heart attack, getting cancer, or being
at risk for handicapping injuries.

We have developed a wide range of health education classes and other
services to help you stay healthy. You can learn how to kick the tobacco
habit for good, effectively manage your weight, improve personal and
family relationships, deal more effectively with a chronic health
problem, have a safe and healthy pregnancy, and much more. Descriptions
of the weight management and tobacco cessation services are shown below.
Over 40 other classes are also offered. Class fees begin as low as \$8
per member for some classes.

Our classes are open to everyone, but we offer them at reduced rates to
our members. You can register over the telephone or through the mail.
For more information or to have a catalog mailed to your home, call:

Health Education Services Membership Services

Portland 503/286-6816 Portland 503/813-2000

8 am -- 5 pm, Monday-Friday 8 am -- 6 pm, Monday-Friday

Salem 503/316-2344 All other areas 800/813-2000

Vancouver 360/604-2070 8 am -- 6 pm, Monday-Friday

Longview-Kelso 360/575-4870

**[Weight Management]{.underline}**

The Cultivating Health Weight Management Kit is an interactive guide to
healthy weight management. It includes a resource guide, workbook, and
more!

The Weight Management Class is a 5-week program using the Cultivating
Health Weight Management Kit.

Freedom from Diets is a 12-week program led by dieticians. It is a
lifestyle approach to weight management, developed by Kaiser Permanente
researchers.

**[Tobacco Cessation]{.underline}**

-   The \"cold turkey\" approach to stop smoking or chewing tobacco.
    Learn the latest and most effective techniques for kicking the habit
    for good. We offer a Freedom from Tobacco Class and a telephone
    counseling program to help you quit.

**[Freedom from Tobacco Class]{.underline}**

These classes are designed to provide you with techniques and support
that will increase your chances for lifelong freedom from tobacco.
Classes cover:

-   Relaxation techniques

-   Understanding cigarette addiction

-   Practicing effective ways to remain a non-smoker

You have the option of using drug therapy with this class. Drug therapy
has been proven to be most successful when used in conjunction with a
behavior change program. The medication treatment is a short-term aid
for people committed to learning how to stop smoking or chewing, and who
have been unsuccessful with other methods.

Your present pharmacy benefit provides coverage for smoking cessation
drugs, nicotine gum, and patches when used in conjunction with this
program.

Benefits on this page are not part of the FEHB contract.

+-----------------------------------------------------------------------+
| > Section 6. General exclusions \-- things we don\'t                  |
| > cover[]{#__RefHeading___Toc20908446 .anchor}                        |
+-----------------------------------------------------------------------+

> 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 related to sex transformations;

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

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

-   Services required for (a) obtaining or maintaining employment or
    participation in employee programs or (b) insurance or governmental
    licensing; or

-   Services provided or arranged by criminal justice institutions for
    members confined therein.

  -----------------------------------------------------------------------
  Section 7. Filing a claim for covered
  services[]{#__RefHeading___Toc20908447 .anchor}

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

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
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, hospital, | In most cases, providers and facilities file  |
| and drug benefits**  | claims for you. Physicians must file on the   |
|                      | form CMS-1500, Health Insurance Claim Form.   |
|                      | Facilities will file on the UB-92 form. For   |
|                      | claims questions and assistance, call us from |
|                      | Portland at 503/813-2000, or from other areas |
|                      | call 800/813-2000 or our TTY number at        |
|                      | 800/735-2900.                                 |
|                      |                                               |
|                      | When you must file a claim -- such as for     |
|                      | services you receive outside of the Plan\'s   |
|                      | service area -- please complete the Emergency |
|                      | Care Information (ECI) form and submit it     |
|                      | with the CMS-1500 or a claim form that        |
|                      | includes the information shown below. ECI     |
|                      | forms may be obtained by calling us from      |
|                      | Portland at 503/813-2000, or from other areas |
|                      | call 800/813-2000 or our TTY number at        |
|                      | 800/735-2900. 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:**                    |
|                      |                                               |
|                      | Claims Administration                         |
|                      |                                               |
|                      | Kaiser Foundation Health Plan of the          |
|                      | Northwest                                     |
|                      |                                               |
|                      | 500 N.E. Multnomah, Suite 100                 |
|                      |                                               |
|                      | Portland, Oregon 97232-2099                   |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Deadline for       | Send us all of the documents for your claim   |
| 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 need more  | Please reply promptly when we ask for         |
| information**        | additional information. We may delay          |
|                      | processing or deny your claim if you do not   |
|                      | respond.                                      |
+----------------------+-----------------------------------------------+

  -----------------------------------------------------------------------
  Section 8. The disputed claims process[]{#__RefHeading___Toc20908451
  .anchor}

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

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
pre-authorization:

