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Home My WebLink AboutAgreement A-24-672 with Kaiser Permanente.pdf This page intentionally left blank �Q►ii,, KAISER PERMANEWEo October 30,2024 HOLLIS MAGILL,DIRECTOR OF HUMAN RESOURCES COUNTY OF FRESNO,RETIREE 2220 TULARE ST FL 14 FRESNO,CA 93721-2122 Re:Renewal Group Agreement for Group ID#604334 Renewal effective date: 01/01/2025 Dear HOLLIS MAGILL, We value being your health care partner,and look forward to continuing to work with you to provide your subscribers with quality care well into the future. Enclosed,please find the new Group Agreement between COUNTY OF FRESNO,RETIREE and Kaiser Foundation Health Plan,Inc.,Northern California Region,for the contract period January 1,2025,through December 31,2025.For a summary of the most important changes,see the enclosed 2025 Notice.Review these documents carefully and keep the Group Agreement for your records.Also,be sure to sign and return the copy of the Agreement Signature Page provided with the Group Agreement. If your group doesn't want to renew the Group Agreement,you'll need to give us advance written notice,as described under "Termination on Notice"in the"Termination of Agreement"section of your Group Agreement. Your new monthly rate See the"Calculating Premiums"section of the enclosed Group Agreement for your new premium rate,which will start January 1,2025. Your premium rates may have been affected by a variety of factors,including: • The periodic adjustment of base rates,resulting from changes in the costs of delivering care • Changes in your group's size or demographics • Changes to the risk characteristics of your group • Your group's actual claims experience,depending on your group size If you have any questions or need enrollment or enrollee materials for your subscribers,please contact your Kaiser Permanente account manager,Dorrenda Thomas,at 559-448-3753. If you receive the Group Agreement or enrollment materials in electronic form,you are not authorized to modify or alter in any way the text or the formatting of these documents.If you post the electronic documents on your intranet site,you must do so in such a way so as to permit your subscribers to download and print a complete and accurate copy of the materials.Please refer to the Group Agreement for details about these requirements. Thank you for continuing to offer Kaiser Permanente to your subscribers. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:36 Sincerely, I Thomas A. Curtin Jr. Senior Vice President,Commercial Group Business cc: PETER P MEILAK COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:36 Agreement No. 24-672 Agreement Signature Page Acceptance of Agreement Group acknowledges acceptance of this Agreement by signing the Signature Page and returning it to Health Plan. If Group does not return it to Health Plan,Group will be deemed as having accepted this Agreement if Group pays Health Plan any amount toward Premiums. Group may not change this Agreement by adding or deleting words,and any such addition or deletion is void.Health Plan might not respond to any changes or comments submitted on or with this Signature Page.Group may not construe Health Plan's lack of response to any submitted changes or comments to imply acceptance.If Group wishes to change anything in this Agreement,Group must contact its Health Plan account manager.Health Plan will issue a new Agreement or amendment if Health Plan and Group agree on any changes. Bindinq Arbitration As more fully set forth in the arbitration provision in the applicable Evidence of Coverage,disputes between Members,their heirs, relatives,or associated parties(on the one hand)and Health Plan,Kaiser Permanente health care providers,or other associated parties(on the other hand)for alleged violation of any duty arising out of or related to this Agreement, including any claim for medical or hospital malpractice(a claim that medical services or items were unnecessary or unauthorized or were improperly,negligently,or incompetently rendered),for premises liability,or relating to the coverage for,or delivery of,services or items pursuant to this Agreement,irrespective of legal theory,must be decided by binding arbitration and not by lawsuit or resort to court process,except as applicable law provides for judicial review of arbitration proceedings. Members enrolled under this Agreement thus give up their right to a court orjury trial,and instead accept the use of binding arbitration as specified in the applicable Evidence of Coverage except that the following types of claims are not subject to binding arbitration: • Claims within the jurisdiction of the Small Claims Court • Claims subject to a Medicare appeals procedure as applicable to Kaiser Permanente Senior Advantage Members • Claims that cannot be subject to binding arbitration under governing law Signatures Kaiser Foundation Foundation Health Plan,Inc.,Northern California Region a. 4- Thomas A.Curtin Jr. Authorized officer Senior Vice President,Commercial Group Business October 30,2024 COUNTY OF FRESNO, RETIREE Authorized Group officer signature NQlhah Magsi q, GhairrnaVl of -(-ham �bar� 7 StAeervjsoKS 1,9-/- -a o- Print name and title J Date Please sign and return this copy of the signature page: • By mail:Kaiser Permanente,California Service Center,P.O.Box 23448,San Diego,CA 92193-3448. • By fax: 1-855-355-5334 ATTEST: BERNICE E.SEIDEL Clerk of the Board of Supervisors County of Fresno,State of lifornia By_ Deputy COUNTY OF FRESNO,RETIREE Purchaser ID:604334 Contract: I Version:36 Helpful information about disclosures that Group must make The Group is required to provide certain disclosures about its group health plan to employees and dependents: • As described in your Group Agreement,Group must notify subscribers and dependents about changes to coverage and provide an Evidence of Coverage(EOC). • If Group's group health plan is subject to Affordable Care Act(ACA)mandates,Group must provide any required ACA notices. • If Group's group health plan is subject to ERISA,Group's plan administrator must provide a Summary Plan Description.In addition,Groups may have additional reporting and disclosure obligations under ERISA.These additional requirements are the Group's responsibility.For more information on your group health plan's obligations under ERISA,we recommend that you seek the advice of your own legal counsel.You may also find general information at dol.gov/agencies/ebsa.A handy Reporting and Disclosure Guide for Employee Benefit Plans is also available on that website. In addition,the EOCs that are part of your Group Agreement provide certain notices as described in this document.The information in this document applies to commercial group coverage offered by Health Plan in its Northern and Southern California Regions(it does not apply to Medicare coverage,the Federal Employees Health Benefit Plan,or self-funded coverage). This document is not legal advice. Group should consult its own legal counsel for specific guidance related to its group health plan requirements. Disclosures required by the ACA The EOCs include the following notices required by the ACA: • Grandfathered status: In EOCs for grandfathered coverage,a notice of grandfathered status is provided in the"Cost Share Summary"section. • Choice of provider.A notice about designating a Plan Primary Care Physician(including a pediatrician for a child)is provided under"Your Personal Plan Physician"in the"How to Obtain Services"section. • Access to Plan obstetricians and gynecologists.A notice that prior authorization is not required to receive care from obstetricians and gynecologists is provided under"Getting a Referral"in the"How to Obtain Services"section. • Claims procedure.The procedure for post-service claims is explained in the"Post-Service Claims and Appeals" section. The procedure for all other requests for payment and services is explained in the"Dispute Resolution"section. The"Dispute Resolution"section says that binding arbitration is not required when governing law prevents the use of binding arbitration. • Nondiscrimination.A nondiscrimination notice and language assistance taglines are provided with the EOC. SPD Disclosures required by ERISA The Employee Retirement Income Security Act(ERISA)is a federal law that sets minimum standards for employee welfare benefit plans,which includes group health plans,and is established by private employers and employee organizations(for example,unions).The plan administrator of an employee welfare benefit plan is responsible for development and distribution of a Summary Plan Description (SPD)to plan participants and beneficiaries. The plan administrator is an employee or designee of the employer or union plan sponsor.Health Plan underwrites group coverage that plan sponsors make available,but Health Plan is neither the`ERISA plan"nor the"plan administrator"of the group health plan. The plan administrator of a group health plan may satisfy the Group's ERISA disclosure obligations by incorporating the EOC into the Group's SPD by reference.However,the EOC by itself does not satisfy the disclosure requirements under ERISA.If a disclosure required under ERISA is not in the EOC,or if the plan administrator chooses to not incorporate the EOC in the SPD,the plan administrator must provide the disclosure in the Group's SPD.If there are discrepancies between COUNTY OF FRESNO,RETIREE Purchaser ID:604334 Contract: 1 Version:36 Page 1 the description of Kaiser Permanente HMO-covered group health plan benefits appearing in the Group's SPD and those reflected in the EOC, the benefit description appearing in Kaiser Permanente's EOC will control. The chart below identifies certain key ERISA disclosure requirements and whether those disclosures are in the EOC.It is intended for use as a reference tool;however,it is the plan administrator's responsibility to verify that the Group's SPD satisfies all ERISA disclosure requirements.For more information about ERISA,visit the Department of Labor website at dol.Eov/a2en cies/eb sa. SPD Disclosure Requirement Evidence of Coverage(EOC) Eligibility The EOC does not explain in detail Group's eligibility requirements(a summary of Health Plan eligibility requirements appears in the"Premiums,Eligibility,and Enrollment"section).The plan administrator must include Group's specific eligibility information in the Group's SPD. Special enrollment,including: The EOC explains special enrollment rights in"How to Enroll and When Coverage • Special enrollment due to new Begins"in the"Premiums,Eligibility and Enrollment"section.The plan dependents administrator is required to document that plan participants and beneficiaries have been informed of these rights. • Special enrollment due to loss of other coverage The EOC does not describe the procedures governing qualified medical child support • Special enrollment due to order(QMCSO)determinations or state that plan participants and beneficiaries can eligibility for premium assistance obtain,without charge,a copy of those procedures from the plan administrator.The • Special enrollment due to court plan administrator should include this information in the Group's SPD. or administrative order • Special enrollment due to reemployment after military service • Otherspecial enrollment events Michelle's law(student status and Michelle's law establishes that dependent children who are under the dependent child eligibility) age limit of the group health plan eligibility rules meet the eligibility age requirement whether or not they are attending school.Therefore,Health Plan provides a notice about student leaves of absence only in EOCs where the dependent child age limit is higher for a student than the non-student.If the student age limit is higher,the notice appears in the"Who Is Eligible"section under"Eligibility as a Dependent." COUNTY OF FRESNO,RETIREE Purchaser ID:604334 Contract: 1 Version:36 Page 2 SPD Disclosure Requirement Evidence of Coverage(EOC) Description of coverage,including: Under ERISA,a Group's SPD may provide only a general description of plan • Cost sharing benefits as long as the SPD references a detailed schedule of benefits and incorporates it by reference.That detailed schedule of benefits can be the Health Plan • Exclusions and limitations EOC,which offers a clear description of the benefits and the rules for obtaining those • Prior authorization requirements benefits.If the plan administrator chooses to incorporate the EOC by reference into • Provider network the Group's SPD,the Group may satisfy the ERISA coverage disclosure requirements by including the following text without changes as the introduction to • Claims procedure the benefit chart in the Group's SPD: "This benefit chart provides summary information only.It does not fully describe your benefit coverage.For details on your benefit coverage,please refer to your Kaiser Foundation Health Plan,Inc. (Health Plan)Evidence of Coverage.The Health Plan Evidence of Coverage is the binding document between Health Plan and its members. As a condition of coverage,a Health Plan physician must determine that any requested services and items are medically necessary to prevent,diagnose,or treat a medical condition.Generally,requested services and items must be provided, prescribed,authorized,or directed by a Health Plan provider.Except as otherwise noted in the Health Plan Evidence of Coverage,you must receive the requested services and items from a Health Plan-designated provider inside the Health Plan Service Area in which you are enrolled. For details on the benefit and claims review and adjudication procedures,please refer to the Health Plan Evidence of Coverage." Newborns' and Mothers' Health Health Plan covers hospital lengths of stay following childbirth for mothers and Protection Act(Newborn Act) newborns in accord with the Newborn Act. To assist the plan administrator in complying with the ERISA notice requirement,a Newborn Act notice is included under"ERISA notices"in the"Miscellaneous Provisions"section of the EOC. Women's Health and Cancer Rights Health Plan covers mastectomy and reconstructive surgery and related services as Act(WHCRA) required by WHCRA.To assist the plan administrator in complying with the ERISA notice requirement,a WHCRA notice is included under"ERISA notices"in the "Miscellaneous Provisions"section of the EOC. ERISA rights The EOC does not include a statement of ERISA rights.The plan administrator should include this information in the Group's SPD. COBRA The EOC states that continuation health care coverage under federal COBRA or under state continuation coverage laws may be available following termination of group health coverage.If your employee benefit plan offers COBRA continuation coverage,your plan administrator is responsible for administration of this coverage (for example,your plan administrator is responsible for providing all notices related to continuation coverage,eligibility,and participation). COUNTY OF FRESNO,RETIREE Purchaser ID:604334 Contract: 1 Version:36 Page 3 SPD Disclosure Requirement Evidence of Coverage(EOC) Information about the employee Health Plan does not collect this information from groups and cannot include it in the benefit plan and how it is EOC. The plan administrator must include this information in the Group's SPD. administered,such as: • Name of the plan • Name and address of the entity maintaining the plan • Employer identification number, plan number,type of plan,and how it is administered • The plan administrator's authority to terminate the plan or amend benefits,circumstances that may trigger ineligibility, denial,or reduction of benefits, and rights upon termination of plan or amendment of benefits COUNTY OF FRESNO,RETIREE Purchaser ID:604334 Contract: 1 Version:36 Page 4 2025 Group Agreement Summary of Changes and Clarifications Notice Effective January 1, 2025, through December 31, 2025 Kaiser Foundation Health Plan,Inc.,Northern California Region("Health Plan")is renewing your Group's Group Agreement(`Agreement'),including the Evidence of Coverage("EOC')documents,effective January 1,2025 (your Group's"Anniversary Date")by sending COUNTY OF FRESNO,RETIREE("Group")this "Group Agreement Summary of Changes and Clarifications Notice"("Notice')in accord with the"Term of Agreement and Renewal"section of your Agreement.This Notice includes a summary of the changes and clarifications that will be effective when your Agreement is renewed on the Anniversary Date,unless a different effective date is stated.Unless otherwise indicated,the changes and clarifications described here apply to each type of coverage that will be effective upon renewal of your Agreement.If you have not already received your renewal contract("2025 Agreement"),please contact your broker or Health Plan account manager to obtain a copy.If your Group does not wish to renew your Agreement,your Group must give us advance written notice in accord with"Termination on Notice"in the"Termination of Agreement"section of your Agreement. In certain circumstances,this summary may also include changes that we made to your Agreement during the 2024 plan year through an amendment.This summary does not include minor changes and clarifications that Health Plan is making to improve the readability of the Agreement or any changes we are making at your Group's request.In addition to the changes and clarifications listed below,Health Plan will also make any changes required by law or by any state or federal agency. The"Calculating Premiums"section of this Notice includes the Premiums that will be applicable to your Agreement upon renewal. Note: Some capitalized terms in this Notice have special meaning.Please see the"Definitions"section of the applicable EOC document in your Agreement for terms you should know.In this Notice"Medicare EOCs"means Kaiser Permanente Senior Advantage EOCs,and"non-Medicare EOCs"means all EOCs other than Senior Advantage EOCs. 2025 Agreement If you have not already received your 2025 Agreement and your Group wants to make changes to benefits or Cost Share, please request them before your Anniversary Date.You will then receive your 2025 Agreement shortly after you tell your Health Plan account manager about changes your Group wants to make.If you don't wish to make changes to benefits or Cost Share,you don't need to do anything to renew your Agreement.We will provide your Group with its 2025 Agreement within 60 days after your Anniversary Date.If you would like to receive it sooner,please contact your Health Plan account manager. We will provide the 2025 Agreement to your Group online.We will mail your Group a notice to let you know when the 2025 Agreement is available to view and download.If your Group would like a paper copy of your 2025 Agreement and you are not able to download it from business.ky.org,please contact our customer service team at 800-731-4661. Please keep in mind that unless your Group notifies us to make changes to benefits or Cost Share,your 2025 Agreement, including the EOC documents,will reflect the same benefits and Cost Share information as your current Agreement, subject to the changes described in this Notice. Global Clarifications to Agreements Renewal Materials Under"Renewal,""Termination of Agreement,""Termination for Nonpayment,""Electronic Delivery of Written Communications,Contracts,and Other Documents,"and"Notices,"we have updated language regarding electronic delivery of notices. Termination on Notice In some Agreements,the timeframe for notice under"Termination on Notice"in the"Termination of Agreement"section has been updated to align with current policy.Groups must provide at least 15 days' notice if the group does not have Senior Advantage Members and 30 days'notice if the group has Senior Advantage Members. Revisions to 2025 Kaiser Permanente EOCs The changes and clarifications to Evidence of Coverage("EOC')documents described below are effective on January 1, 2025(unless a different effective date is stated). Note: Some capitalized terms in this Notice have special meaning.Please see the"Definitions"section of the applicable EOC for terms you should know.In this Notice"Medicare EOCs"means Kaiser Permanente Senior Advantage EOCs,and "non-Medicare EOCs"means all EOCs other than Senior Advantage EOCs. Changes Contraceptive Equity(SB 523) In non-Medicare EOCs,for consistency with state law effective January 1,2024: • We have removed the verbiage "when prescribed by a Plan Provider"from the "Contraceptive Drugs and Devices" table in the "Cost Share Summary"section of non-Medicare EOCs,for consistency with other tables in the Cost Share Summary.Drugs still require a prescription, as specified in the "Outpatient Prescription Drugs, Supplies, and Supplements"section, except for over-the-counter contraceptives • Sterilization Services for Members assigned male at birth are covered at no charge for plans that include the ACA preventive package, except that these Services continue to be subject to the Plan Deductible in all HSA-Compatible High Deductible Health Plan EOCs COVID-19 Services For consistency with federal guidance, non preventive COVID-19 tests and therapeutics are subject to the Plan Deductible in HSA-Compatible High Deductible Health Plan EOCs. Doula Services (AB 904) We have updated non-Medicare EOCs to add coverage for doulas, as required by state law effective January 1,2025: • Under `Reproductive Health Services"in the Cost Share Summary, we have added a table for "Plan Doula services" • Under `Definitions,"we have added "Plan Doula"as a defined term • Under `Reproductive Health Services"in the "Benefits"section, we have added a section called "Plan Doula services"outlining the scope of coverage for doulas, and added exclusions for doula services to "Reproductive Health Services exclusions" Fitness benefit for Senior Advantage Members A fitness benefit is being added to all Group Senior Advantage plans to help members take control of their health and feel their best. The fitness benefit will be provided through the One PassTM program, which includes access to in-network gyms, online fitness classes and resources, home fitness kits, and an online brain health program at no charge. Note:If your plan already includes the Silver&Fit®Healthy Aging and Exercise Program, it will automatically change to the One PassTM fitness program effective January 1,2025. Medicare Part D Outpatient Prescription Drug Coverage In Medicare EOCs with Part D coverage, the Senior Advantage Medicare Part D Catastrophic Coverage Stage threshold is decreasing from$8,000 to$2,000 for calendar year 2025, in accordance with the Centers for Medicare&Medicaid Services(CMS)requirements. If your drug plan includes a Coverage Gap Stage, the Coverage Gap Stage is going to be eliminated for calendar year 2025. The Coverage Gap Stage and the Coverage Gap Discount Program will no longer exist in the Part D benefit. The Coverage Gap Discount Program will be replaced by the Manufacturer Discount Program. Under the Manufacturer Discount Program, drug manufacturers pay a portion of the plan's full cost for covered Part D brand name drugs and biologics during the Initial Coverage Stage and the Catastrophic Coverage Stage.Discounts paid by manufacturers under the Manufacturer Discount Program do not count toward out-of-pocket costs. Service Area Expansion Due to an expansion of our Service Area, in non-Medicare EOCs, the Service Area of our Northern California Region now includes the following zip codes in Monterey County:93901, 93902, 93905, 93906, 93907, 93912, 93915, 93933, 93955, 93962, 95004, 95012, 95039, 95076.Members may obtain care from Plan Providers in Monterey County. Weight Loss Drug Exclusion Due to a change in policy, under "Outpatient prescription drugs,supplies, and supplements exclusions"in the "Outpatient Prescription Drugs, Supplies, and Supplements"section, we have added an exclusion for drugs to treat obesity or weight loss, when prescribed solely for the purpose of losing weight, except when medically necessary for the treatment of morbid obesity.Also, we have added that we may require Members who areprescribed drugs for morbid obesity to be enrolled in a covered comprehensive weight loss program,for a reasonable period of time prior to or concurrent with receiving the prescription drug. For cases in which a Member does not have morbid obesity, coverage for drugs prescribed solely for the purpose of losing weight will only be available when your Group has purchased a weight-loss drug rider.If your Group wishes to have this coverage,please contact your Health Plan account manager to request pricing.If your Group purchases this rider, we will add a disclosure under "Outpatientprescription drugs,supplies, and supplements limitations"in the "Outpatient Prescription Drugs, Supplies, and Supplements"section that weight loss drug coverage may require enrollment in a comprehensive weight loss program. Clarifications 988 Services Under"Services from Non-Plan Providers"in the"Mental Health Services"and"Substance Use Disorder Treatment" sections of non-Medicare EOCs,we have clarified 988 Services are subject to prior authorization after the mental health or substance use disorder condition has been stabilized. About Kaiser Permanente Point-of-Service(POS) Plan for Large Group Under"About Kaiser Permanente Point-of-Service(POS)Plan for Large Group"in the"Introduction"section of POS Plan EOCs,we have updated the description of the POS Plan for clarity. Behavioral Health Treatment We have revised language related to Behavioral Health Treatment for Autism Spectrum Disorder in non-Medicare EOCs, for consistency with the level of detail included about other benefits described in EOCs.These changes are editorial only and do not represent any change to benefits: • Coverage for Behavioral Health Treatment for Autism Spectrum Disorder is now described under"Mental Health Services"in the"Cost Share Summary"and"Benefits"sections,and we have eliminated the separate"Behavioral Health Treatment for Autism Spectrum Disorder"sections from the EOC • In conjunction with this change,we have also added"Behavioral Health Treatment for Autism Spectrum Disorder"to the"Definitions"section,and updated various cross-references throughout the EOC CARE Plan In HSA-Compatible High Deductible Health Plan EOCs,under"CARE Plan"in the"Cost Share Summary,"we have clarified that Services covered due to a court-ordered CARE Plan are subject to the Plan Deductible,except for prescription drugs and Preventive Services. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Issue Date:October 30,2024 Page 3 COVID-19 Therapeutics Under"How to obtain covered items"in the"Outpatient Prescription Drugs,Supplies,and Supplements"section,we have clarified that COVID-19 therapeutics may be obtained from a Non-Plan Provider.In Medicare EOCs,this only applies to Senior Advantage plans when Medicare is secondary coverage. Definitions Under"Definitions,"we have made the following revisions: • Updated the definition of"Region"to remove"Idaho,"as there are no longer Kaiser Permanente providers in Idaho • Updated the definition of"Surrogacy Arrangement"to clarify that the surrogate may be impregnated in any manner Drug Tiers Under"About Drug Tiers"in the"Outpatient Prescription Drugs,Supplies,and Supplements"section of non-Medicare EOCs,we have revised the description of drug tiers to clarify that drugs are categorized as Tier 1,Tier 2,or Tier 4 whether they are on the formulary or not and how to find out which tier a particular drug is on.Also,we have revised the drug tier descriptions under"Note"in the"General rules about coverage and your Cost Share"section for consistency with how the drug tiers are described elsewhere in the EOC. Fertility Services Benefit Limit In EOCs that include a benefit limit for fertility Services,under"Fertility Services benefit limit"in the"Fertility Services" section,we have clarified that a lifetime maximum benefit limit may be a cycle or dollar maximum. Internally Implanted Prosthetic and Orthotic Devices Under"Prosthetic and Orthotic Devices"in the"Cost Share Summary"section of non-Medicare EOCs,we have deleted the row for internally implanted prosthetic and orthotic devices.We have instead added language under"Internally implanted devices"in the"Benefits"section to state that the member pays the Cost Share for the procedure to implant the device.This is not a change in policy. Issue Date We have added the issue date to the cover of the EOC so it is clear when that EOC was issued.The issue date was previously only provided in the footer of the EOC. Massage Therapy Exclusion Under"Massage Therapy"in the"Exclusions,Limitations,Coordination of Benefits,and Reductions"section,we have revised the massage therapy exclusion to clarify that services of massage therapists are also excluded.We have also removed language that references physical therapy services to reduce ambiguity(the purpose and outcome of physical therapy is different than massage therapy and the qualifications for the people who provide these services are also different). This is not a change in coverage. Outpatient prescription drugs, supplies, and supplements Under"Outpatient prescription drugs,supplies,and supplements"in the"Benefits and Your Cost Share"section of Medicare EOCs,we have revised the section to clarify coverage for drugs not covered by Medicare. This is not a change in coverage. Over-the-Counter Oral Contraceptives In the"Contraceptive drugs and devices"table in the"Cost Share Summary"section of non-Medicare EOCs, we have clarified that the availability of hormonal contraceptives by mail varies since over-the-counter oral contraceptives are not available by mail order. Reversal of Sterilization Under"Fertility Services"and"Reproductive Health Services"in the"Benefits"section of non-Medicare EOCs,for clarity, we have replaced the term"voluntary sterilization"with"surgical sterilization originally performed for family planning purposes."This is an editorial change only and does not represent a change in coverage. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Issue Date:October 30,2024 Page 4 Services Related to Mental Health and Substance Use Disorder Treatment Under"Mental Health Services,""Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services,"and "Substance Use Disorder Treatment"in non-Medicare EOCs,we have updated language to add examples of covered Services.These revisions do not represent a change in coverage. Special Enrollment Under"Special enrollment due to new Dependents"in the"Premiums,Eligibility,and Enrollment"section,we have made editorial changes to clarify when enrollment of newly acquired Dependent children is effective. Third Party Liability Under"Injuries or illnesses alleged to be caused by other parties"in the"Reductions"section,we have removed some language regarding providers whose contract may allow the provider to assert a lien to recover fees from a judgment or settlement a member receives,as this arrangement is no longer applicable. Timely Access to Care Under"Access to mental health Services and substance use disorder treatment"in the"Timely Access to Care"section of non-Medicare EOCs,we have clarified that if we are not able to arrange timely and geographically accessible mental health or substance use disorder treatment Services for you,we will cover and arrange such Services from a Non-Plan Provider,as required by state law. Utilization Review Materials Under"Additional information about utilization review determination criteria for mental health Services or substance use disorder treatment"in the"Getting a Referral"and"Grievances"sections of non-Medicare EOCs,we have added a disclosure that utilization review determination criteria and any education program materials for individuals making authorization decisions related to mental health Services or substance use disorder treatment are available at no cost. Calculating Premiums To calculate the amount of Full Premiums that apply to a Family(a Subscriber and all of their Dependents): 1. If this Agreement includes more than one contract option,determine the coverage(EOCs and contract options)that apply to each Member in the Family(for example,Traditional Plan and any Ancillary Coverage). 2. Determine the family role type and Medicare status of each Member(for family role types,please see the"Definitions" section of the EOC for the definition of Subscriber,Dependent,and Spouse). 3. Identify the Premiums for each Member for each EOC and contract option(including contract options issued through a separate contract)based on the family role type and Medicare status of each Member: • Premiums for coverage issued under this Agreement appear in the Premium tables below. • If this Agreement includes a POS Plan contract option(a contract option with one tier underwritten by Health Plan and two tiers underwritten by Kaiser Permanente Insurance Company),the amounts shown below for the POS Plan (for Large Groups)product includes premiums for the Health Plan and Kaiser Permanente Insurance Company portions of Group's POS Plan coverage,and Group submits payment for this coverage as part of Full Premium. • If Ancillary Coverage has been issued under a separate contract and Premiums for that coverage are not listed in the Premium tables below,refer to that contract for Premiums.This Ancillary Coverage is part of the contract options selected by Group,and Group submits payment for this Ancillary Coverage as part of Full Premium. 4. Add the amounts of Premiums for each Member together to arrive at the total,Full Premiums required for the Family. Monthly Premiums for Kaiser Permanente Traditional HMO Plan — EOC # 1 TRADITIONAL PLAN HIGH-HIGH OPTION Members under age 65 who are not eligible for Medicare Family role type Premiums Subscriber $1,677.13 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Issue Date:October 30,2024 Page 5 Family role type Premiums Spouse $1,408.79 1 st child without Spouse $905.65 1st child with Spouse $872.11 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1 st child without Spouse $905.65 1st child with Spouse $872.11 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1 st child without Spouse $905.65 1 st child with Spouse $872.11 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1st child without Spouse $905.65 1 st child with Spouse $872.11 Each additional Dependent $0.00 Members under age 65 who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1st child without Spouse $2,017.67 1 st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members under age 65 when Medicare is secondary Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1st child without Spouse $905.65 1st child with Spouse $872.11 Each additional Dependent $0.00 Members age 65 and over whose Medicare eligibility is unknown Family role type Premiums Subscriber $2,017.67 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:36 Issue Date:October 30,2024 Page 6 Family role type Premiums Spouse $2,017.67 1 st child without Spouse $2,017.67 1 st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members age 65 and over who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,607.02 Spouse $1,607.02 1 st child without Spouse $1,607.02 1 st child with Spouse $1,607.02 Each additional Dependent $1,607.02 Members age 65 and over who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1st child without Spouse $2,017.67 1 st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members age 65 and over who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,607.02 Spouse $1,607.02 1 st child without Spouse $1,607.02 1 st child with Spouse $1,607.02 Each additional Dependent $1,607.02 Members age 65 and over who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1 st child without Spouse $2,017.67 1st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members age 65 and over when Medicare is secondary Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1 st child without Spouse $905.65 1 st child with Spouse $872.11 Each additional Dependent $0.00 Note:Members who are"eligible for"Medicare Part A or B are those who would qualify for Medicare Part A or B coverage if they applied for it.Members who"have"Medicare Part A or B are those who have been granted Medicare Part A or B coverage.Medicare Part A provides inpatient coverage and Part B provides outpatient coverage. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Issue Date:October 30,2024 Page 7 Monthly Premiums for Kaiser Permanente Senior Advantage (HMO) with Part D — EOC #2 SENIOR ADVANTAGE HIGH-HIGH OPTION Family role type Medicare Parts A&B Medicare Part B only Subscriber $341.24 $651.24 1 st Dependent $341.24 $651.24 2nd Dependent 1 $341.24 1 $651.24 Each additional Dependent 1 $341.24 1 $651.24 Monthly Premiums for American Specialty Health Plans Chiropractic Plan — EOC #3 CHIROPRACTIC BENEFIT-HIGH OPTION Family role type Premiums Subscriber $1.55 Spouse $1.31 1st child without Spouse $0.84 1 st child with Spouse $0.80 Monthly Premiums for Kaiser Permanente Senior Advantage (HMO) with Part D — EOC #4 SENIOR ADVANTAGE-LOW OPTION Family role type Medicare Parts A&B Medicare Part B only Subscriber $270.41 $580.41 1 st Dependent $270.41 $580.41 2nd Dependent 1 $270.41 1 $580.41 Each additional Dependent 1 $270.41 1 $580.41 Monthly Premiums for Kaiser Permanente Traditional HMO Plan — EOC # 5 TRADITIONAL PLAN-LOW OPTION Members under age 65 who are not eligible for Medicare Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1st child without Spouse $905.65 1st child with Spouse $872.11 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1 st child without Spouse $905.65 1st child with Spouse $872.11 Each additional Dependent $0.00 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:36 Issue Date:October 30,2024 Page 8 Members under age 65 who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1 st child without Spouse $905.65 1st child with Spouse $872.11 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1 st child without Spouse $905.65 1st child with Spouse $872.11 Each additional Dependent $0.00 Members under age 65 who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1st child without Spouse $2,017.67 1 st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members under age 65 when Medicare is secondary Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1st child without Spouse $905.65 1 st child with Spouse $872.11 Each additional Dependent $0.00 Members age 65 and over whose Medicare eligibility is unknown Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1st child without Spouse $2,017.67 1 st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members age 65 and over who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,607.02 Spouse $1,607.02 1 st child without Spouse $1,607.02 1st child with Spouse $1,607.02 Each additional Dependent $1,607.02 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:36 Issue Date:October 30,2024 Page 9 Members age 65 and over who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1st child without Spouse $2,017.67 1 st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members age 65 and over who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,607.02 Spouse $1,607.02 1 st child without Spouse $1,607.02 1 st child with Spouse $1,607.02 Each additional Dependent $1,607.02 Members age 65 and over who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1 st child without Spouse $2,017.67 1 st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members age 65 and over when Medicare is secondary Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1 st child without Spouse $905.65 1st child with Spouse $872.11 Each additional Dependent $0.00 Note:Members who are"eligible for"Medicare Part A or B are those who would qualify for Medicare Part A or B coverage if they applied for it.Members who"have"Medicare Part A or B are those who have been granted Medicare Part A or B coverage.Medicare Part A provides inpatient coverage and Part B provides outpatient coverage. Monthly Premiums for American Specialty Health Plans Chiropractic Plan — EOC #9 HMO CHIRO ACN NCR-LOW OPTION Family role type Premiums Subscriber $1.55 Spouse $1.31 1 st child without Spouse $0.84 1 st child with Spouse $0.80 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Issue Date:October 30,2024 Page 10 Enrollment Unit Chart Contract name:COUNTY OF FRESNO,RETIREE Group ID: 604334 Contract: 1 The charts below describe how the coverage your Group has purchased(called contract options)are organized into administrative groupings(called enrollment units)for the purposes of enrollment and billing.Please keep this document handy for future reference as the information it contains will be helpful when reporting membership changes. An Evidence of Coverage(EOC)for each Health Plan coverage that your Group has purchased is incorporated into the enclosed Group Agreement(the EOC number is the same as the contract option number). If your Group has purchased non- Health Plan coverage(such as dental coverage),the carrier(s)for the applicable coverage will send its agreement to your Group under separate cover. Contract option:A unique contract option name and number exists for each coverage option that you offer to your Members.For example,if you offer the same benefits to all of your Members,but have different eligibility rules for different segments of your membership,you will have a separate contract option for each coverage option. Enrollment unit:An enrollment unit is a grouping of contract options for a specific segment of your Member population for enrollment and billing purposes.If there are contract options only available to a specific segment of your Member population,then there will be a distinct enrollment unit for that segment.If your Member population is billed separately, there will be a separate enrollment unit(or billing unit)for each segment.Note:An enrollment unit may also be referred to as a subgroup. The following are the enrollment units associated with this contract: Enrollment unit number: 0 Enrollment unit name: COUNTY OF FRESNO,RETIREE HI Billing contact:Brittany Simmons Contract Option Product name Contract option name 1 Kaiser Permanente Traditional HMO Plan TRADITIONAL PLAN HIGH-HIGH OPTION 2 Kaiser Permanente Senior Advantage SENIOR ADVANTAGE HIGH-HIGH (HMO)with Part D OPTION 3 American Specialty Health Plans Chiropractic CHIROPRACTIC BENEFIT-HIGH OPTION Plan Enrollment unit number: 1 Enrollment unit name: COUNTY OF FRESNO,RETIRE LOW Billing contact:Brittany Simmons Contract Option Product name Contract option name 4 Kaiser Permanente Senior Advantage SENIOR ADVANTAGE-LOW OPTION (HMO)with Part D 5 Kaiser Permanente Traditional HMO Plan TRADITIONAL PLAN-LOW OPTION 9 American Specialty Health Plans Chiropractic HMO CHIRO ACN NCR-LOW OPTION Plan COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Issue Date:October 30,2024 Page 1 Enrollment unit number: 8500 Enrollment unit name: COUNTY OF FRESNO,RETIREE/LIS REFUNDS Billing contact:Brittany Simmons Contract Option Product name Contract option name 1 Kaiser Permanente Traditional HMO Plan TRADITIONAL PLAN HIGH-HIGH OPTION 2 Kaiser Permanente Senior Advantage SENIOR ADVANTAGE HIGH-HIGH (HMO)with Part D OPTION 3 American Specialty Health Plans Chiropractic CHIROPRACTIC BENEFIT-HIGH OPTION Plan COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Issue Date:October 30,2024 Page 2 ��Ai% KAISER PERMANEWE® Kaiser Foundation Health Plan, Inc. Northern California Region A nonprofit corporation Group Agreement for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 36 Issue Date: October 30, 2024 January 1,2025, through December 31, 2025 TABLE OF CONTENTS Introduction............................................................................................................................................................................1 Health Plan and Other Ancillary Products.........................................................................................................................1 Term of Agreement and Renewal...........................................................................................................................................1 Termof Agreement.............................................................................................................................................................1 Renewal..............................................................................................................................................................................1 Amendmentof Agreement......................................................................................................................................................2 Amendments Effective on your Group's Anniversary Date..............................................................................................2 Amendments Related to Government Approval................................................................................................................2 AmendmentDue to Medicare Changes..............................................................................................................................2 Amendment Due to Tax or Other Charges.........................................................................................................................2 OtherAmendments.............................................................................................................................................................3 Acceptanceof Amendments...............................................................................................................................................3 Terminationof Agreement......................................................................................................................................................3 Terminationon Notice........................................................................................................................................................3 Termination Due to Nonacceptance of Amendments........................................................................................................3 Terminationfor Nonpayment.............................................................................................................................................4 Termination for Fraud or Intentionally Furnishing Incorrect or Incomplete Information.................................................4 Termination for Violation of Contribution or Participation Requirements........................................................................4 Termination for Discontinuance of a Product or all Products within a Market.................................................................5 Contribution and Participation Requirements........................................................................................................................5 MiscellaneousProvisions.......................................................................................................................................................6 Assignment.........................................................................................................................................................................6 AttorneyFees and Costs.....................................................................................................................................................6 Confidential Information about Health Plan or its Affiliates.............................................................................................6 ContractProviders..............................................................................................................................................................7 Delegationof Claims Review.............................................................................................................................................7 Electronic Delivery of Written Communications,Contracts,and Other Documents........................................................7 Enrollment Application Requirements...............................................................................................................................7 Grandfathered Health Plan Coverage.................................................................................................................................7 GoverningLaw...................................................................................................................................................................8 MemberInformation..........................................................................................................................................................8 NoWaiver..........................................................................................................................................................................9 NonduplicationAgreement................................................................................................................................................9 Notices................................................................................................................................................................................9 OpenEnrollment..............................................................................................................................................................10 Other Group coverage that covers Essential Health Benefits..........................................................................................10 Reporting Membership Changes and Retroactivity.........................................................................................................10 Representation Regarding Waiting Periods.....................................................................................................................11 Rightto Examine Records................................................................................................................................................11 Social Security and Tax Identification Numbers.............................................................................................................11 Premiums..............................................................................................................................................................................11 Due Date and Payment of Premiums...............................................................................................................................11 NewMembers..................................................................................................................................................................12 MembershipTermination.................................................................................................................................................12 PremiumRebates..............................................................................................................................................................12 Medicare...........................................................................................................................................................................12 Subscriber Contributions for Medicare Part C and Part D Coverage...............................................................................13 CalculatingPremiums......................................................................................................................................................14 Monthly Premiums for Kaiser Permanente Traditional HMO Plan—EOC# 1.............................................................15 Monthly Premiums for Kaiser Permanente Senior Advantage(HMO)with Part D—EOC#2....................................17 Monthly Premiums for American Specialty Health Plans Chiropractic Plan—EOC#3..............................................17 Monthly Premiums for Kaiser Permanente Senior Advantage(HMO)with Part D—EOC#4....................................17 Monthly Premiums for Kaiser Permanente Traditional HMO Plan—EOC#5.............................................................17 Monthly Premiums for American Specialty Health Plans Chiropractic Plan—EOC#9..............................................20 AgreementSignature Page....................................................................................................................................................21 Acceptanceof Agreement.................................................................................................................................................21 BindingArbitration..........................................................................................................................................................21 Signatures.........................................................................................................................................................................21 Introduction This Group Agreement(Agreement),including the Evidence of Coverage(EOC)and other documents listed below under "Health Plan and Other Ancillary Products,"the group application that Group submitted to Health Plan,and any amendments to any of them,all of which are incorporated into this Agreement by reference,constitute the contract between Kaiser Foundation Health Plan,Inc.,(Health Plan)and COUNTY OF FRESNO,RETIREE(Group). If Group has applied for Ancillary Coverage through Health Plan,provided under a separate contract,it is the intent of Group and Health Plan that coverage under this Agreement and those other contract(s)be treated as one package of benefits for the purposes of term,renewal,termination and payment of Premiums. In consideration of timely payment of Premium,Health Plan will provide or arrange for covered Services to Members in accord with the documents listed below under"Health Plan and Other Ancillary Products." Health Plan and Other Ancillary Products Health Plan products, including Ancillary Coverage offered by Health Plan Product name Contract option name for product EOC# Kaiser Permanente Traditional HMO Plan TRADITIONAL PLAN HIGH-HIGH OPTION 1 Kaiser Permanente Senior Advantage(HMO)with Part D SENIOR ADVANTAGE HIGH-HIGH 2 OPTION American Specialty Health Plans Chiropractic Plan CHIROPRACTIC BENEFIT-HIGH OPTION 3 Kaiser Permanente Senior Advantage(HMO)with Part D SENIOR ADVANTAGE-LOW OPTION 4 Kaiser Permanente Traditional HMO Plan TRADITIONAL PLAN-LOW OPTION 5 American Specialty Health Plans Chiropractic Plan HMO CHIRO ACN NCR-LOW OPTION 9 Pediatric dental coverage Not applicable Other Ancillary Coverage Not applicable In this Agreement, some capitalized terms have special meaning;please see the"Definitions"section in the EOC documents for definitions of terms that are used in EOC documents and this Agreement. Term of Agreement and Renewal Term of Agreement Unless terminated as set forth in the"Termination of Agreement'section,this Agreement is effective from January 1,2025, through December 31,2025. Renewal This Agreement does not automatically renew.If Group complies with all of the terms of this Agreement,Health Plan will provide prior written notice of any offer to renew the Agreement,in a timely manner consistent with applicable state and federal requirements,by doing one of the following: • Providing Group with a new Group Agreement to become effective immediately after termination of this Agreement COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 1 • Extending the term of this Agreement and making other changes pursuant to"Amendments Effective on your Group's Anniversary Date"in the"Amendment of Agreement"section Health Plan will provide Group a renewal notice,which will include a summary of changes to this Agreement. The new or extended-term Group Agreement will incorporate the changes summarized in the renewal notice.Health Plan will issue to Group the new or extended-term Group Agreement after Group confirms its intent to renew coverage,or 60 days after Group's Anniversary Date if Group does not provide affirmative confirmation of its intent to renew coverage prior to that date. If Group does not want to renew the Agreement,Group must give Health Plan written notice as described under "Termination on Notice"or"Termination due to Nonacceptance of Amendments"in the"Termination of Agreement" section. Note:Your Group's Anniversary Date is January 1. Amendment of Agreement Amendments Effective on your Group's Anniversary Date Upon 60 days prior written notice to Group,Health Plan may extend the term of this Agreement and make other changes by amending this Agreement effective January 1 (the Anniversary Date). Amendments Related to Government Approval If Health Plan notified Group that Health Plan had not received all necessary governmental approvals related to this Agreement,Health Plan may amend this Agreement by giving written notice to Group after receiving all necessary governmental approvals.Any such government-approved provisions go into effect on January 1,2025 (unless the government requires a later effective date). Amendment Due to Medicare Changes Health Plan contracts on a calendar year basis with the Centers for Medicare&Medicaid Services(CMS)to offer Kaiser Permanente Senior Advantage.Health Plan may amend this Agreement to change any Kaiser Permanente Senior Advantage EOCs and Premiums effective January 1,2026(unless the federal government requires or allows a different effective date). The amendment may include an increase or decrease in Premiums and benefits(including Member Cost Sharing and any Medicare Part D coverage level thresholds).Health Plan will give Group written notice of any such amendment. In addition,Health Plan may amend this Agreement at any time by giving written notice to Group,in order to increase any benefits of any Medicare product approved by the Centers for Medicare&Medicaid Services(CMS). Amendment Due to Tax or Other Charges If a government agency or other taxing authority imposes or increases a tax or other charge(other than a tax on or measured by net income)upon Health Plan or Plan Providers(or any of their activities),then upon 60 days prior written notice, Health Plan may increase Group's Premiums to include Group's share of the new or increased tax or charge. Group's share will be determined by dividing the number of Members enrolled through Group by the total number of members enrolled in Health Plan's Northern California Region. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: l/1/25-12/31/25 Issue Date:October 30,2024 Page 2 Other Amendments Health Plan may amend this Agreement at any time by giving written notice to Group,in order to address any law or regulatory requirement,which may include an increase in Premiums to reflect an increase in costs to Health Plan or Plan Providers(Health Plan will give Group 60 days prior written notice of any increase in Premiums or reduction in benefits). Acceptance of Amendments All amendments are deemed accepted by Group unless Group gives Health Plan written notice of nonacceptance within 15 days after the date of Health Plan's amendment notice,in which case this Agreement will terminate pursuant to "Termination due to Nonacceptance of Amendments"in the"Termination of Agreement"section. Termination of Agreement This Agreement will terminate under any of the conditions listed below.All rights to benefits under this Agreement end on the termination date,except as expressly provided in the"Termination of Membership"or"Continuation of Membership" sections of an Evidence of Coverage.The termination date is the first day when this Agreement is no longer in effect(for example,if the termination date is January 1,2026,the last minute this Agreement was in effect was at 11:59 p.m.on December 31,2025). If Health Plan terminates this Agreement, Health Plan will give Group written notice.In the case of"Termination for Nonpayment","Termination for Fraud or Intentionally Furnishing Incorrect or Incomplete Information",and"Termination for Discontinuance of a Product or all Products within a Market,"Health Plan will provide both advance notice of the termination in addition to a final notice of termination.Within five business days of receipt of an advance or final notice of termination,Group will provide each Subscriber a legible copy of the notice and will give Health Plan proof of that notice was provided including the date thereof. Termination on Notice If Group has Kaiser Permanente Senior Advantage Members If Group has Senior Advantage Members enrolled under this Agreement at the time Health Plan receives written notice from Group that it is terminating this Agreement,Group may terminate this Agreement effective as of the Anniversary Date by giving prior written notice to Health Plan at least 30 days prior to the Anniversary Date,except that the termination will be effective on the first of the month following the Anniversary Date if the Anniversary Date is not the first of the month. Group remains responsible for remitting all amounts payable relating to this Agreement,including Premiums,for the period through the termination date. If Group does not have Kaiser Permanente Senior Advantage Members If Group does not have Senior Advantage Members enrolled under this Agreement at the time Health Plan receives written notice from Group that it is terminating this Agreement,Group may terminate this Agreement effective as of the Anniversary Date by giving prior written notice to Health Plan at least 15 days prior to the Anniversary Date,except that termination will be effective on the first of the month following the Anniversary Date if the Anniversary Date is not the first of the month.Group remains responsible for remitting all amounts payable relating to this Agreement,including Premiums,for the period through the termination date. Termination Due to Nonacceptance of Amendments All amendments are deemed accepted by Group unless Group gives Health Plan written notice of nonacceptance within 15 days after the date of Health Plan's amendment notice and Group remits all amounts payable related to this Agreement, COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 3 including Premiums,for the period prior to the amendment effective date,in which case this Agreement will terminate on the following date,as applicable: • In the case of amendments described in the"Amendment of Agreement"section under"Amendments Related to Government Approval"and"Amendments Due to Medicare Changes,"and amendments described under"Other Amendments"that do not require 60 days notice by Health Plan,if Group has Kaiser Permanente Senior Advantage Members enrolled under this Agreement at the time Health Plan receives written notice of nonacceptance,the termination date will be first of the month following 30 days after Health Plan receives written notice of nonacceptance • In all other cases,the termination date will be the day before the effective date of the amendment Termination for Nonpayment Premiums are due for the Full Premium owed as described in the"Premiums"section.If Health Plan does not receive the required Premium payment for all coverage issued under this Agreement on or before the due date,we will provide a notice of start of grace period to Group as described under"Notices"in the"Miscellaneous Provisions"section.This notice will include the following information: • A statement that we have not received Full Premium payment and that we will terminate this Agreement for nonpayment if we do not receive the required Premiums by the specified date • The amount of Premiums past due If we do not receive the required Premiums by the date indicated in the notice of start of grace period,the Agreement will terminate and all coverage issued under the Agreement will end on the date specified in the notice of start of grace period, which will be at least 30 days after the date of the notice.The Agreement will remain in effect during this grace period,but upon termination Group will be responsible for paying all past due Premiums,including the Premiums for coverage provided during this grace period. We will provide notice of termination to Group as described under"Notices"in the"Miscellaneous Provisions"section if we do not receive Full Premium payment within 30 days after the date of the notice of start of grace period. If Group has Kaiser Permanente Senior Advantage Members enrolled under this Agreement at the time Health Plan gives written notice to Group,Health Plan may terminate this Agreement effective on one date with respect to Members other than Senior Advantage Members and effective on a later date with respect to Senior Advantage Members,in order to comply with CMS termination notice requirements. Termination for Fraud or Intentionally Furnishing Incorrect or Incomplete Information If Group commits fraud or intentionally furnishes incorrect or incomplete material information to Health Plan,Health Plan may terminate this Agreement by giving advance written notice to Group,and Group is liable for all unpaid Premiums up to the termination date. If Group has Kaiser Permanente Senior Advantage Members enrolled under this Agreement at the time Health Plan gives written notice to Group,Health Plan may terminate this Agreement effective on one date with respect to Members other than Senior Advantage Members and effective on a later date with respect to Senior Advantage Members,in order to comply with CMS termination notice requirements. Termination for Violation of Contribution or Participation Requirements If Group fails to comply with Health Plan's participation or contribution requirements(including those discussed in the "Contribution and Participation Requirements"section),Health Plan may terminate this Agreement by giving advance written notice to Group,and Group is liable for all unpaid Premiums up to the termination date. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 4 If Group has Kaiser Permanente Senior Advantage Members enrolled under this Agreement at the time Health Plan gives written notice to Group,Health Plan may terminate this Agreement effective on one date with respect to Members other than Senior Advantage Members and effective on a later date with respect to Senior Advantage Members,in order to comply with CMS termination notice requirements. Termination for Discontinuance of a Product or all Products within a Market Grandfathered products Health Plan may terminate a particular product or all products offered in a small or large group market as permitted or required by law.If Health Plan discontinues offering a particular grandfathered product in a market,Health Plan may terminate this Agreement with respect to that product upon 90 days prior written notice to Group.Health Plan will offer Group another product that it makes available to groups in the small or large group market,as applicable.If Health Plan discontinues offering all products to groups in a small or large group market,as applicable,Health Plan may terminate this Agreement upon 180 days prior written notice to Group and Health Plan will not offer any other product to Group.A "product"is a combination of benefits and services that is defined by a distinct Evidence of Coverage. All other products Health Plan may terminate a particular product or all products offered in the group market as permitted or required by law. If Health Plan discontinues offering a particular product(other than a grandfathered product)in the group market,Health Plan may terminate this Agreement with respect to that product upon 90 days prior written notice to Group.Health Plan will offer Group another product that it makes available in the group market.If Health Plan discontinues offering all products in the group market,Health Plan may terminate this Agreement upon 180 days prior written notice to Group and Health Plan will not offer any other product to Group.A"product"is a combination of benefits and services that is defined by a distinct Evidence of Coverage. Contribution and Participation Requirements No change in Group's contribution or participation requirements listed below is effective for purposes of this Agreement unless Health Plan consents in writing.As a condition to consenting to Group's revised contribution and participation requirements,Health Plan may require Group to agree to amend the Premiums,benefits,or other provisions of this Agreement. Group must: • Ensure that: ♦ all Subscribers live or work inside the Service Area applicable to their coverage when they enroll(except that Group must ensure that Subscribers live inside the Service Area applicable to their coverage when they enroll if Group chooses not to have a"live or work"eligibility rule,and that Kaiser Permanente Senior Advantage Members live inside the Service Area applicable to their coverage when they enroll in Senior Advantage and thereafter) ♦ at least one employee,proprietor,or partner who lives or works inside the Service Area is eligible to enroll as a Subscriber • Meet all applicable legal and contractual requirements, such as: ♦ meet all Health Plan requirements set forth in the"Rate Assumptions and Requirements"section of the Rate Proposal document(Group's Health Plan account manager can provide Group with a copy of the Rate Proposal if Group does not have one) ♦ offer enrollment in accord with eligibility requirements in state law(for example,domestic partners must be eligible if married spouses are eligible and disabled dependents must be eligible if dependent children are eligible) COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 5 Miscellaneous