+---+------------------------------------------------------------------+
| * | **Description**                                                  |
| * |                                                                  |
| S |                                                                  |
| t |                                                                  |
| e |                                                                  |
| p |                                                                  |
| * |                                                                  |
| * |                                                                  |
+---+------------------------------------------------------------------+
| * | Ask us in writing to reconsider our initial decision. You must:  |
| * |                                                                  |
| 1 | (a) \(a\) Write to us within 6 months from the date of our       |
| * |     decision; and                                                |
| * |                                                                  |
|   | (b) \(b\) Send your request to us at: Kaiser Foundation Health   |
|   |     Plan of the Northwest, 500 N.E. Multnomah, Suite 100,        |
|   |     Portland, Oregon 97232-2099; and                             |
|   |                                                                  |
|   | (c) \(c\) Include a statement about why you believe our initial  |
|   |     decision was wrong, based on specific benefit provisions in  |
|   |     this brochure; and                                           |
|   |                                                                  |
|   | (d) \(d\) 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) \(a\) Pay the claim (or, if applicable, arrange for the      |
| * |     health care provider to give you the care); or               |
| * |                                                                  |
|   | (b) \(b\) Write to you and maintain our denial \-- go to step 4; |
|   |     or                                                           |
|   |                                                                  |
|   | (c) \(c\) 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 20415-3620.                           |
+---+------------------------------------------------------------------+
|   | 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 approval, then call us from Portland at
    503/813-2000, or from other areas call 800/813-2000 or our TTY
    number at 800/735-2900 and we will expedite our review; or

(b) We denied your initial request for care or pre-authorization/prior
    approval, 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

```{=html}
<!-- -->
```
-   You may call OPM\'s Health Insurance Group 3 at 202/606-0755 between
    8 a.m. and 5 p.m. eastern time.

  -----------------------------------------------------------------------
  Section 9. Coordinating benefits with other
  coverage[]{#__RefHeading___Toc20908452 .anchor}

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

+----------------------+-----------------------------------------------+
| **When you have      | You must tell us if you or a covered family   |
| other health         | member have coverage under another group      |
| coverage**[]{#__RefH | health plan or have automobile insurance that |
| eading___Toc20908453 | pays health care expenses without regard to   |
| .anchor}             | fault. This is called \"double coverage.\"    |
|                      |                                               |
|                      | When you have double coverage, one plan is    |
|                      | the primary payer; it pays benefits first.    |
|                      | 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    |
|                      | payer 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 is a Health Insurance Program for:   |
| > M                  |                                               |
| edicare?**[]{#__RefH | -   People 65 years of age and older.         |
| eading___Toc20908454 |                                               |
| > .anchor}           | -   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 I       | The decision to enroll in Medicare is yours.  |
|     enroll in        | We encourage you to apply for Medicare        |
|     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 you enroll in | If you enroll in Medicare Part B, we require  |
| > Medicare Part B**  | you to assign your Medicare Part B benefits   |
|                      | to the Plan for its services.                 |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| > **The Original     | The Original Medicare Plan (Original          |
| > Medicare Plan      | Medicare) is available everywhere in the      |
| > (Part A or Part    | United States. It is the way everyone used to |
| > B)**[]{#__RefH     | get Medicare benefits and is the way most     |
| eading___Toc20908455 | people get their Medicare Part A and Part B   |
| > .anchor}           | 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     |
|                      |     from Portland at 503/813-2000 or from     |
|                      |     other areas at 800/813-2000 or our TTY    |
|                      |     number at 800/735-2900.                   |
+----------------------+-----------------------------------------------+