Provisions Assignment Health Plan may assign this Agreement. Group may not assign this Agreement or any of the rights,interests,claims for money due,benefits,or obligations hereunder without Health Plan's prior written consent.This Agreement shall be binding on the successors and permitted assignees of Health Plan and Group. Attorney Fees and Costs If Health Plan or Group institutes legal action against the other to collect any sums owed under this Agreement,the party that substantially prevails will be reimbursed for its reasonable litigation expenses,including attorneys' fees,by the other party. Confidential Information about Health Plan or its Affiliates For the purposes of this"Confidential Information about Health Plan or its Affiliates"section,"Confidential Information" means any oral,written,or electronic information concerning Health Plan or its affiliates,if the information either is marked"confidential"or is by its nature proprietary or non-public,except that it does not include any of the following: • Information that is or becomes available to the public other than as a result of disclosure by Group or its employees, advisors,or representatives • Information that was available to Group or within its knowledge before Health Plan disclosed it to Group • Information that becomes available to Group from a source other than Health Plan,but only if that source is not bound by a confidentiality agreement with Health Plan If Group receives any Confidential Information,it will use that information only to evaluate Health Plan and actual or proposed group agreements with Health Plan. Group will ensure that the information is not disclosed to anyone other than a limited number of Group's employees and advisors,and only to the extent necessary in connection with the evaluation of Health Plan and actual or proposed group agreements with Health Plan.Group will inform any such employees and advisors that the information is confidential and that they must treat it confidentially. Upon Health Plan's request Group will promptly return to Health Plan all Confidential Information,and will destroy any other copies and any notes or other Group documents about the information. If Group is requested or required(by oral questions,interrogatories,request for information or documents,subpoena,civil investigative demand,or similar process)to disclose any Confidential Information,Group will give Health Plan prompt notice of the request or requirement,and Group will cooperate with Health Plan in seeking to legally avoid the disclosure. If,in the absence of a protective order,Group is legally compelled,in the opinion of its counsel,to disclose any of the information,Health Plan either will seek and obtain appropriate protective orders against the disclosure or will be deemed to waive Group's compliance with the provisions of this"Confidential Information about Health Plan or its Affiliates" section to the extent necessary to satisfy the request or requirement. Group understands(and will inform any employees and advisors who receive Confidential Information)that United States securities laws prohibit anyone who has material non-public information about a company from buying or selling that company's securities in reliance upon that information or from communicating the information to any other person or entity under circumstances in which it is reasonably foreseeable that the person or entity is likely to buy or sell that company's securities in reliance upon the information.Group agrees that it and its affiliates,associates,employees,agents,and advisors will not rely on any Confidential Information in directly or indirectly buying or selling any Health Plan securities. Monetary damages would not be a sufficient remedy for any breach or threatened breach of this"Confidential Information about Health Plan or its Affiliates"section.Health Plan will be entitled to equitable relief by way of injunction or specific performance if Group or any of its officers,directors,employees,attorneys,accountants,agents,advisors,or COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: l/1/25-12/31/25 Issue Date:October 30,2024 Page 6 representatives breach,or threaten to breach,any of the provisions of this"Confidential Information about Health Plan or its Affiliates"section. Group's obligations under this"Confidential Information about Health Plan or its Affiliates"section will continue indefinitely and will survive the termination or expiration of this Agreement. Contract Providers Health Plan will give Group written notice within a reasonable time of any termination or breach of contract by,or inability to perform of,any health care provider that contracts with Health Plan if Group may be materially and adversely affected thereby. Delegation of Claims Review Group delegates to Health Plan the discretion to determine whether a Member is entitled to benefits under this Agreement. In making these determinations,Health Plan has discretionary authority to review claims in accord with the procedures contained in this Agreement and to construe this Agreement to determine whether the Member is entitled to benefits.If coverage under an EOC is subject to the Employee Retirement Income Security Act(ERISA)claims procedure regulation (29 CFR 2560.503-1),Health Plan is a"named claims fiduciary"to review claims under that EOC. Electronic Delivery of Written Communications, Contracts, and Other Documents Written communications,contracts,and other documents may be provided electronically to Group,as allowed by law.If provided by posting to an electronic system,Health Plan will inform Group when a document is available for retrieval.A communication or document that is sent electronically shall be deemed received when the Group is able to retrieve the electronic communication or document from the electronic or information processing system designated for the purpose of receiving electronic records or information of the type sent. Communications and documents that may be delivered electronically include this Agreement,the annual renewal notice,and other communications between Group and Health Plan as allowed by law to be delivered electronically.A notice of termination will not be delivered electronically. Group may opt-out of electronic delivery of communications and documents at any time by providing notice to Health Plan. Enrollment Application Requirements Group must use enrollment application forms that are provided by Health Plan.If Group wants to use a different form or system for enrolling Members,Group must obtain Health Plan's prior approval of the form or system.Other forms and systems include a"universal"enrollment application form,interactive voice recording(IVR)enrollment system,or intranet online enrollment system.All forms and systems must meet Health Plan requirements for enrolling Members,including disclosure of binding arbitration in accord with Section 1363.1 of the California Health and Safety Code and other applicable law.Group must retain documentation of each Member's acceptance of the use of binding arbitration indefinitely,and upon request,must be able to produce documentation relating to a specific Member to Health Plan at any time.In the event that the contract between Health Plan and Group terminates or Group is unable to comply with this document retention requirement,Group must transfer possession of all such documentation to Health Plan in a mutually agreeable manner. Group's Health Plan account manager can provide Group with Health Plan's current requirements for enrollment application forms and systems. Grandfathered Health Plan Coverage For any coverage identified in an EOC as a"grandfathered health plan"under the Patient Protection and Affordable Care Act and regulations,Group must immediately inform Health Plan if this coverage does not meet(or no longer meets)the requirements for grandfathered status including but not limited to any change in its contribution rate to the cost of any COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: l/1/25-12/31/25 Issue Date:October 30,2024 Page 7 grandfathered health plans during the plan year.Group represents that,for any coverage identified as a"grandfathered health plan"in the applicable EOC,Group has not decreased its contribution rate more than five percent(5%)for any rate tier for such grandfathered health plan when compared to the contribution rate in effect on March 23,2010 for the same plan.Health Plan will rely on Group's representation in issuing and continuing any and all grandfathered health plan coverage. Governing Law Except as preempted by federal law,this Agreement will be governed in accord with California law and any provision that is required to be in this Agreement by state or federal law,shall bind Group and Health Plan whether or not set forth in this Agreement. Member Information Group will inform Members and prospective Members of eligibility requirements for Subscribers and Dependents and when coverage becomes effective and terminates. When Health Plan notifies Group about changes to this Agreement or provides Group other information that affects Members,Group will disseminate the information to Members by the next regular communication to them,but in no event later than 30 days after Group receives the information. For each Health Plan coverage included in this Agreement,Health Plan will provide Group with the following disclosures for Group to distribute in accord with applicable laws("Member Materials"): • A Disclosure Form(D-F)for each non-Medicare coverage.Group will provide DFs(or combined EOC/DFs)to Subscribers and potential Subscribers when the coverage is offered • A Summary of Benefits and Coverage(SBC)for each non-Medicare coverage other than retiree plans with fewer than two current employees.Group will provide electronic or paper SBCs to Members and potential Members to the extent required by law,except that Health Plan will provide SBCs to Members who make a request to Health Plan • Pre-enrollment materials that CMS requires for Kaiser Permanente Senior Advantage coverage,which are available upon request from Health Plan.Group will provide these materials to potential Members before they enroll in Senior Advantage coverage • An EOC for each non-Medicare coverage. Group will provide EOCs(or combined EOC/DFs)to Subscribers,except that Health Plan will provide EOCs(or combined EOC/DFs)to Members and potential Members who make a request to Health Plan If Group receives the Agreement or Member Materials in electronic form,Group is not authorized to modify or alter in any way the text or the formatting of the electronic Agreement or Member Materials. Health Plan assumes no responsibility for any changes in text or formatting that may occur in the Agreement or Member Materials after they are provided to Group.If Group posts the electronic Agreement or Member Materials on its intranet site,it shall do so in such a way so as to permit employees of Group to download and print a complete and accurate copy of the Agreement or Member Materials. In the event Health Plan reasonably concludes that Group is either using the electronic Agreement or Member Materials in a manner not permitted by this Agreement or is not providing Subscribers with access to the Member Materials in accord with applicable laws,then Health Plan will print copies of the Agreement or Member Materials and Group will cooperate with Health Plan to ensure that printed copies of the Agreement or Member Materials are provided in a timely manner to all employees of Group enrolled with Health Plan. Group agrees to reimburse Health Plan for the reasonable cost of printing and delivering the Agreement or Member Materials. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: l/1/25-12/31/25 Issue Date:October 30,2024 Page 8 No Waiver Health Plan's failure to enforce any provision of this Agreement will not constitute a waiver of that or any other provision, or impair Health Plan's right thereafter to require Group's strict performance of any provision. Nonduplication Agreement Health Plan agrees to undertake performance of the following regulatory requirements,and Group may rely on Health Plan's performance in order to satisfy its obligation to perform the same activities with respect to the health plan coverages issued to Group by Health Plan: • Preparation and publication of machine-readable files on a public website for in-network rates and billed charges and allowed amounts for out-of-network providers in the required form and manner as set forth in applicable regulations and any sub-regulatory guidance • Provision of an internet,self-service tool as well as paper reports and telephone assistance to provide personalized estimates of cost sharing for 500 shoppable services beginning on January 1,2023,and for all covered services as of January 1,2024 as set forth in applicable regulations and any sub-regulatory guidance • Annual reporting of prescription drug and health care costs reporting required to be furnished in accordance with applicable regulations and any sub-regulatory guidance • Publication of a consumer notice regarding federal and,when applicable,any state legal requirements related to balance billing by non-participating providers in accordance with applicable regulations and any sub-regulatory guidance • Annual reporting of data related to the provision and cost of air ambulance services for 2022 and 2023 in the required form and manner as set forth in applicable regulations and any sub-regulatory guidance • Annual submission of a Gag Clause Prohibition Compliance Attestation in the required form and manner as set forth in applicable regulations,if any,and sub-regulatory guidance Notices Notice under this Agreement shall be in writing and is deemed given when delivered in person or deposited in the U.S. mail.Notice may also be provided by email if Group has furnished its email address as part of its address of record,and as allowed by law.Health Plan or Group may change its addresses,or email address,for notices by giving written notice to the other. Notices from Health Plan to Group must be sent to: HOLLIS MAGILL,DIRECTOR OF HUMAN RESOURCES COUNTY OF FRESNO,RETIREE 2220 TULARE ST FL 14 FRESNO,CA 93721-2122 If Group has chosen to receive group agreements electronically through Health Plan's website at ky.org/vourcontract, Health Plan will send a notice to Group when a group agreement has been posted to that website. Note:When Health Plan sends Group a new(renewed)Agreement,Health Plan will enclose a summary of changes that discusses the changes Health Plan has made to the Group Agreement. If Group wants information about changes before receiving the Agreement,Group may request advance information from their Health Plan account manager.Also,if Group designates a third party in writing(for example,"Broker of Record"statements),Health Plan may send the advance information to the third party rather than to Group(unless Group requests a copy too). COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: l/1/25-12/31/25 Issue Date:October 30,2024 Page 9 Notices from Group to Health Plan must be sent to: Kaiser Permanente 1 Kaiser Plaza Oakland,CA 94612 Attn:Thomas A.Curtin Jr., Senior Vice President,Commercial Group Business Open Enrollment Group must hold an annual open enrollment period during which all eligible people,in accord with state law,may enroll in Health Plan or in any other health care plan available through Group.Also,Group must not hold open enrollment for 2026 until Group receives its 2026 group agreement Premium and coverage information from Health Plan.If Group holds the open enrollment without receiving 2026 group agreement Premium and coverage information,Health Plan may change Premiums and coverage(including benefits and Cost Sharing)when it offers to renew Group's Agreement as described under"Renewal"in the"Term of Agreement and Renewal"section. Other Group coverage that covers Essential Health Benefits For each non-grandfathered non-Medicare Health Plan coverage,except for any retiree-only coverage,Group must do all of the following if Group provides Health Plan Members with other medical or dental coverage(for example,separate pharmacy coverage)that covers any Essential Health Benefits: • Notify Health Plan of the out-of-pocket maximum(OOPM)that applies to the Essential Health Benefits in each of the other medical or dental coverage. • Ensure that the sum of the OOPM in Health Plan's coverage plus the OOPMs that apply to Essential Health Benefits in all of the other medical and dental coverage does not exceed the annual limitation on cost sharing described in 45 CFR 156.130. Reporting Membership Changes and Retroactivity Group must report membership changes(including sending appropriate membership forms)within the time limit for retroactive changes and in accord with any applicable"rescission"provisions of the Patient Protection and Affordable Care Act and regulations.Except for Senior Advantage membership terminations discussed below,the time limit for retroactive membership changes is the calendar month when Health Plan's California Service Center receives Group's notification of the change plus the previous 2 months. Representation regarding communication of membership changes Group represents that its communication regarding membership changes to Health Plan is accurate.Group and its representative are bound by all membership data,including any changes or updates that it,or its representative,submits to Health Plan via any medium,electronic or otherwise,including but not limited to the following: • Electronic data submissions regarding enrollment and eligibility • Health Plan approved online tool for submission of data • Paper enrollments submitted through postal mail or fax Health Plan's Administrative Handbook includes the details about how to report membership changes.Group's Health Plan account manager can provide Group with an Administrative Handbook if Group does not have one. Involuntary Kaiser Permanente Senior Advantage Membership Terminations Group must give Health Plan's California Service Center 30 days'prior written notice of Senior Advantage involuntary membership terminations.An involuntary membership termination is a termination that is not in response to a disenrollment notice issued by CMS to Health Plan or received by Health Plan directly from a Member(these events are usually in response to a Member's request for disenrollment to CMS because the Member has enrolled in another Medicare COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: l/1/25-12/31/25 Issue Date:October 30,2024 Page 10 health plan or wants Original Medicare coverage or has lost Medicare eligibility). The membership termination date is the first of the month following 30 days after the date when Health Plan's California Service Center receives a Senior Advantage membership termination notice unless Group specifies a later termination date.For example,if Health Plan's California Service Center receives a termination notice on March 5 for a Senior Advantage Member,the earliest termination date is May 1 and Group is required to pay applicable Premiums for the months of March and April. Voluntary Kaiser Permanente Senior Advantage Membership Terminations If Health Plan's California Service Center receives a disenrollment notice from CMS or a membership termination request from the Member,the membership termination date will be in accord with CMS requirements. Representation Regarding Waiting Periods By entering into this Agreement,Group hereby represents that Group does not impose a waiting period exceeding 90 days on employees who meet Group's eligibility requirements.For purposes of this requirement,a"waiting period"is the period that must pass before coverage for an individual who is otherwise eligible to enroll in non-Medicare coverage under the terms of a group health plan can become effective in accord with the waiting period requirements in the Patient Protection and Affordable Care Act and regulations. In addition,Group represents that eligibility data provided by the Group to Health Plan will include coverage effective dates for Group's employees that correctly account for eligibility in compliance with the waiting period requirements in the Patient Protection and Affordable Care Act and regulations and will not exceed the waiting period established by Group. For example,if the hire date of an otherwise-eligible employee is January 19,the waiting period begins on January 19 and the effective date of coverage cannot be any later than April 19.Note: If the effective date of your Group's coverage is always on the first day of the month,in this example the effective date cannot be any later than April 1. Right to Examine Records Upon reasonable notice,Health Plan may examine Group's records with respect to contribution and participation requirements,eligibility,and payments under this Agreement. Social Security and Tax Identification Numbers Within 60 days after Health Plan sends Group a written request,Group will send Health Plan a list of all Members covered under this Agreement,along with the following: • The Social Security number of the Member • The tax identification number of the employer of the Subscriber in the Member's Family • Any other information that Health Plan is required by law to collect Premiums Only Members for whom Health Plan(or its designee)has received the Full Premium payment as described below are entitled to coverage under this Agreement,and then only for the period for which Health Plan(or its designee)has received required Premium payment.Group is responsible for paying Premiums,except that Members who have Cal-COBRA coverage under an EOC that is included in this Agreement are responsible for paying Premiums for Cal-COBRA coverage. Due Date and Payment of Premiums The payment due date for each enrollment unit(or subgroup)associated with Group will be reflected on the monthly membership invoice if applicable to Group(if not applicable,then as specified in writing by Health Plan).If Group does COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: l/1/25-12/31/25 Issue Date:October 30,2024 Page 11 not pay Full Premiums by the first of the coverage month,the Premiums may include an additional administrative charge upon renewal."Full Premiums"means 100 percent of monthly Premiums for all of the coverage issued to each enrolled Member,as set forth under"Calculating Premiums"in this"Premiums"section. New Members Premiums are payable for the entire month for a new Member whose coverage effective date falls between the first day of the month and the fifteenth day of the month.No Premiums are due for the month for a new Member whose coverage becomes effective after the fifteenth day of that month. Note:Membership begins at the beginning(12:00 a.m.)of the effective date of coverage. Membership Termination Premiums are payable for the entire month for Members whose last day of coverage is on or after the sixteenth day of that month.No Premiums are due for the month for a Member whose last day of coverage is before the sixteenth day of that month. Note:The membership termination date is the first day a Member is not covered(for example,if the termination date is January 1,2026,the last minute of coverage was at 11:59 p.m. on December 31,2025). Involuntary Kaiser Permanente Senior Advantage Membership Terminations Group must give Health Plan's California Service Center 30 days'prior written notice of Senior Advantage involuntary membership terminations.An involuntary membership termination is a termination that is not in response to a disenrollment notice issued by CMS to Health Plan or received by Health Plan directly from a Member(these events are usually in response to a Member's request for disenrollment to CMS because the Member has enrolled in another Medicare health plan or wants Original Medicare coverage or has lost Medicare eligibility). The membership termination date is the first of the month following 30 days after the date when Health Plan's California Service Center receives a Senior Advantage membership termination notice unless Group specifies a later termination date.For example,if Health Plan's California Service Center receives a termination notice on March 5 for a Senior Advantage Member,the earliest termination date is May 1 and Group is required to pay applicable Premiums for the months of March and April. Voluntary Kaiser Permanente Senior Advantage Membership Terminations If Health Plan's California Service Center receives a disenrollment notice from CMS or a membership termination request from the Member,the membership termination date will be in accord with CMS requirements. Premium Rebates If state or federal law requires Health Plan to rebate premiums from this or any earlier contract year and Health Plan rebates premiums to Group,Group represents that Group will use that rebate for the benefit of Members,in a manner consistent with the requirements of the Public Health Service Act and the Affordable Care Act and if applicable with the obligations of a fiduciary under the Employee Retirement Income Security Act(ERISA). Medicare Medicare as primary coverage For Members who are(or the subscriber in the family is)retired,age 65 or over,and eligible for Medicare as primary coverage,Premiums are based on the assumption that Health Plan or its designee will receive Medicare payments for Medicare-covered services provided to Members whose Medicare coverage is primary.If a Member age 65 or over is(or becomes)eligible for Medicare as primary coverage and is not for any reason enrolled through Group under a Kaiser Permanente Senior Advantage EOC(including inability to enroll under that EOC because they do not meet the plan's eligibility requirements,the plan is not available through Group,or the plan is closed to enrollment),Group must pay the COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: l/1/25-12/31/25 Issue Date:October 30,2024 Page 12 Premiums listed below for the EOC under which the Member is enrolled that apply to Members age 65 or over who are not enrolled through Group under one of Health Plan's Medicare plans. If a Member age 65 or over who is eligible for Medicare as primary coverage and enrolled under a Kaiser Permanente Senior Advantage EOC is no longer eligible for that plan,Health Plan may transfer the Member's membership to one of Group's plans that does not require Members to have Medicare,and Group must pay the Premiums listed below for the EOC under which the Member is enrolled that apply to Members age 65 or over who are not enrolled through Group under one of Health Plan's Medicare plans. Medicare as secondary coverage Medicare is the primary coverage except when federal law requires that Group's health care coverage be primary and Medicare coverage be secondary.Members entitled to Medicare when Medicare is secondary by law are subject to the same Premiums and receive the same benefits as Members who are under age 65 and not eligible for Medicare.In addition, Members for whom Medicare is secondary who meet the Kaiser Permanente Senior Advantage eligibility requirements may also enroll in the Senior Advantage plan under this Agreement that is applicable when Medicare is secondary.These Members receive the benefits and coverage described in both the EOC for the non-Medicare plan(the plan that does not require Members to have Medicare)and the Senior Advantage EOC that is applicable when Medicare is secondary. Subscriber Contributions for Medicare Part C and Part D Coverage Medicare Part C coverage This"Medicare Part C coverage"section applies to Group's Kaiser Permanente Senior Advantage coverage. Group's Senior Advantage Premiums include the Medicare Part C premium for coverage of items and services covered under Parts A and B of Medicare,and supplemental benefits. Group may determine how much it will require Subscribers to contribute toward the Medicare Part C premium for each Senior Advantage Member in the Subscriber's Family,subject to the following restrictions: • If Group requires different contribution amounts for different classes of Senior Advantage Members for the Medicare Part C premium,then Group agrees to the following: ♦ any such differences in classes of Members are reasonable and based on objective business criteria,such as years of service,business location,and job category ♦ Group will not require different Subscriber contributions toward the Medicare Part C premium for Members within the same class • Group will not require Subscribers to pay a contribution for Medicare Part C coverage for a Senior Advantage Member that exceeds the Medicare Part C Premium for items and services covered under Parts A and B of Medicare,and supplemental benefits.As applicable,Health Plan will pass through monthly payments received from CMS (the monthly payments described in 42 C.F.R.422.304(a))to reduce the amount the Member contributes toward the Medicare Part C premium Medicare Part D coverage This"Medicare Part D coverage"section applies only to Group's Kaiser Permanente Senior Advantage coverage that includes Medicare Part D prescription drug coverage.Group's Senior Advantage Premiums include the Medicare Part D premium.Group may determine how much it will require Subscribers to contribute toward the Medicare Part D premium for each Senior Advantage Member in the Subscriber's Family,subject to the following restrictions: • If Group requires different contribution amounts for different classes of Senior Advantage Members for the Medicare Part D premium,then Group agrees to the following: ♦ any such differences in classes of Members are reasonable and based on objective business criteria,such as years of service,business location,and job category,and are not based on eligibility for the Medicare Part D Low Income Subsidy(the subsidies described in 42 C.F.R. Section 423 Subpart P,which are offered by the Medicare program to certain low-income Medicare beneficiaries enrolled in Medicare Part D,and which reduce the Medicare beneficiaries'Medicare Part D premiums and/or Medicare Part D cost-sharing amounts) COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: l/1/25-12/31/25 Issue Date:October 30,2024 Page 13 ♦ Group will not require different Subscriber contributions toward the Medicare Part D premium for Members within the same class • Group will not require Subscribers to pay a contribution for prescription drug coverage for a Senior Advantage Member that exceeds the Premium for prescription drug coverage(including the Medicare Part D premium).The Group will pass through direct subsidy payments received from CMS to reduce the amount the Member contributes toward the Medicare Part D premium • Health Plan will credit Group with any Low Income Subsidy amounts that Health Plan receives from CMS for Group's Members,and Health Plan will identify those Members for Group as required by CMS.For those Members,Group will first credit the Low Income Subsidy amount toward the Subscriber's contribution for that Member's Senior Advantage Premium for the same month,and will then apply any remaining portion of the Member's Low Income Subsidy toward the portion of the Senior Advantage Premium that Group pays on behalf of that Member for that month.If Group is unable to reduce the Subscriber's contribution before the Subscriber makes the contribution,Group shall,consistent with CMS guidance,refund the Low Income Subsidy amount to the Subscriber(up to the amount of the Subscriber Premium contribution for the Member for that month)within 45 days after the date Health Plan receives the Low Income Subsidy amount from CMS.Health Plan reserves the right to periodically require Group to certify that Group is either reducing Subscribers'monthly Premium contributions or refunding the Low Income Subsidy amounts to Subscribers in accord with CMS guidance • For any Members who are eligible for the Low Income Subsidy,if the amount of that Low Income Subsidy is less than the Member's contribution for the Medicare Part D premium,then Group should inform the Member of the financial consequences of the Member's enrolling in the Member's current coverage,as compared to enrolling in another Medicare Part D plan with a monthly premium equal to or less than the Low Income Subsidy amount Late Enrollment Penalty If any Members are subject to the Medicare Part D late enrollment penalty,Premiums for those Members will increase to include the amount of the penalty. Calculating Premiums To calculate the amount of Full Premiums that apply to a Family(a Subscriber and all of their Dependents): 1. If this Agreement includes more than one contract option,determine the coverage(EOCs and contract options)that apply to each Member in the Family(for example,Traditional Plan and any Ancillary Coverage). 2. Determine the family role type and Medicare status of each Member(for family role types,please see the"Definitions" section of the EOC for the definition of Subscriber,Dependent,and Spouse). 3. Identify the Premiums for each Member for each EOC and contract option(including contract options issued through a separate contract)based on the family role type and Medicare status of each Member: • Premiums for coverage issued under this Agreement appear in the Premium tables below. • If this Agreement includes a POS Plan contract option(a contract option with one tier underwritten by Health Plan and two tiers underwritten by Kaiser Permanente Insurance Company),the amounts shown below for the POS Plan (for Large Groups)product includes premiums for the Health Plan and Kaiser Permanente Insurance Company portions of Group's POS Plan coverage,and Group submits payment for this coverage as part of Full Premium. • If Ancillary Coverage has been issued under a separate contract and Premiums for that coverage are not listed in the Premium tables below,refer to that contract for Premiums.This Ancillary Coverage is part of the contract options selected by Group,and Group submits payment for this Ancillary Coverage as part of Full Premium. 4. Add the amounts of Premiums for each Member together to arrive at the total,Full Premiums required for the Family. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 14 Monthly Premiums for Kaiser Permanente Traditional HMO Plan — EOC # 1 TRADITIONAL PLAN HIGH-HIGH OPTION Members under age 65 who are not eligible for Medicare Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1 st child without Spouse $905.65 1st child with Spouse $872.11 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1st child without Spouse $905.65 1 st child with Spouse $872.11 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1st child without Spouse $905.65 1 st child with Spouse $872.11 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1st child without Spouse $905.65 1 st child with Spouse $872.11 Each additional Dependent $0.00 Members under age 65 who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1 st child without Spouse $2,017.67 1st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members under age 65 when Medicare is secondary Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1 st child without Spouse $905.65 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:36 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 15 Family role type Premiums 1st child with Spouse $872.11 Each additional Dependent $0.00 Members age 65 and over whose Medicare eligibility is unknown Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1 st child without Spouse $2,017.67 1st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members age 65 and over who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,607.02 Spouse $1,607.02 1 st child without Spouse $1,607.02 1st child with Spouse $1,607.02 Each additional Dependent $1,607.02 Members age 65 and over who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1 st child without Spouse $2,017.67 1 st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members age 65 and over who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,607.02 Spouse $1,607.02 1st child without Spouse $1,607.02 1 st child with Spouse $1,607.02 Each additional Dependent $1,607.02 Members age 65 and over who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1st child without Spouse $2,017.67 1 st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members age 65 and over when Medicare is secondary Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:36 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 16 Family role type Premiums 1 st child without Spouse $905.65 1 st child with Spouse $872.11 Each additional Dependent $0.00 Note:Members who are"eligible for"Medicare Part A or B are those who would qualify for Medicare Part A or B coverage if they applied for it.Members who"have"Medicare Part A or B are those who have been granted Medicare Part A or B coverage.Medicare Part A provides inpatient coverage and Part B provides outpatient coverage. Monthly Premiums for Kaiser Permanente Senior Advantage (HMO) with Part D — EOC #2 SENIOR ADVANTAGE HIGH-HIGH OPTION Family role type Medicare Parts A&B Medicare Part B only Subscriber $341.24 $651.24 1 st Dependent $341.24 $651.24 2nd Dependent $341.24 $651.24 Each additional Dependent 1 $341.24 1 $651.24 Monthly Premiums for American Specialty Health Plans Chiropractic Plan — EOC #3 CHIROPRACTIC BENEFIT-HIGH OPTION Family role type Premiums Subscriber $1.55 Spouse $1.31 1 st child without Spouse $0.84 1 st child with Spouse $0.80 Monthly Premiums for Kaiser Permanente Senior Advantage (HMO) with Part D — EOC #4 SENIOR ADVANTAGE-LOW OPTION Family role type Medicare Parts A&B Medicare Part B only Subscriber $270.41 $580.41 1 st Dependent $270.41 $580.41 2nd Dependent $270.41 $580.41 Each additional Dependent $270.41 $580.41 Monthly Premiums for Kaiser Permanente Traditional HMO Plan — EOC # 5 TRADITIONAL PLAN-LOW OPTION Members under age 65 who are not eligible for Medicare Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1 st child without Spouse $905.65 1 st child with Spouse $872.11 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 17 Family role type Premiums Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1st child without Spouse $905.65 1 st child with Spouse $872.11 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1st child without Spouse $905.65 1 st child with Spouse $872.11 Each additional Dependent $0.00 Members under age 65 who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1st child without Spouse $905.65 1 st child with Spouse $872.11 Each additional Dependent $0.00 Members under age 65 who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1 st child without Spouse $2,017.67 1st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members under age 65 when Medicare is secondary Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1 st child without Spouse $905.65 1st child with Spouse $872.11 Each additional Dependent $0.00 Members age 65 and over whose Medicare eligibility is unknown Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1 st child without Spouse $2,017.67 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:36 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 18 Family role type Premiums 1st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members age 65 and over who are eligible for or have Medicare Part A only Family role type Premiums Subscriber $1,607.02 Spouse $1,607.02 1 st child without Spouse $1,607.02 1st child with Spouse $1,607.02 Each additional Dependent $1,607.02 Members age 65 and over who are eligible for or have Medicare Part B only Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1 st child without Spouse $2,017.67 1st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members age 65 and over who are eligible for or have Medicare Parts A&B Family role type Premiums Subscriber $1,607.02 Spouse $1,607.02 1 st child without Spouse $1,607.02 1 st child with Spouse $1,607.02 Each additional Dependent $1,607.02 Members age 65 and over who are enrolled in another carrier's Medicare Risk product Family role type Premiums Subscriber $2,017.67 Spouse $2,017.67 1st child without Spouse $2,017.67 1 st child with Spouse $2,017.67 Each additional Dependent $2,017.67 Members age 65 and over when Medicare is secondary Family role type Premiums Subscriber $1,677.13 Spouse $1,408.79 1st child without Spouse $905.65 1 st child with Spouse $872.11 Each additional Dependent $0.00 Note: Members who are"eligible for"Medicare Part A or B are those who would qualify for Medicare Part A or B coverage if they applied for it.Members who"have"Medicare Part A or B are those who have been granted Medicare Part A or B coverage. Medicare Part A provides inpatient coverage and Part B provides outpatient coverage. COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:36 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 19 Monthly Premiums for American Specialty Health Plans Chiropractic Plan — EOC # 9 HMO CHIRO ACN NCR-LOW OPTION Family role type Premiums Subscriber $1.55 Spouse $1.31 1 st child without Spouse $0.84 1 st child with Spouse $0.80 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: 1 Version:36 Effective: l/1/25-12/31/25 Issue Date:October 30,2024 Page 20 Agreement Signature Page Acceptance of Agreement Group acknowledges acceptance of this Agreement by signing the Signature Page and returning it to Health Plan. If Group does not return it to Health Plan,Group will be deemed as having accepted this Agreement if Group pays Health Plan any amount toward Premiums. Group may not change this Agreement by adding or deleting words,and any such addition or deletion is void.Health Plan might not respond to any changes or comments submitted on or with this Signature Page.Group may not construe Health Plan's lack of response to any submitted changes or comments to imply acceptance.If Group wishes to change anything in this Agreement,Group must contact its Health Plan account manager.Health Plan will issue a new Agreement or amendment if Health Plan and Group agree on any changes. Binding Arbitration As more fully set forth in the arbitration provision in the applicable Evidence of Coverage,disputes between Members, their heirs,relatives,or associated parties(on the one hand)and Health Plan,Kaiser Permanente health care providers,or other associated parties(on the other hand)for alleged violation of any duty arising out of or related to this Agreement, including any claim for medical or hospital malpractice(a claim that medical services or items were unnecessary or unauthorized or were improperly,negligently,or incompetently rendered),for premises liability,or relating to the coverage for,or delivery of,services or items pursuant to this Agreement,irrespective of legal theory,must be decided by binding arbitration and not by lawsuit or resort to court process,except as applicable law provides for judicial review of arbitration proceedings.Members enrolled under this Agreement thus give up their right to a court or jury trial,and instead accept the use of binding arbitration as specified in the applicable Evidence of Coverage except that the following types of claims are not subject to binding arbitration: • Claims within the jurisdiction of the Small Claims Court • Claims subject to a Medicare appeals procedure as applicable to Kaiser Permanente Senior Advantage Members • Claims that cannot be subject to binding arbitration under governing law Signatures Kaiser Foundation Health Plan,Inc.,Northern California Region Thomas A.Curtin Jr. Authorized officer Senior Vice President,Commercial Group Business October 30,2024 COUNTY OF FRESNO,RETIREE Authorized Group officer signature Print name and title Date Please keep this copy of the signature page with your Agreement.An extra copy is included in your contract package to sign and return: • By mail:Kaiser Permanente,California Service Center,P.O.Box 23448,San Diego,CA 92193-3448. • By fax: 1-855-355-5334 COUNTY OF FRESNO,RETIREE Group ID:604334 Contract: I Version:36 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 21 KAISER PERMANEMEo Kaiser Foundation Health Plan, Inc. Northern California Region A nonprofit corporation EOC #1 - Kaiser Permanente Traditional HMO Plan Evidence of Coverage for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 36 EOC Number: 1 Issue Date: October 30, 2024 January 1,2025, through December 31, 2025 Member Services 24 hours a day, seven days a week(closed holidays) 1-800-464-4000(TTY users call 711) kp.or coaccum NGF ACA p 103 TABLE OF CONTENTS FOR EOC #1 CostShare Summary..............................................................................................................................................................1 AccumulationPeriod..........................................................................................................................................................1 Deductibles and Out-of-Pocket Maximums.......................................................................................................................1 CostShare Summary Tables by Benefit.............................................................................................................................1 CAREPlan.......................................................................................................................................................................19 Introduction..........................................................................................................................................................................20 AboutKaiser Permanente.................................................................................................................................................20 Termof this EOC.............................................................................................................................................................20 Definitions............................................................................................................................................................................21 Premiums,Eligibility,and Enrollment.................................................................................................................................26 Premiums..........................................................................................................................................................................26 WhoIs