> **(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**                           |   |   |         |
+-----------------------------------------------------+---+---+---------+
| **A. When you - or your covered spouse - are age 65 | * |   |         |
| or over and have Medicare and you...**              | * |   |         |
|                                                     | T |   |         |
|                                                     | h |   |         |
|                                                     | e |   |         |
|                                                     | p |   |         |
|                                                     | r |   |         |
|                                                     | i |   |         |
|                                                     | m |   |         |
|                                                     | a |   |         |
|                                                     | r |   |         |
|                                                     | y |   |         |
|                                                     | p |   |         |
|                                                     | a |   |         |
|                                                     | y |   |         |
|                                                     | e |   |         |
|                                                     | r |   |         |
|                                                     | f |   |         |
|                                                     | o |   |         |
|                                                     | r |   |         |
|                                                     | t |   |         |
|                                                     | h |   |         |
|                                                     | e |   |         |
|                                                     | i |   |         |
|                                                     | n |   |         |
|                                                     | d |   |         |
|                                                     | i |   |         |
|                                                     | v |   |         |
|                                                     | i |   |         |
|                                                     | d |   |         |
|                                                     | u |   |         |
|                                                     | a |   |         |
|                                                     | l |   |         |
|                                                     | w |   |         |
|                                                     | i |   |         |
|                                                     | t |   |         |
|                                                     | h |   |         |
|                                                     | M |   |         |
|                                                     | e |   |         |
|                                                     | d |   |         |
|                                                     | i |   |         |
|                                                     | c |   |         |
|                                                     | a |   |         |
|                                                     | r |   |         |
|                                                     | e |   |         |
|                                                     | i |   |         |
|                                                     | s |   |         |
|                                                     | . |   |         |
|                                                     | . |   |         |
|                                                     | . |   |         |
|                                                     | * |   |         |
|                                                     | * |   |         |
+-----------------------------------------------------+---+---+---------+
|                                                     | * |   | **This  |
|                                                     | * |   | Plan**  |
|                                                     | M |   |         |
|                                                     | e |   |         |
|                                                     | d |   |         |
|                                                     | i |   |         |
|                                                     | c |   |         |
|                                                     | a |   |         |
|                                                     | r |   |         |
|                                                     | e |   |         |
|                                                     | * |   |         |
|                                                     | * |   |         |
+-----------------------------------------------------+---+---+---------+
| 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 | f |   | for     |
|     employment status                               | o |   | other   |
|                                                     | r |   | s       |
|                                                     | P |   | ervices |
|                                                     | a |   |         |
|                                                     | r |   |         |
|                                                     | t |   |         |
|                                                     | B |   |         |
|                                                     | s |   |         |
|                                                     | e |   |         |
|                                                     | r |   |         |
|                                                     | v |   |         |
|                                                     | i |   |         |
|                                                     | c |   |         |
|                                                     | e |   |         |
|                                                     | s |   |         |
+-----------------------------------------------------+---+---+---------+
| 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...**       |   |   |         |
+-----------------------------------------------------+---+---+---------+
| ###### Have Medicare solely                         |   |   |         |
|  based on end stage renal disease (ESRD) and**...** |   |   |         |
|                                                     |   |   |         |
| ###### It is within the fi                          |   |   |         |
| rst 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                         |   |   |         |
+-----------------------------------------------------+---+---+---------+
| 1)  Become eligible for Medicare due to ESRD while  |   | f |         |
|     already a Medicare beneficiary and**...**       |   | o |         |
|                                                     |   | r |         |
| -   This Plan was the primary payer before          |   | 3 |         |
|     eligibility due to ESRD                         |   | 0 |         |
|                                                     |   | - |         |
|                                                     |   | m |         |
|                                                     |   | o |         |
|                                                     |   | n |         |
|                                                     |   | t |         |
|                                                     |   | h |         |
|                                                     |   | c |         |
|                                                     |   | o |         |
|                                                     |   | o |         |
|                                                     |   | r |         |
|                                                     |   | d |         |
|                                                     |   | i |         |
|                                                     |   | n |         |
|                                                     |   | a |         |
|                                                     |   | t |         |
|                                                     |   | i |         |
|                                                     |   | o |         |
|                                                     |   | n |         |
|                                                     |   | p |         |
|                                                     |   | e |         |
|                                                     |   | r |         |
|                                                     |   | i |         |
|                                                     |   | o |         |
|                                                     |   | d |         |
+-----------------------------------------------------+---+---+---------+
| -   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**...**                     |   | [ |         |
|                                                     |   | ] |         |
|     -   You have FEHB coverage on your own or       |   | { |         |
|         through your spouse who is also an          |   | . |         |
|         annuitant                                   |   | m |         |
|                                                     |   | a |         |
|                                                     |   | r |         |
|                                                     |   | k |         |
|                                                     |   | } |         |
+-----------------------------------------------------+---+---+---------+
| -   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

+-------------------+--------------------------------------------------+
| > **              | If you are eligible for Medicare, you may choose |
| Medicare+Choice** | to enroll in and get your Medicare benefits from |
| > []{#__RefHead   | a Medicare+Choice plan. These are health care    |
| ing___Toc20908456 | choices (like HMOs) in some areas of the         |
| > .anchor}        | 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](http://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 waive or lower some  |
|                   | of our copayments and coinsurance for your FEHB  |
|                   | and Medicare coverage. If you would like         |
|                   | information about our Medicare+Choice plan,      |
|                   | please call from Portland 503/813-2000 or from   |
|                   | other areas 800/813-2000 or our TTY number at    |
|                   | 800/735-2900. Your Kaiser Permanente Senior      |
|                   | Advantage-FEHBP benefits that we lowered or      |
|                   | waived include:                                  |
|                   |                                                  |
|                   | -   Primary and Specialty care visits such as    |
|                   |     physical exams, allergy testing and          |
|                   |     injections, respiratory therapy, radiation   |
|                   |     therapy, same-day outpatient surgery,        |
|                   |     gynecological visits, hearing and vision     |
|                   |     exams, and manual manipulation of the spine: |
|                   |     \$0                                          |
|                   |                                                  |
|                   | ```{=html}                                       |
|                   | <!-- -->                                         |
|                   | ```                                              |
|                   | -   Dialysis: \$0                                |
|                   |                                                  |
|                   | ```{=html}                                       |
|                   | <!-- -->                                         |
|                   | ```                                              |
|                   | -   Hospital care: \$0                           |
|                   |                                                  |
|                   | -   Durable medical equipment, prosthetics,      |
|                   |     orthotics, supplies (including diabetic      |
|                   |     supplies) and certain drugs per Medicare     |
|                   |     criteria: \$0                                |
|                   |                                                  |
|                   | -   Family planning: \$0                         |
|                   |                                                  |
|                   | -   Home health care: \$0                        |
|                   |                                                  |
|                   | -   Hospice care: \$0                            |
|                   |                                                  |
|                   | -   House calls: \$0                             |
|                   |                                                  |
|                   | ```{=html}                                       |
|                   | <!-- -->                                         |
|                   | ```                                              |
|                   | -   Medical social services: \$0                 |
|                   |                                                  |
|                   | -   Mental health and substance abuse: inpatient |
|                   |     and outpatient services (residential/day     |
|                   |     treatment does have a copayment): \$0        |
|                   |                                                  |
|                   | -   Physical, occupational and speech therapy,   |
|                   |     and multidisciplinary rehabilitation         |
|                   |     services: \$0                                |
|                   |                                                  |
|                   | -   Reconstructive therapy: \$0                  |
|                   |                                                  |
|                   | -   Skilled Nursing Facility care: up to 100     |
|                   |     days per benefit period: \$0                 |
|                   |                                                  |
|                   | -   Transplants: \$0                             |
|                   |                                                  |
|                   | -   Vision exams: \$0                            |
|                   |                                                  |
|                   | ```{=html}                                       |
|                   | <!-- -->                                         |
|                   | ```                                              |
|                   | -   X-ray, lab tests, and other special          |
|                   |     procedures: \$0                              |
|                   |                                                  |
|                   | **This Plan and another plan's 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 lower or |
|                   | waive 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 |
|                   | service area.                                    |
+-------------------+--------------------------------------------------+
|                   |                                                  |
+-------------------+--------------------------------------------------+
| **TRICARE and     | TRICARE is the health care program for eligible  |
| CHAMP             | dependents of military persons and retirees of   |
| VA**[]{#__RefHead | the military. TRICARE includes the CHAMPUS       |
| ing___Toc20908459 | program. CHAMPVA provides health coverage to     |
| .anchor}          | 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.   |
+-------------------+--------------------------------------------------+
| **Workers'        | We do not cover services that:                   |
| Compensati        |                                                  |
| on**[]{#__RefHead | -   you need because of a workplace-related      |
| ing___Toc20908460 |     illness or injury that the Office of         |
| .anchor}          |     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.         |
+-------------------+--------------------------------------------------+
|                   |                                                  |
+-------------------+--------------------------------------------------+
| **Medica          | When you have this Plan and Medicaid, we pay     |
| id**[]{#__RefHead | first.                                           |
| ing___Toc20908461 |                                                  |
| .anchor}          | **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      | We do not cover services and supplies when a     |
| Government        | local, State, or Federal Government agency       |
| agencies are      | directly or indirectly pays for them.            |
| responsible for   |                                                  |
| your              |                                                  |
| ca                |                                                  |
| re**[]{#__RefHead |                                                  |
| ing___Toc20908462 |                                                  |
| .anchor}          |                                                  |
+-------------------+--------------------------------------------------+
|                   |                                                  |
+-------------------+--------------------------------------------------+
| **When others are | When you receive money to compensate you for     |
| responsible for   | medical or hospital care for injuries or illness |
| injuri            | caused by another person, you must reimburse us  |
| es**[]{#__RefHead | for any expenses we paid. However, we will cover |
| ing___Toc20908463 | the cost of treatment that exceeds the amount    |
| .anchor}          | 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[]{#__RefHeading___Toc20908464 .anchor}

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

  ----------------------- -----------------------------------------------
  **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.

                          

  **Copayment**           A copayment is a fixed amount of money you pay
                          when you receive covered services.

                          

  **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.

                          

  **Durable medical       Durable medical equipment (DME) is 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 a
  coverage**              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, it is either
                          the amount that we have negotiated with the
                          non-Plan Provider, or if we do not have a
                          negotiated amount, the amount that we believe
                          is usual and customary for the service or
                          supply, compared to the billed charges. Our
                          allowance is based upon the reasonableness of
                          the billed 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 of the Northwest.