Eligible.................................................................................................................................................................27 How to Enroll and When Coverage Begins.....................................................................................................................29 Howto Obtain Services........................................................................................................................................................31 RoutineCare.....................................................................................................................................................................32 UrgentCare......................................................................................................................................................................32 Not Sure What Kind of Care You Need?.........................................................................................................................32 Your Personal Plan Physician..........................................................................................................................................32 Gettinga Referral.............................................................................................................................................................33 Traveland Lodging for Certain Services.........................................................................................................................35 SecondOpinions...............................................................................................................................................................35 Contractswith Plan Providers..........................................................................................................................................36 Receiving Care Outside of Your Home Region Service Area.........................................................................................36 YourID Card....................................................................................................................................................................36 TimelyAccess to Care.....................................................................................................................................................37 GettingAssistance............................................................................................................................................................38 PlanFacilities.......................................................................................................................................................................38 Emergency Services and Urgent Care..................................................................................................................................39 EmergencyServices.........................................................................................................................................................39 UrgentCare......................................................................................................................................................................40 Paymentand Reimbursement...........................................................................................................................................41 Benefits.................................................................................................................................................................................41 YourCost Share...............................................................................................................................................................42 AdministeredDrugs and Products....................................................................................................................................45 AmbulanceServices.........................................................................................................................................................45 BariatricSurgery..............................................................................................................................................................46 Dentaland Orthodontic Services......................................................................................................................................46 DialysisCare....................................................................................................................................................................47 Durable Medical Equipment("DME")for Home Use.....................................................................................................47 Emergency Services and Urgent Care..............................................................................................................................49 FertilityServices...............................................................................................................................................................49 Fertility Preservation Services for Iatrogenic Infertility..................................................................................................49 HealthEducation..............................................................................................................................................................50 HearingServices...............................................................................................................................................................50 HomeHealth Care............................................................................................................................................................50 HospiceCare....................................................................................................................................................................51 HospitalInpatient Services...............................................................................................................................................52 Injuryto Teeth..................................................................................................................................................................52 MentalHealth Services....................................................................................................................................................52 OfficeVisits.....................................................................................................................................................................54 Ostomyand Urological Supplies......................................................................................................................................54 Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services............................................................54 Outpatient Prescription Drugs,Supplies,and Supplements.............................................................................................55 Outpatient Surgery and Outpatient Procedures................................................................................................................58 PreventiveServices..........................................................................................................................................................59 Prostheticand Orthotic Devices.......................................................................................................................................59 ReconstructiveSurgery....................................................................................................................................................60 Rehabilitative and Habilitative Services..........................................................................................................................61 ReproductiveHealth Services..........................................................................................................................................61 Services in Connection with a Clinical Trial....................................................................................................................62 SkilledNursing Facility Care...........................................................................................................................................63 SubstanceUse Disorder Treatment..................................................................................................................................63 TelehealthVisits...............................................................................................................................................................64 TransplantServices..........................................................................................................................................................64 VisionServices for Adult Members.................................................................................................................................65 VisionServices for Pediatric Members............................................................................................................................66 Exclusions,Limitations,Coordination of Benefits,and Reductions...................................................................................67 Exclusions........................................................................................................................................................................67 Limitations........................................................................................................................................................................70 Coordinationof Benefits..................................................................................................................................................70 Reductions........................................................................................................................................................................70 Post-Service Claims and Appeals.........................................................................................................................................72 WhoMay File...................................................................................................................................................................72 SupportingDocuments.....................................................................................................................................................73 InitialClaims....................................................................................................................................................................73 Appeals.............................................................................................................................................................................74 ExternalReview...............................................................................................................................................................75 AdditionalReview............................................................................................................................................................75 DisputeResolution...............................................................................................................................................................75 Grievances........................................................................................................................................................................75 Independent Review Organization for Non-Formulary Prescription Drug Requests......................................................78 Department of Managed Health Care Complaints...........................................................................................................79 IndependentMedical Review("IMR")............................................................................................................................79 Officeof Civil Rights Complaints....................................................................................................................................80 AdditionalReview............................................................................................................................................................80 BindingArbitration..........................................................................................................................................................80 Terminationof Membership.................................................................................................................................................82 Termination Due to Loss of Eligibility............................................................................................................................82 Terminationof Agreement................................................................................................................................................83 Terminationfor Cause......................................................................................................................................................83 Termination of a Product or all Products.........................................................................................................................83 Paymentsafter Termination.............................................................................................................................................83 State Review of Membership Termination......................................................................................................................83 Continuationof Membership................................................................................................................................................83 Continuationof Group Coverage.....................................................................................................................................83 Continuation of Coverage under an Individual Plan........................................................................................................86 MiscellaneousProvisions.....................................................................................................................................................87 Administrationof Agreement...........................................................................................................................................87 AdvanceDirectives..........................................................................................................................................................87 Amendmentof Agreement................................................................................................................................................87 Applicationsand Statements............................................................................................................................................87 Assignment.......................................................................................................................................................................87 Attorney and Advocate Fees and Expenses.....................................................................................................................87 ClaimsReview Authority.................................................................................................................................................87 EOCBinding on Members...............................................................................................................................................87 ERISANotices.................................................................................................................................................................87 GoverningLaw.................................................................................................................................................................88 Group and Members Not Our Agents..............................................................................................................................88 NoWaiver........................................................................................................................................................................88 Notices Regarding Your Coverage...................................................................................................................................88 OverpaymentRecovery....................................................................................................................................................88 PrivacyPractices..............................................................................................................................................................88 PublicPolicy Participation...............................................................................................................................................89 HelpfulInformation..............................................................................................................................................................89 How to Obtain this EOC in Other Formats......................................................................................................................89 ProviderDirectory............................................................................................................................................................89 OnlineTools and Resources.............................................................................................................................................89 Document Delivery Preferences.......................................................................................................................................89 Howto Reach Us..............................................................................................................................................................90 PaymentResponsibility....................................................................................................................................................91 Cost Share Summary This"Cost Share Summary"is part of your Evidence of Coverage(EOC)and is meant to explain the amount you will pay for covered Services under this plan.It does not provide a full description of your benefits.For a full description of your benefits, including any limitations and exclusions,please read this entire EOC,including any amendments,carefully. Accumulation Period The Accumulation Period for this plan is January 1 through December 31. Deductibles and Out-of-Pocket Maximums For Services that apply to the Plan Out-of-Pocket Maximum,you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below. If your Group's plan changes during an Accumulation Period,your deductibles and out-of-pocket maximums may increase or decrease,which may change the total amount you must accumulate to reach the deductibles or out-of-pocket maximums during that Accumulation Period. Self-Only Coverage Family Coverage Family Coverage Amounts Per Accumulation Period (a Family of one Member) Each Member in a Family Entire Family of two or of two or more Members more Members Plan Deductible None None None Drug Deductible None None None Plan Out-of-Pocket Maximum("OOPM") $1,500 $1,500 $3,000 Cost Share Summary Tables by Benefit How to read the Cost Share summary tables Each table below explains the Cost Share for a category of benefits. Specific Services related to the benefit are described in the first column of each table.For a detailed description of coverage for a particular benefit,refer to the same benefit heading in the"Benefits"section of this EOC. • Copayment/Coinsurance. This column describes the Cost Share you will pay for Services after you have met your Plan Deductible or Drug Deductible,if applicable.(Please see the"Deductibles and Out-of-Pocket Maximums" section above to determine if your plan includes deductibles.)If the Services are not covered in your plan,this column will read"Not covered."If we provide an Allowance that you can use toward the cost of the Services,this column will include the Allowance. • Subject to Deductible. This column explains whether the Cost Share you pay for Services is subject to a Plan Deductible or Drug Deductible.If the Services are subject to a deductible,you will pay Charges for those Services until you have met your deductible.If the Services are subject to a deductible,there will be a"✓"or"D"in this column,depending on which deductible applies("✓"for Plan Deductible,"D"for Drug Deductible).If the Services do not apply to a deductible,or if your plan does not include a deductible,this column will be blank.For a more detailed explanation of deductibles,refer to"Plan Deductible"and"Drug Deductible"in the`Benefits"section of this EOC. • Applies to OOPM.This column explains whether the Cost Share you pay for Services counts toward the Plan Out- of-Pocket Maximum("OOPM")after you have met any applicable deductible. If the Services count toward the Plan OOPM,there will be a"✓"in this column.If the Services do not count toward the Plan OOPM,this column will be blank.For a more detailed explanation of the Plan OOPM,refer to"Plan Out-of-Pocket Maximum"in the "Benefits"section of this EOC. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 1 Administered drugs and products Copayment/ Subject to Applies to Description of Administered Drugs and Products Services Coinsurance Deductible OOPM Whole blood,red blood cells,plasma,and platelets No charge Allergy antigens(including administration) $3 per visit Cancer chemotherapy drugs and adjuncts No charge Drugs and products that are administered via intravenous therapy or No charge injection that are not for cancer chemotherapy,including blood factor products and biological products("biologics")derived from tissue, cells,or blood All other administered drugs and products No charge Drugs and products administered to you during a home visit No charge Ambulance Services Copayment/ Subject to Applies to Description of Ambulance Services Coinsurance Deductible OOPM Emergency ambulance Services $50 per trip Nonemergency ambulance and psychiatric transport van Services $50 per trip Dialysis care Copayment/ Subject to Applies to Description of Dialysis Care Services Coinsurance Deductible OOPM Equipment and supplies for home hemodialysis and home peritoneal No charge ✓ dialysis One routine outpatient visit per month with the multidisciplinary No charge ✓ nephrology team for a consultation,evaluation,or treatment Hemodialysis and peritoneal dialysis treatment at a Plan Facility $15 per visit Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC9#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 2 Durable Medical Equipment ("DME") for home use Copayment/ Subject to Applies to Description of DME Services Coinsurance Deductible OOPM Blood glucose monitors for diabetes blood testing and their supplies 20%Coinsurance Peak flow meters 20%Coinsurance Insulin pumps and supplies to operate the pump 20%Coinsurance Other Base DME Items as described in this EOC 20%Coinsurance Supplemental DME items as described in this EOC 20%Coinsurance Retail-grade milk pumps No charge Hospital-grade milk pumps No charge Emergency Services and Urgent Care Copayment/ Subject to Applies to Description of Emergency Services and Urgent Care Coinsurance Deductible OOPM Emergency department visits $100 per visit Urgent Care visits $15 per visit Note:If you are admitted to the hospital as an inpatient from the emergency department,the emergency department visits Cost Share above does not apply.Instead,the Services you received in the emergency department,including any observation stay,if applicable,will be considered part of your hospital inpatient stay. For the Cost Share for inpatient Services,refer to "Hospital inpatient Services"in this"Cost Share Summary."The emergency department Cost Share does apply if you are admitted for observation but are not admitted as an inpatient. Fertility Services Diagnosis and treatment of Infertility Copayment/ Subject to Applies to Description of Diagnosis and Treatment of Infertility Services Coinsurance Deductible OOPM Office visits $15 per visit Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 3 Copayment/ Subject to Applies to Description of Diagnosis and Treatment of Infertility Services Coinsurance Deductible OOPM Outpatient surgery and outpatient procedures(including imaging and $15 per procedure diagnostic Services)when performed in an outpatient or ambulatory surgery center or in a hospital operating room,or any setting where a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort Any other outpatient surgery that does not require a licensed staff $15 per procedure member to monitor your vital signs as described above Outpatient imaging No charge Outpatient laboratory No charge Outpatient administered drugs No charge Hospital inpatient Services(including room and board,drugs, No charge imaging,laboratory,other diagnostic and treatment Services,and Plan Physician Services) Artificial insemination Copayment/ Subject to Applies to Description of Artificial Insemination Services Coinsurance Deductible OOPM Office visits $15 per visit Outpatient surgery and outpatient procedures(including imaging and $15 per procedure diagnostic Services)when performed in an outpatient or ambulatory surgery center or in a hospital operating room,or any setting where a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort Any other outpatient surgery that does not require a licensed staff $15 per procedure member to monitor your vital signs as described above Outpatient imaging No charge Outpatient laboratory No charge Outpatient administered drugs No charge Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 4 Copayment/ Subject to Applies to Description of Artificial Insemination Services Coinsurance Deductible OOPM Hospital inpatient Services(including room and board,drugs, No charge imaging,laboratory,other diagnostic and treatment Services,and Plan Physician Services) Assisted reproductive technology("ART")Services Copayment/ Subject to Applies to Description of ART Services Coinsurance Deductible OOPM Assisted reproductive technology("ART")Services such as invitro Not covered fertilization("IVF"),gamete intra-fallopian transfer("GIFT"),or zygote intrafallopian transfer("ZIFT") Health education Copayment/ Subject to Applies to Description of Health Education Services Coinsurance Deductible OOPM Covered health education programs,which may include programs No charge provided online and counseling over the phone Individual counseling during an office visit related to tobacco No charge ✓ cessation Individual counseling during an office visit related to diabetes No charge ✓ management Other covered individual counseling when the office visit is solely for No charge health education Covered health education materials No charge Hearing Services Copayment/ Subject to Applies to Description of Hearing Services Coinsurance Deductible OOPM Hearing exams with an audiologist to determine the need for hearing $15 per visit ✓ correction Physician Specialist Visits to diagnose and treat hearing problems $15 per visit Group ID:604334 Kaiser Pertnanente Traditional HMO Plan Contract: 1 Version:36 EOCW 1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 5 Copayment/ Subject to Applies to Description of Hearing Services Coinsurance Deductible OOPM Hearing aids,including,fitting,counseling,adjustment,cleaning,and We provide a$1,000 inspection Allowance for each ear every 36 months Home health care Copayment/ Subject to Applies to Description of Home Health Care Services Coinsurance Deductible OOPM Home health care Services(100 visits per Accumulation Period) No charge ,/ Hospice care Copayment/ Subject to Applies to Description of Hospice Care Services Coinsurance Deductible OOPM Hospice Services No charge Hospital inpatient Services Copayment/ Subject to Applies to Description of Hospital Inpatient Services Coinsurance Deductible OOPM Hospital inpatient stays No charge Injury to teeth Copayment/ Subject to Applies to Description of Injury to Teeth Services Coinsurance Deductible OOPM Accidental injury to teeth Not covered Mental health Services Copayment/ Subject to Applies to Description of Mental Health Services Coinsurance Deductible OOPM Inpatient mental health hospital stays No charge Individual mental health evaluation and treatment $15 per visit Group mental health treatment $7 per visit Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC9#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 6 Copayment/ Subject to Applies to Description of Mental Health Services Coinsurance Deductible OOPM Partial hospitalization No charge Other intensive psychiatric treatment programs No charge Residential mental health treatment Services No charge Behavioral Health Treatment for Autism Spectrum Disorder No charge Electroconvulsive therapy $15 per visit Transcranial magnetic stimulation $15 per visit Office visits Copayment/ Subject to Applies to Description of Office Visit Services Coinsurance Deductible OOPM Primary Care Visits and Non-Physician Specialist Visits that are not $15 per visit ✓ described elsewhere in this"Cost Share Summary" Physician Specialist Visits that are not described elsewhere in this $15 per visit "Cost Share Summary" Group appointments that are not described elsewhere in this"Cost $7 per visit ✓ Share Summary" Acupuncture Services $15 per visit Ostomy and urological supplies Copayment/ Subject to Applies to Description of Ostomy and Urological Services Coinsurance Deductible OOPM Ostomy and urological supplies as described in this EOC No charge Outpatient imaging, laboratory, and other diagnostic and treatment Services Description of Outpatient Imaging,Laboratory,and Other Diagnostic Copayment/ Subject to Applies to and Treatment Services Coinsurance Deductible OOPM Complex imaging(other than preventive) such as CT scans,MRIs, No charge and PET scans Group ID:604334 Kaiser Pertnanente Traditional HMO Plan Contract: 1 Version:36 EOCW I Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 7 Description of Outpatient Imaging,Laboratory,and Other Diagnostic Copayment/ Subject to Applies to and Treatment Services Coinsurance Deductible OOPM Basic imaging Services,such as diagnostic and therapeutic X-rays, No charge ✓ mammograms,and ultrasounds Nuclear medicine No charge Routine retinal photography screenings No charge Routine laboratory tests to monitor the effectiveness of dialysis No charge Over-the-counter COVID-19 tests obtained from Plan Providers as No charge described in this EOC(up to a total of 8 tests from Plan Providers and Non-Plan Providers per calendar month) Over-the-counter COVID-19 tests obtained from Non-Plan Providers 50%Coinsurance as described in this EOC(up to a total of 8 tests from Plan Providers and Non-Plan Providers per calendar month,not to exceed$12 per test,including all fees and taxes,if you obtain the test from a Non- Plan Provider) Laboratory tests to diagnose or screen for COVID-19 obtained from No charge Plan Providers Laboratory tests to diagnose or screen for COVID-19 obtained from 50%Coinsurance Non-Plan Providers(except for providers of Emergency Services or Out-of-Area Urgent Care) All other laboratory tests(including tests for specific genetic No charge ✓ disorders for which genetic counseling is available) Diagnostic Services provided by Plan Providers who are not No charge physicians(such as EKGs and EEGs) Radiation therapy No charge Ultraviolet light treatments(including ultraviolet light therapy No charge equipment as described in this EOC) Outpatient prescription drugs, supplies, and supplements If the"Cost Share at a Plan Pharmacy"column in this section provides Cost Share for a 30-day supply and your Plan Physician prescribes more than this,you may be able to obtain more than a 30-day supply at one time up to the day supply limit for that drug.Applicable Cost Share will apply.For example,two 30-day copayments may be due when picking up a 60-day prescription,three copayments may be due when picking up a 100-day prescription at the pharmacy. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 8 Most items Cost Share Cost Share Subject to Applies to Description of Most Items at a Plan Pharmacy by Mail Deductible OOPM Items on Tier 1 not described elsewhere in $10 for up to a 30-day $20 for up to a 100-day ✓ this"Cost Share Summary" supply supply Items on Tier 2 not described elsewhere in $20 for up to a 30-day $40 for up to a 100-day ✓ this"Cost Share Summary" supply supply Items on Tier 4 not described elsewhere in $20 for up to a 30-day Availability for mail this"Cost Share Summary" supply order varies by item. ✓ Talk to your local pharmacy Base drugs,supplies,and supplements Description of Base Drugs, Supplies and Cost Share Cost Share Subject to Applies to Supplements at a Plan Pharmacy by Mail Deductible OOPM Hematopoietic agents for dialysis No charge for up to a Not available ✓ 30-day supply Elemental dietary enteral formula when No charge for up to a Not available used as a primary therapy for regional 30-day supply ✓ enteritis All other items on Tier 1 as described in $10 for up to a 30-day Availability for mail this EOC supply order varies by item. ✓ Talk to your local pharmacy All other items on Tier 2 as described in $20 for up to a 30-day Availability for mail this EOC supply order varies by item. ✓ Talk to your local pharmacy All other items on Tier 4 as described in $20 for up to a 30-day Availability for mail this EOC supply order varies by item. ✓ Talk to your local pharmacy Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 9 Anticancer drugs and certain critical adjuncts following a diagnosis of cancer Description of Anticancer Drugs and Cost Share Cost Share Subject to Applies to Certain Critical Adjuncts at a Plan Pharmacy by Mail Deductible OOPM Oral anticancer drugs on Tier 1 $10 for up to a 30-day Availability for mail supply order varies by item. Talk to your local pharmacy Oral anticancer drugs on Tier 2 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Oral anticancer drugs on Tier 4 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Non-oral anticancer drugs on Tier 1 $10 for up to a 30-day Availability for mail supply order varies by item. Talk to your local pharmacy Non-oral anticancer drugs on Tier 2 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Non-oral anticancer drugs on Tier 4 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Home infusion drugs Cost Share Cost Share Subject to Applies to Description of Home Infusion Drugs at a Plan Pharmacy by Mail Deductible OOPM Home infusion drugs No charge for up to a Not available 30-day supply Supplies necessary for administration of No charge No charge ✓ home infusion drugs Home infusion drugs are self-administered intravenous drugs,fluids,additives,and nutrients that require specific types of parenteral-infusion,such as an intravenous or intraspinal-infusion. Group ID:604334 Kaiser Pertnanente Traditional HMO Plan Contract: 1 Version:36 EOCW 1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 10 Certain state-mandated items Description of Certain State-Mandated Cost Share Cost Share Subject to Applies to Items at a Plan Pharmacy by Mail Deductible OOPM Amino acid—modified products used to No charge for up to a Not available treat congenital errors of amino acid 30-day supply metabolism(such as phenylketonuria) Therapeutics for COVID-19 obtained No charge for up to a Availability for mail from Plan Providers 30-day supply order varies by item. Talk to your local pharmacy Therapeutics for COVID-19 obtained 50%Coinsurance for up Not available from Non-Plan Providers(except for to a 30-day supply providers of Emergency Services or Out- of-Area Urgent Care) Ketone test strips and sugar or acetone test No charge for up to a Not available ✓ tablets or tapes for diabetes urine testing 100-day supply Insulin-administration devices:pen $10 for up to a 100-day Availability for mail delivery devices,disposable needles and supply order varies by item. ✓ syringes,and visual aids required to Talk to your local ensure proper dosage(except eyewear) pharmacy For drugs related to the treatment of diabetes(for example,insulin),and for continuous insulin delivery devices that use disposable items such as patches or pods,refer to the"Most items"table above.For insulin pumps,refer to the"Durable Medical Equipment("DME")for home use"table above. Contraceptive drugs and devices Description of Contraceptive Drugs and Cost Share Cost Share Subject to Applies to Devices at a Plan Pharmacy by Mail Deductible OOPM The following hormonal contraceptive No charge for up to a No charge for up to a items on Tier 1: 365-day supply 365-day supply • Rings Availability for mail • Patches order varies by item. Talk to your local • Oral contraceptives pharmacy The following contraceptive items on No charge for up to a Not available Tier 1: 100-day supply • Spermicide • Sponges • Contraceptive gel Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 11 Description of Contraceptive Drugs and Cost Share Cost Share Subject to Applies to Devices at a Plan Pharmacy by Mail Deductible OOPM The following hormonal contraceptive No charge for up to a No charge for up to a items on Tier 2: 365-day supply 365-day supply • Rings Availability for mail • Patches order varies by item. Talk to your local • Oral contraceptives pharmacy The following contraceptive items on No charge for up to a Not available Tier 2: 100-day supply • Spermicide • Sponges • Contraceptive gel Emergency contraception No charge Not available Diaphragms,cervical caps,and up to a 30- No charge Not available ✓ day supply of condoms Certain preventive items Cost Share Cost Share Subject to Applies to Description of Certain Preventive Items at a Plan Pharmacy by Mail Deductible OOPM Items on our Preventive Services list on No charge for up to a Not available our website at kp.m/prevention when 100-day supply prescribed by a Plan Provider Fertility and sexual dysfunction drugs Description of Fertility and Sexual Cost Share Cost Share Subject to Applies to Dysfunction Drugs at a Plan Pharmacy by Mail Deductible OOPM Drugs on Tier 1 prescribed to treat $10 for up to a 30-day $20 for up to a 100-day Infertility or in connection with covered supply supply artificial insemination Services Drugs on Tier 2 and Tier 4 prescribed to $20 for up to a 30-day $40 for up to a 100-day treat Infertility or in connection with supply supply covered artificial insemination Services Drugs on Tier 1 prescribed in connection Not covered Not covered with covered assisted reproductive technology("ART")Services Group ID:604334 Kaiser Pertnanente Traditional HMO Plan Contract: 1 Version:36 EOCW I Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 12 Description of Fertility and Sexual Cost Share Cost Share Subject to Applies to Dysfunction Drugs at a Plan Pharmacy by Mail Deductible OOPM Drugs on Tier 2 and Tier 4 prescribed in Not covered Not covered connection with covered assisted reproductive technology("ART") Services Drugs on Tier 1 prescribed for sexual 50%Coinsurance(not to 50%Coinsurance(not to dysfunction disorders exceed$50)for up to a exceed$50)for up to a ✓ 100-day supply 100-day supply Drugs on Tier 2 and Tier 4 prescribed for 50%Coinsurance(not to 50%Coinsurance(not to sexual dysfunction disorders exceed$100)for up to a exceed$100)for up to a ✓ 100-day supply 100-day supply Outpatient surgery and outpatient procedures Copayment/ Subject to Applies to Description of Outpatient Surgery and Outpatient Procedure Services Coinsurance Deductible OOPM Outpatient surgery and outpatient procedures(including imaging and $15 per procedure diagnostic Services)when provided in an outpatient or ambulatory surgery center or in a hospital operating room,or any setting where a ✓ licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort Any other outpatient surgery that does not require a licensed staff $15 per procedure ✓ member to monitor your vital signs as described above Preventive Services Copayment/ Subject to Applies to Description of Preventive Services Coinsurance Deductible OOPM Routine physical exams,including well-woman,postpartum follow- No charge ✓ up,and preventive exams for Members age 2 and older Well-child preventive exams for Members through age 23 months No charge ✓ Normal series of regularly scheduled preventive prenatal care exams No charge ✓ after confirmation of pregnancy Immunizations(including the vaccine)administered to you in a Plan No charge ✓ Medical Office Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC9#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 13 Copayment/ Subject to Applies to Description of Preventive Services Coinsurance Deductible OOPM Immunizations(including the vaccine)for COVID-19 administered 50%Coinsurance by Non-Plan Providers(except for providers of Emergency Services or Out-of-Area Urgent Care) Tuberculosis skin tests No charge Screening and counseling Services when provided during a routine No charge physical exam or a well-child preventive exam,such as obesity counseling,routine vision and hearing screenings,alcohol and ✓ substance abuse screenings,health education,depression screening, and developmental screenings to diagnose and assess potential developmental delays Screening colonoscopies No charge Screening flexible sigmoidoscopies No charge Routine imaging screenings such as mammograms No charge Bone density CT scans No charge Bone density DEXA scans No charge Routine laboratory tests and screenings,such as cancer screening No charge tests,sexually transmitted infection("STI")tests,cholesterol screening tests,and glucose tolerance tests Other laboratory screening tests,such as fecal occult blood tests and No charge hepatitis B screening tests Prosthetic and orthotic devices Copayment/ Subject to Applies to Description of Prosthetic and Orthotic Device Services Coinsurance Deductible OOPM External prosthetic and orthotic devices as described in this EOC No charge Supplemental prosthetic and orthotic devices as described in this No charge ✓ EOC Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW I Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 14 Rehabilitative and habilitative Services Copayment/ Subject to Applies to Description of Rehabilitative and Habilitative Services Coinsurance Deductible OOPM Individual outpatient physical,occupational,and speech therapy $15 per visit Group outpatient physical,occupational,and speech therapy $7 per visit Physical,occupational,and speech therapy provided in an organized, $15 per day multidisciplinary rehabilitation day-treatment program Reproductive Health Services Family planning Services Copayment/ Subject to Applies to Description of Family Planning Services Coinsurance Deductible OOPM Family planning counseling No charge Injectable contraceptives,internally implanted time-release No charge contraceptives or intrauterine devices("IUDs")and office visits ✓ related to their insertion,removal,and management when provided to prevent pregnancy Sterilization procedures for Members assigned female at birth if No charge performed in an outpatient or ambulatory surgery center or in a hospital operating room All other sterilization procedures for Members assigned female at No charge ✓ birth Sterilization procedures for Members assigned male at birth if No charge performed in an outpatient or ambulatory surgery center or in a hospital operating room All other sterilization procedures for Members assigned male at birth No charge Abortion and abortion-related Services Copayment/ Subject to Applies to Description of abortion and abortion-related Services Coinsurance Deductible OOPM Surgical abortion No charge Prescription drugs,in accord with our drug formulary guidelines No charge Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 15 Copayment/ Subject to Applies to Description of abortion and abortion-related Services Coinsurance Deductible OOPM Other abortion-related Services No charge ,/ Plan Doula services Copayment/ Subject to Applies to Description of Plan Doula services Coinsurance Deductible OOPM Initial,prenatal,or postpartum visits No charge Support during labor and delivery No charge Skilled nursing facility care Copayment/ Subject to Applies to Description of Skilled Nursing Facility Care Services Coinsurance Deductible OOPM Skilled nursing facility Services up to 100 days per benefit period* No charge *A benefit period begins on the date you are admitted to a hospital or Skilled Nursing Facility at a skilled level of care.A benefit period ends on the date you have not been an inpatient in a hospital or Skilled Nursing Facility,receiving a skilled level of care,for 60 consecutive days.A new benefit period can begin only after any existing benefit period ends.A prior three-day stay in an acute care hospital is not required. Substance use disorder treatment Copayment/ Subject to Applies to Description of Substance Use Disorder Treatment Services Coinsurance Deductible OOPM Inpatient detoxification No charge Individual substance use disorder evaluation and treatment $15 per visit Group substance use disorder treatment $5 per visit Intensive outpatient and day-treatment programs No charge Methadone maintenance treatment No charge Residential substance use disorder treatment No charge Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW I Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 16 Telehealth visits Interactive video visits Copayment/ Subject to Applies to Description of Interactive Video Visit Services Coinsurance Deductible OOPM Primary Care Visits and Non-Physician Specialist Visits No charge Physician Specialist Visits No charge Scheduled telephone visits Copayment/ Subject to Applies to Description of Scheduled Telephone Visit Services Coinsurance Deductible OOPM Primary Care Visits and Non-Physician Specialist Visits No charge Physician Specialist Visits No charge Vision Services for Adult Members Copayment/ Subject to Applies to Description of Vision Services for Adult Members Coinsurance Deductible OOPM Routine eye exams with a Plan Optometrist to