                          

  **You**                 You refers to the enrollee and each covered
                          family member.
  ----------------------- -----------------------------------------------

  -----------------------------------------------------------------------
  Section 11. FEHB facts[]{#__RefHeading___Toc20908465 .anchor}

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

+----------------------+-----------------------------------------------+
| **Coverage           |                                               |
| information**        |                                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **No pre-existing    | We will not refuse to cover the treatment of  |
| condition            | a condition that you had before you enrolled  |
| li                   | in this Plan solely because you had the       |
| mitation**[]{#__RefH | condition before you enrolled.                |
| eading___Toc20908466 |                                               |
| .anchor}             |                                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Where you can get  | See [www.opm.gov/insure]{.underline}. Also,   |
| information about    | your employing or retirement office can       |
| enrolling in the     | answer your questions, and give you a *Guide  |
| FEHB                 | to Federal Employees Health Benefits Plans,*  |
| Program**[]{#__RefH  | brochures for other plans, and other          |
| eading___Toc20908467 | materials you need to make an informed        |
| .anchor}             | 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 coverage  | Self Only coverage is for you alone. Self and |
| available for you    | Family coverage is for you, your spouse, and  |
| and your             | your unmarried dependent children under age   |
| family**[]{#__RefH   | 22, including any foster children or          |
| eading___Toc20908468 | stepchildren your employing or retirement     |
| .anchor}             | 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 31     |
|                      | days 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.                  |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **Children's Equity  | OPM has implemented the Federal Employees     |
| Act**[]{#__RefH      | Health Benefits Children\'s Equity Act of     |
| eading___Toc20908469 | 2000. This law mandates that you be enrolled  |
| .anchor}             | 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,                                   |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   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               |
|                      |                                               |
|                      | ```{=html}                                    |
|                      | <!-- -->                                      |
|                      | ```                                           |
|                      | -   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 benefits and  | The benefits in this brochure are effective   |
| premiums             | on January 1. If you joined this Plan during  |
| start**[]{#__RefH    | Open Season, your coverage begins on the      |
| eading___Toc20908470 | first day of your first pay period that       |
| .anchor}             | 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           | When you retire, you can usually stay in the  |
| retire**[]{#__RefH   | FEHB Program. Generally, you must have been   |
| eading___Toc20908471 | enrolled in the FEHB Program for the last     |
| .anchor}             | 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).     |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| **When you lose      |                                               |
| benefits**[]{#__RefH |                                               |
| eading___Toc20908472 |                                               |
| .anchor}             |                                               |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| > **When FEHB        | You will receive an additional 31 days of     |
| > coverage           | coverage, for no additional premium, when:    |
| > ends**[]{#__RefH   |                                               |
| eading___Toc20908473 | -   Your enrollment ends, unless you cancel   |
| > .anchor}           |     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).                |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| > **Spouse equity    | If you are divorced from a Federal employee   |
| >                    | or annuitant, you may not continue to get     |
| coverage**[]{#__RefH | benefits under your former spouse's           |
| eading___Toc20908474 | enrollment. This is the case even when the    |
| > .anchor}           | 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       |
|                      | website, www.opm.gov/insure.                  |
+----------------------+-----------------------------------------------+
|                      |                                               |
+----------------------+-----------------------------------------------+
| > **Temporary        | If you leave Federal service, or if you lose  |
| > continuation of    | coverage because you no longer qualify as a   |
| > coverage           | family member, you may be eligible for        |
| > (TCC)**[]{#__RefH  | Temporary Continuation of Coverage (TCC). For |
| eading___Toc20908475 | example, you can receive TCC if you are not   |
| > .anchor}           | 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]{.underline}. It explains |
|                      | what you have to do to enroll.                |
+----------------------+-----------------------------------------------+
| > **Converting to    | You may convert to a non-FEHB individual      |
| > Individual         | policy if:                                    |
| >                    |                                               |
| Coverage**[]{#__RefH | -   Your coverage under TCC or the spouse     |
| eading___Toc20908476 |     equity law ends (if you canceled your     |
| > .anchor}           |     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.      |
|                      | Conversion to an individual dental plan is    |
|                      | not available.                                |
|                      |                                               |
|                      | 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.                      |
+----------------------+-----------------------------------------------+
| > **Getting a        | The Health Insurance Portability and          |
| > Certificate of     | Accountability Act of 1996 (HIPAA) is a       |
| > Group Health Plan  | Federal law that offers limited Federal       |
| >                    | protections for health coverage availability  |
| Coverage**[]{#__RefH | and continuity to people who lose employer    |
| eading___Toc20908477 | group coverage. If you leave the FEHB         |
| > .anchor}           | 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 website                                  |
|                      | ([www.opm.gov/insure/health]{.underline});    |
|                      | 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.                                  |
+----------------------+-----------------------------------------------+

  -----------------------------------------------------------------------
  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.

**The Federal Flexible Spending Account Program - *FSAFEDS***

-   **What is an FSA?** It is a tax-favored benefit that allows you 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%!!*

There are two types of FSAs offered by the FSAFEDS Program:

**Health Care Flexible**

**Spending Account**

> **(HCFSA)** Covers eligible health care expenses not reimbursed by
> this Plan, or any 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 than that 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.

```{=html}
<!-- -->
```
-   Covers eligible dependent care expenses incurred so you can work, or
    if you are married, so you and your spouse can work, or your spouse
    can look for work 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.

-   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 Open Season** You **must make an election** to enroll in
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 [**www.fsafeds.com**](http://www.fsafeds.com/).

-   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 enroll?** If you are a Federal employee eligible
> for 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 I** Plan carefully when deciding how much to
    contribute to an FSA.

> **contribute to my FSA?** Because of the tax 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 HCFSA** Every FEHB health plan includes cost sharing
    features, such as deductibles

> **pay for?** 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 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 the High Option of this Plan, typical out-of-pocket expenses
> include: office visit copayments, pharmacy copayments and durable
> medical goods coinsurance.
>
> Under the Standard Option of this Plan, typical out-of-pocket expenses
> include: office visit copayments, pharmacy copayments and durable
> medical goods 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 website at
> <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** An FSA lets you allot money for eligible
    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 a FSA: \$ 2,000       -\$0-

  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
    income tax return if you receive

> **deductions** reimbursement for them from your HCFSA or DCFSA. Below
> are some guidelines that may help you decide whether to participate in
> FSAFEDS.
>
> **Health care expenses** The HCFSA is tax-free from the first dollar.
> In addition, you may be reimbursed from the HCFSA at any time during
> 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 a HCFSA is also exempt from FICA taxes. This exemption is not
> available on your Federal income tax return.

**Dependent care expenses** The DCFSA generally allows many families to
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 anything** Probably not. While there is an
    administrative fee of \$4.00 per month

> **to participate in FSAFEDS?** for an HCFSA and 1.5% of the annual
> election 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 website 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
website** at

> [**www.fsafeds.com**](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: <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)

**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
1-800-843-3557)

**to request an application** or visit
[www.ltcfeds.com](http://www.ltcfeds.com/).

  -----------------------------------------------------------------------
  **Index**[]{#__RefHeading___Toc20908479 .anchor}

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

Do not rely on this page; it is for your convenience and may not show
all pages where the terms appear.

**A**ccidental injury to teeth 50

Allergy Care 20

Alternative treatment 27

Ambulance 33, 36, 39

Anesthesia 32

Autologous bone marrow transplant 20, 31

**B**iopsy 28

Blood and blood plasma 34

Breast cancer screening 17

**C**asts 34, 35

Centers of Excellence 47

Changes for 2004 10

Chemotherapy 20

Chiropractic 27

Cholesterol tests 17

Coinsurance 63

Colorectal cancer screening 17

Congenital anomalies 28, 29

Contraceptive devices and drugs 10, 19, 29, 44

Coordination of benefits 58

Covered providers 11

**D**eaf and hearing impaired service 46

Deductible 14, 63

Dental care 49, 50, 51, 52

Diagnostic services 16

Disputed claims review 56

Donor expenses (transplants) 31

Dressings 34

Drugs, prescription 43, 44, 45

Durable medical equipment (DME) 26, 63

**E**ducational classes and programs 53

Effective date of enrollment 66

Emergency 37, 38, 39

Exclusions, general 54

Experimental or investigational 63

Eyeglasses 22

**F**amily planning 19

Fecal occult blood test 17

Flexible benefits options 46

**G**eneral exclusions 54

**H**earing services 22

Home health services 26

Hospice care 36

Hospital 33

**I**mmunizations 18

Infertility 20

Inpatient hospital benefits 33

Insulin 44

**L**aboratory and pathological services 17, 27

Long term care insurance 72

**M**agnetic resonance imagings (MRIs) 17, 27

Mail order prescription drugs 43

Mammograms 17

Maternity benefits 19

Medicaid 62

Medically necessary 64

Medicare 58

Mental conditions/substance abuse benefits 40

**N**ewborn care 16, 19

Non-FEHB benefits 53

Nursery charges 19

**O**bstetrical care 19

Occupational therapy 21

Oral and maxillofacial surgery 30

Orthopedic devices 24

Out-of-pocket expenses 14

Outside the service area student coverage 48

Oxygen 26, 34

**P**ap test 17

Physical examination 18

Physical therapy 21

Prescription drugs 43, 44, 45

Preventive care, adult 17

Preventive care, children 18

Preventive services 17

Prior approval 13

Prostate cancer screening 17

Prosthetic devices 24

Psychotherapy 42

**R**adiation therapy 20

Renal dialysis 20

Room and board 33

**S**econd surgical opinion 16

Services from other Kaiser Permanente Plans 48

Skilled nursing care benefits 35

Smoking cessation 53

Speech therapy 22

Splints 34

Sterilization procedures 29

Student coverage outside the service area 48

Subrogation 62

Substance abuse 40

Surgery 28

-   Anesthesia 32

-   Oral 30

-   Outpatient 35

-   Reconstructive 29

Syringes 44

**T**emporary continuation of coverage 67

Transplants 31

Travel benefit 47

Treatment therapies 20

**V**ision services 22, 23, 24

**W**ell child care 18

Workers' compensation 62

**X**-rays 17

**24** hour nurse line 46

  -----------------------------------------------------------------------
  **Summary of benefits**[]{#__RefHeading___Toc20908480 .anchor} **for
  Kaiser Foundation Health Plan of the Northwest -- Standard Option --
  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**          | * |
|                                           |                      | * |
|                                           |                      | P |
|                                           |                      | a |
|                                           |                      | g |
|                                           |                      | e |
|                                           |                      | * |
|                                           |                      | * |
+-------------------------------------------+----------------------+---+
| Medical services provided by physicians:  | \$15 per office      | > |
|                                           | visit                |   |
| -   Diagnostic and treatment services     |                      | 1 |
|     provided in the office                |                      | 6 |
+-------------------------------------------+----------------------+---+
| Services provided by a hospital:          | > Nothing            | > |
|                                           | >                    |   |
| -   Inpatient                             | > Nothing            | 3 |
|                                           |                      | 3 |
| -   Outpatient                            |                      | > |
|                                           |                      | > |
|                                           |                      |   |
|                                           |                      | 3 |
|                                           |                      | 5 |
+-------------------------------------------+----------------------+---+
| Emergency benefits:                       | > \$75 per visit     | > |
|                                           | >                    |   |
| -   In-area                               | > \$75 per visit     | 3 |
|                                           |                      | 8 |
| -   Out-of-area                           |                      | > |
|                                           |                      | > |
|                                           |                      |   |
|                                           |                      | 3 |
|                                           |                      | 8 |
+-------------------------------------------+----------------------+---+
| Mental health and substance abuse         | > Regular cost       | > |
| treatment:                                | > sharing            |   |
|                                           |                      | 4 |
|                                           |                      | 0 |
+-------------------------------------------+----------------------+---+
| -   Prescription drugs                    | > \$15 per           | > |
|                                           | > prescription or    |   |
|                                           | > refill for generic | 4 |
|                                           | > drugs              | 3 |
|                                           | >                    |   |
|                                           | > \$30 per           |   |
|                                           | > prescription or    |   |
|                                           | > refill for         |   |
|                                           | > brand-name drugs   |   |
+-------------------------------------------+----------------------+---+
| Dental Care                               | > No current benefit | > |
|                                           |                      |   |
|                                           |                      | N |
|                                           |                      | A |
+-------------------------------------------+----------------------+---+
| Vision Care                               | > Refractions; \$15  | > |
|                                           | > per office visit   |   |
|                                           |                      | 2 |
|                                           |                      | 2 |
+-------------------------------------------+----------------------+---+
| Special features: Flexible benefits       |                      | > |
| option; 24 hour nurse line; Services for  |                      |   |
| deaf and hearing impaired; Language       |                      | 4 |
| interpretation; High risk pregnancies;    |                      | 6 |
| Centers of Excellence; Travel benefit;    |                      |   |
| Services from other Kaiser Permanente     |                      |   |
| Plans; Student coverage outside the       |                      |   |
| service area                              |                      |   |
+-------------------------------------------+----------------------+---+
| Protection against catastrophic costs     | Nothing after        | > |
|                                           | \$600/Self Only or   |   |
| (your catastrophic protection             | \$1,200/Family       | 1 |
| out-of-pocket maximum)                    | enrollment per year  | 4 |
|                                           |                      |   |
|                                           | > Some costs do not  |   |
|                                           | > count toward this  |   |
|                                           | > protection         |   |
+-------------------------------------------+----------------------+---+

  -----------------------------------------------------------------------
  **Summary of benefits for Kaiser Foundation Health Plan of the
  Northwest -- High Option -- 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**          | * |
|                                           |                      | * |
|                                           |                      | P |
|                                           |                      | a |
|                                           |                      | g |
|                                           |                      | e |
|                                           |                      | * |
|                                           |                      | * |
+-------------------------------------------+----------------------+---+
| Medical services provided by physicians:  | \$10 per office      | > |
|                                           | visit                |   |
| -   Diagnostic and treatment services     |                      | 1 |
|     provided in the office                |                      | 6 |
+-------------------------------------------+----------------------+---+
| Services provided by a hospital:          | > Nothing            | > |
|                                           | >                    |   |
| -   Inpatient                             | > Nothing            | 3 |
|                                           |                      | 3 |
| -   Outpatient                            |                      | > |
|                                           |                      | > |
|                                           |                      |   |
|                                           |                      | 3 |
|                                           |                      | 5 |
+-------------------------------------------+----------------------+---+
| Emergency benefits:                       | > \$75 per visit     | > |
|                                           | >                    |   |
| -   In-area                               | > \$75 per visit     | 3 |
|                                           |                      | 8 |
| -   Out-of-area                           |                      | > |
|                                           |                      | > |
|                                           |                      |   |
|                                           |                      | 3 |
|                                           |                      | 8 |
+-------------------------------------------+----------------------+---+
| Mental health and substance abuse         | > Regular cost       | > |
| treatment:                                | > sharing            |   |
|                                           |                      | 4 |
|                                           |                      | 0 |
+-------------------------------------------+----------------------+---+
| -   Prescription drugs                    | > \$10 per           | > |
|                                           | > prescription or    |   |
|                                           | > refill for generic | 4 |
|                                           | > drugs              | 3 |
|                                           | >                    |   |
|                                           | > \$20 per           |   |
|                                           | > prescription or    |   |
|                                           | > refill for         |   |
|                                           | > brand-name drugs   |   |
+-------------------------------------------+----------------------+---+
| Dental Care                               | > Various copayments | > |
|                                           | > based on procedure |   |
|                                           | > rendered           | 4 |
|                                           |                      | 9 |
+-------------------------------------------+----------------------+---+
| Vision Care                               | > Refractions; \$10  | > |
|                                           | > per office visit   |   |
|                                           |                      | 2 |
|                                           |                      | 2 |
+-------------------------------------------+----------------------+---+
| Special features: Flexible benefits       |                      | > |
| option; 24 hour nurse line; Services for  |                      |   |
| deaf and hearing impaired; Language       |                      | 4 |
| interpretation; High risk pregnancies;    |                      | 6 |
| Centers of Excellence; Travel benefit;    |                      |   |
| Services from other Kaiser Permanente     |                      |   |
| Plans; Student coverage outside the       |                      |   |
| service area                              |                      |   |
+-------------------------------------------+----------------------+---+
| Protection against catastrophic costs     | Nothing after        | > |
|                                           | \$600/Self Only or   |   |
| (your catastrophic protection             | \$1,200/Family       | 1 |
| out-of-pocket maximum)                    | enrollment per year  | 4 |
|                                           |                      |   |
|                                           | > Some costs do not  |   |
|                                           | > count toward this  |   |
|                                           | > protection         |   |
+-------------------------------------------+----------------------+---+

  -----------------------------------------------------------------------
  **Notes**

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

  -----------------------------------------------------------------------
  **Notes**

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  **Notes**

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  **Notes**

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**2004 Rate Information for**

**Kaiser Foundation Health Plan of the Northwest**

**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.

+--------------+-----+-------+-------+-------+-------+-------+-------+
|              |     | **    |       |       |       | **P   |       |
|              |     | Non-P |       |       |       | ostal |       |
|              |     | ostal |       |       |       | Prem  |       |
|              |     | Prem  |       |       |       | ium** |       |
|              |     | ium** |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
|              |     | **    |       | *     |       | **    |       |
|              |     | Biwee |       | *Mont |       | Biwee |       |
|              |     | kly** |       | hly** |       | kly** |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Type of**  | **  | **Go  | **Y   | **Go  | **Y   | **U   | **Y   |
|              | Cod | v't** | our** | v't** | our** | SPS** | our** |
| **           | e** |       |       |       |       |       |       |
| Enrollment** |     | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  | **Sh  |
|              |     | are** | are** | are** | are** | are** | are** |
+--------------+-----+-------+-------+-------+-------+-------+-------+

+--------------+-----+-------+-------+-------+-------+-------+-------+
| **High       | *   | **    | *     | **    | **    | **    | *     |
| Option**     | *57 | \$121 | *\$49 | \$263 | \$106 | \$143 | *\$27 |
|              | 1** | .40** | .22** | .03** | .65** | .32** | .30** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **High       | *   | **    | **    | **    | **    | **    | *     |
| Option**     | *57 | \$277 | \$114 | \$600 | \$248 | \$327 | *\$64 |
|              | 2** | .09** | .48** | .36** | .04** | .12** | .45** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | *     | **    | *     | **    | *     |
| Option**     | *57 | \$112 | *\$37 | \$243 | *\$81 | \$132 | *\$16 |
|              | 4** | .25** | .42** | .22** | .07** | .83** | .84** |
| **Self       |     |       |       |       |       |       |       |
| Only**       |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+
| **Standard   | *   | **    | *     | **    | **    | **    | *     |
| Option**     | *57 | \$257 | *\$85 | \$558 | \$186 | \$304 | *\$38 |
|              | 5** | .62** | .87** | .17** | .06** | .85** | .64** |
| **Self and   |     |       |       |       |       |       |       |
| Family**     |     |       |       |       |       |       |       |
+--------------+-----+-------+-------+-------+-------+-------+-------+

##  {#section-24 .StyleK2}