determine the need for No charge vision correction and to provide a prescription for eyeglass lenses Physician Specialist Visits to diagnose and treat injuries or diseases $15 per visit of the eye Non-Physician Specialist Visits to diagnose and treat injuries or $15 per visit ✓ diseases of the eye Aniridia lenses:up to two Medically Necessary contact lenses per eye No charge ✓ (including fitting and dispensing)in any 12-month period Aphakia lenses:up to six Medically Necessary aphakic contact lenses No charge ✓ per eye(including fitting and dispensing)in any 12-month period Specialty contact lenses(other than aniridia and aphakia lenses)that No charge after optical will provide a significant improvement in vision not obtainable with Allowance applied eyeglass lenses: either one pair of contact lenses(including fitting and dispensing)or an initial supply of disposable contact lenses(up to six months,including fitting and dispensing)in any 24-month period Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 17 Copayment/ Subject to Applies to Description of Vision Services for Adult Members Coinsurance Deductible OOPM Eyeglasses and contact lenses as described in this EOC We provide a$175 Allowance every 24 months Replacement lenses if there has been a change in prescription of at We provide a$30 least.50 diopter in one or both eyes within 12 months of the initial Allowance for a single point of sale of an eyeglass lens or contact lens that we provided an vision eyeglass lens or Allowance toward(or otherwise covered) contact lens,a$45 Allowance for a multifocal or lenticular eyeglass lens Low vision devices(including fitting and dispensing) Not covered Vision Services for Pediatric Members Copayment/ Subject to Applies to Description of Vision Services for Pediatric Members Coinsurance Deductible OOPM Routine eye exams with a Plan Optometrist to determine the need for No charge ✓ vision correction and to provide a prescription for eyeglass lenses Physician Specialist Visits to diagnose and treat injuries or diseases $15 per visit ✓ of the eye Non-Physician Specialist Visits to diagnose and treat injuries or $15 per visit ✓ diseases of the eye Aniridia lenses:up to two Medically Necessary contact lenses per eye No charge ✓ (including fitting and dispensing)in any 12-month period Aphakia lenses:up to six Medically Necessary aphakic contact lenses No charge per eye(including fitting and dispensing)in any 12-month period Specialty contact lenses(other than aniridia and aphakia lenses)that No charge after optical will provide a significant improvement in vision not obtainable with Allowance applied eyeglass lenses: either one pair of contact lenses(including fitting and dispensing)or an initial supply of disposable contact lenses(up to six months,including fitting and dispensing)in any 24-month period Eyeglasses and contact lenses as described in this EOC We provide a$175 Allowance every 24 months Group ID:604334 Kaiser Pertnanente Traditional HMO Plan Contract: 1 Version:36 EOC9#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 18 Copayment/ Subject to Applies to Description of Vision Services for Pediatric Members Coinsurance Deductible OOPM Replacement lenses if there has been a change in prescription of at No charge least.50 diopter in one or both eyes within 12 months of the initial point of sale of an eyeglass lens or contact lens that we provided an Allowance toward(or otherwise covered) Low vision devices(including fitting and dispensing) Not covered CARE Plan The California Community Assistance,Recovery,and Empowerment("CARE")Act established a system for individuals with severe mental illness to be evaluated and given a treatment plan developed by a county behavioral health agency ("CARE Plan").If a Member has a court-approved CARE Plan,we cover the Services required under that plan when provided by Plan Providers or Non-Plan Providers at no charge,with the exception of prescription drugs.Prescription drugs required under a court-approved CARE Plan are subject to the same Cost Share as drugs prescribed by Plan Providers,as described in this Cost Share Summary,and are also subject to prior authorization by Health Plan.To inform us that you have a court-approved CARE Plan,please call Member Services. Group ID:604334 Kaiser Pertnanente Traditional HMO Plan Contract: 1 Version:36 EOCW 1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 19 Introduction coverage information in this EOC applies when you obtain care in your Home Region.When you visit the This Evidence of Coverage('EOC")describes the health other California Region,you may receive care as described in"Receiving Care Outside of Your Home care coverage of this Kaiser Penmanente Traditional Region Service Area"in the"How to Obtain Services" HMO Plan provided under the Group Agreement section. ("Agreement")between Kaiser Foundation Health Plan, Inc. ("Health Plan")and the entity with which Health Kaiser Penmanente provides Services directly to our Plan has entered into the Agreement(your"Group"). Members through an integrated medical care program. Health Plan,Plan Hospitals,and the Medical Group This EOC is part of the Agreement between work together to provide our Members with quality care. Health Plan and your Group. The Agreement Our medical care program gives you access to all of the contains additional terms such as Premiums, covered Services you may need,such as routine care when coverage can change, the effective date with your own personal Plan Physician,hospital of coverage, and the effective date of Services,laboratory and pharmacy Services,Emergency Services,Urgent Care,and other benefits described in termination. The Agreement must be consulted this EOC.Plus,our health education programs offer you to determine the exact terms of coverage. A great ways to protect and improve your health. copy of the Agreement is available from your Group. We provide covered Services to Members using Plan Providers located in our Service Area,which is described Once enrolled in other coverage made available through in the"Definitions"section.You must receive all Health Plan,that other plan's evidence of coverage covered care from Plan Providers inside our Service cannot be cancelled without cancelling coverage under Area,except as described in the sections listed below for this EOC,unless the change is made during open the following Services: enrollment or a special enrollment period. • Authorized referrals as described under"Getting a Referral"in the"How to Obtain Services"section For benefits provided under any other program offered . Covered Services received outside of your Home by your Group(for example,workers compensation Region Service Area as described under"Receiving benefits),refer to your Group's materials. Care Outside of Your Home Region Service Area"in the"How to Obtain Services"section In this EOC,Health Plan is sometimes referred to as "we"or"us."Members are sometimes referred to as • COVID-19 Services as described under"Outpatient "you."Some capitalized terms have special meaning in Imaging,Laboratory,and Other Diagnostic and this EOC;please see the"Definitions"section for terms Treatment Services,""Outpatient Prescription Drugs, you should know. Supplies,and Supplements,"and"Preventive Services"in the"Benefits"section It is important to familiarize yourself with your coverage • Emergency ambulance Services as described under by reading this EOC completely,so that you can take full "Ambulance Services"in the"Benefits"section advantage of your Health Plan benefits.Also,if you have • Emergency Services,Post-Stabilization Care,and special health care needs,please carefully read the Out-of-Area Urgent Care as described in the sections that apply to you. "Emergency Services and Urgent Care"section • Hospice care as described under"Hospice Care"in About Kaiser Permanente the"Benefits"section PLEASE READ THE FOLLOWING Term of this EOC INFORMATION SO THAT YOU WILL KNOW FROM WHOM OR WHAT GROUP OF This EOC is for the period January 1,2025,through PROVIDERS YOU MAY GET HEALTH CARE. December 31,2025,unless amended.Your Group can tell you whether this EOC is still in effect and give you a When you join Kaiser Pennanente,you are enrolling in current one if this EOC has expired or been amended. one of two Health Plan Regions in California(either our Northern California Region or Southern California Region),which we call your"Home Region."The Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 20 Definitions schedule of charges that Kaiser Permanente negotiates with the capitated provider Some terms have special meaning in this EOC.When we • For items obtained at a pharmacy owned and operated use a term with special meaning in only one section of by Kaiser Permanente,the amount the pharmacy this EOC,we define it in that section.The terms in this would charge a Member for the item if a Member's "Definitions"section have special meaning when benefit plan did not cover the item(this amount is an capitalized and used in any section of this EOC. estimate of:the cost of acquiring,storing,and dispensing drugs,the direct and indirect costs of Accumulation Period:A period of time no greater than providing Kaiser Permanente pharmacy Services to 12 consecutive months for purposes of accumulating Members,and the pharmacy program's contribution amounts toward any deductibles(if applicable),out-of- to the net revenue requirements of Health Plan) pocket maximums,and benefit limits.For example,the Accumulation Period may be a calendar year or contract • For air ambulance Services received from Non-Plan year.The Accumulation Period for this EOC is from Providers when you have an Emergency Medical January 1 through December 31. Condition,the amount required to be paid by Health Plan pursuant to federal law Allowance:A specified amount that you can use toward the purchase price of an item.If the price of the items • For other Emergency Services received from Non- you select exceeds the Allowance,you will pay the Plan Providers(including Post-Stabilization Care that amount in excess of the Allowance(and that payment constitutes Emergency Services under federal law), will not apply toward any deductible or out-of-pocket the amount required to be paid by Health Plan maximum). pursuant to state law,when it is applicable,or federal law Ancillary Coverage: Optional benefits such as . For all other Services received from Non-Plan acupuncture,chiropractic,or dental coverage that may be available to Members enrolled under this EOC. If your Providers(including Post-Stabilization Services that plan includes Ancillary Coverage,this coverage will be are not Emergency Services under federal law),the described in an amendment to this EOC or a separate amount(1)required to be paid pursuant to state law, agreement from the issuer of the coverage. when it is applicable,or federal law,or(2)in the event that neither state or federal law prohibiting Behavioral Health Treatment for Autism Spectrum balance billing apply,then the amount agreed to by Disorder: Professional Services and treatment programs, the Non-Plan Provider and Health Plan or,absent including applied behavior analysis and evidence-based such an agreement,the usual,customary and behavior intervention programs,that develop or restore, reasonable rate for those services as determined by to the maximum extent practicable,the functioning of a Health Plan based on objective criteria person with autism spectrum disorder(or treat mental . For all other Services,the payments that Kaiser health conditions other than autism spectrum disorder Permanente makes for the Services or,if Kaiser when this treatment is clinically indicated)that meet the Permanente subtracts your Cost Share from its following criteria: payment,the amount Kaiser Permanente would have • The treatment is prescribed by a Plan Physician,or is paid if it did not subtract your Cost Share developed by a Plan Provider who is a psychologist • The treatment is administered by a Plan Provider who Cigna Healthcare PPO Network: The Cigna is a qualified autism service provider,qualified Healthcare PPO Network refers to the health care autism service professional,or qualified autism providers(doctors,hospitals,specialists)contracted as service paraprofessional,as defined in California part of a shared administration network arrangement Health and Safety Code section 1374.73(c) called Cigna Healthcare PPO for Shared Administration. Charges: "Charges"means the following: Cigna Healthcare is an independent company and not • For Services provided by the Medical Group or affiliated with Kaiser Foundation Health Plan,Inc.,and Kaiser Foundation Hospitals,the charges in Health its subsidiary health plans.Access to the Cigna Plan's schedule of Medical Group and Kaiser Healthcare PPO Network is available through Cigna Foundation Hospitals charges for Services provided Healthcare's contractual relationship with the Kaiser to Members Permanente health plans.The Cigna Healthcare PPO • For Services for which a provider(other than the Network is provided exclusively by or through operating Medical Group or Kaiser Foundation Hospitals)is subsidiaries of The Cigna Group,including Cigna Health compensated on a capitation basis,the charges in the and Life Insurance Company.The Cigna Healthcare Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 21 name,logo,and other marks are owned by Cigna by acute symptoms of sufficient severity such that either Intellectual Property,Inc. of the following is true: Coinsurance:A percentage of Charges that you must • The person is an immediate danger to themself or to pay when you receive a covered Service under this EOC. others Copayment:A specific dollar amount that you must pay • The person is immediately unable to provide for,or when you receive a covered Service under this EOC. use,food,shelter,or clothing,due to the mental Note:The dollar amount of the Copayment can be$0 disorder (no charge). Emergency Services:All of the following with respect Cost Share: The amount you are required to pay for to an Emergency Medical Condition: covered Services.For example,your Cost Share may be • A medical screening exam that is within the a Copayment or Coinsurance.If your coverage includes a capability of the emergency department of a hospital Plan Deductible and you receive Services that are subject or an independent freestanding emergency to the Plan Deductible,your Cost Share for those department,including ancillary services(such as Services will be Charges until you reach the Plan imaging and laboratory Services)routinely available Deductible. Similarly,if your coverage includes a Drug to the emergency department to evaluate the Deductible,and you receive Services that are subject to Emergency Medical Condition the Drug Deductible,your Cost Share for those Services . Within the capabilities of the staff and facilities will be Charges until you reach the Drug Deductible. available at the facility,Medically Necessary Dependent:A Member who meets the eligibility examination and treatment required to Stabilize the requirements as a Dependent(for Dependent eligibility patient(once your condition is Stabilized, Services requirements,see"Who Is Eligible"in the"Premiums, you receive are Post-Stabilization Care and not Eligibility,and Enrollment"section). Emergency Services) Disclosure Form("DF"):A summary of coverage for • Post-Stabilization Care furnished by a Non-Plan prospective Members.For some products,the DF is Provider is covered as Emergency Services when combined with the evidence of coverage. federal law applies,as described under"Post- Drug Deductible: The amount you must pay under this Stabilization Care"in the"Emergency Services" EOC in the Accumulation Period for certain drugs, section supplies,and supplements before we will cover those EOC: This Evidence of Coverage document,including Services at the applicable Copayment or Coinsurance in any amendments,which describes the health care that Accumulation Period.Refer to the"Cost Share coverage of"Kaiser Permanente Traditional HMO Plan" Summary"section to learn whether your coverage under Health Plan's Agreement with your Group. includes a Drug Deductible,the Services that are subject Family:A Subscriber and all of their Dependents. to the Drug Deductible,and the Drug Deductible amount. Group: The entity with which Health Plan has entered Emergency Medical Condition:A medical condition into the Agreement that includes this EOC. manifesting itself by acute symptoms of sufficient Health Plan:Kaiser Foundation Health Plan,Inc.,a severity(including severe pain)such that you reasonably California nonprofit corporation.Health Plan is a health believed that the absence of immediate medical attention care service plan licensed to offer health care coverage would result in any of the following: by the Department of Managed Health Care. This EOC • Placing the person's health(or,with respect to a sometimes refers to Health Plan as"we"or"us." pregnant person,the health of the pregnant person or Home Region:The Region where you enrolled(either unborn child)in serious jeopardy the Northern California Region or the Southern • Serious impairment to bodily functions California Region). • Serious dysfunction of any bodily organ or part Infertility:A person's inability to conceive a pregnancy or cant'a pregnancy to live birth either as an individual A mental health condition is an Emergency Medical or with their partner;or,a Plan Physician's determination Condition when it meets the requirements of the of Infertility,based on a patient's medical,sexual,and paragraph above,or when the condition manifests itself reproductive history,age,physical findings,diagnostic testing,or any combination of those factors. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 22 Kaiser Permanente:Kaiser Foundation Hospitals(a Non—Plan Provider:A provider other than a Plan California nonprofit corporation),Health Plan,and the Provider. Medical Group. Non—Plan Psychiatrist:A psychiatrist who is not a Plan Kaiser Permanente State:California,Colorado,District Physician. of Columbia,Georgia,Hawaii,Maryland,Oregon, Virginia,and Washington. Out-of--Area Urgent Care:Medically Necessary Services to prevent serious deterioration of your(or your Medical Group: The Permanente Medical Group,Inc.,a unborn child's)health resulting from an unforeseen for-profit professional corporation. illness,unforeseen injury,or unforeseen complication of Medically Necessary:For Services related to mental an existing condition(including pregnancy)if all of the health or substance use disorder treatment,a Service is following are true: Medically Necessary if it is addressing your specific • You are temporarily outside our Service Area needs,for the purpose of preventing,diagnosing,or • A reasonable person would have believed that your treating an illness,injury,condition,or its symptoms, (or your unborn child's)health would seriously including minimizing the progression of that illness, deteriorate if you delayed treatment until you returned injury,condition,or its symptoms,in a manner that is all to our Service Area of the following: Physician Specialist Visits: Consultations,evaluations, • In accordance with the generally accepted standards and treatment by physician specialists,including of mental health and substance use disorder care personal Plan Physicians who are not Primary Care • Clinically appropriate in terms of type,frequency, Physicians. extent,site,and duration Plan Deductible: The amount you must pay under this • Not primarily for the economic benefit of the health EOC in the Accumulation Period for certain Services care service plan and subscribers or for the before we will cover those Services at the applicable convenience of the patient,treating physician,or Copayment or Coinsurance in that Accumulation Period. other health care provider Refer to the"Cost Share Summary"section to learn For all other Services,a Service is Medically Necessary whether your coverage includes a Plan Deductible,the if it is medically appropriate and required to prevent, Services that are subject to the Plan Deductible,and the diagnose,or treat your condition or clinical symptoms in Plan Deductible amount. accord with generally accepted professional standards of practice that are consistent with a standard of care in the Plan Doula:A contracted birth worker who provides medical community. physical,emotional,and non-medical support for pregnant and postpartum persons before,during,and Medicare:The federal health insurance program for after childbirth. people 65 years of age or older,some people under age 65 with certain disabilities,and people with end-stage Plan Facility: Any facility listed in the Provider renal disease(generally those with permanent kidney Directory on our website at kp.org/facilities.Plan failure who need dialysis or a kidney transplant). Facilities include Plan Hospitals,Plan Medical Offices, Member:A person who is eligible and enrolled under and other facilities that we designate in the directory. this EOC,and for whom we have received applicable The directory is updated periodically.The availability of Premiums. This EOC sometimes refers to a Member as Plan Facilities may change.If you have questions,please "YOU." call Member Services. Non-Physician Specialist Visits: Consultations, Plan Hospital:Any hospital listed in the Provider evaluations,and treatment by non-physician specialists Directory on our website at kp.org/facilities.In the (such as nurse practitioners,physician assistants, directory,some Plan Hospitals are listed as Kaiser optometrists,podiatrists,and audiologists).For Services Permanente Medical Centers.The directory is updated described under"Dental and Orthodontic Services"in periodically. The availability of Plan Hospitals may the"Benefits"section,non-physician specialists include change.If you have questions,please call Member dentists and orthodontists. Services. Non—Plan Hospital:A hospital other than a Plan Plan Medical Office:Any medical office listed in the Hospital. Provider Directory on our website at kp.org/facilities. In the directory,Kaiser Permanente Medical Centers may Non—Plan Physician: A physician other than a Plan include Plan Medical Offices. The directory is updated Physician. periodically. The availability of Plan Medical Offices Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 23 may change.If you have questions,please call Member Premiums:The periodic amounts that your Group is Services. responsible for paying for your membership under this Plan Optical Sales Office:An optical sales office EOC, except that you are responsible for paying owned and operated by Kaiser Permanente or another Premiums if you have Cal-COBRA coverage."Full optical sales office that we designate.Refer to the Premiums"means 100 percent of Premiums for all of the Provider Directory on our website at ky.org/facilities for coverage issued to each enrolled Member,as set forth in locations of Plan Optical Sales Offices.In the directory, the"Premiums"section of Health Plan's Agreement with Plan Optical Sales Offices may be called"Vision your Group. Essentials."The directory is updated periodically.The Preventive Services: Covered Services that prevent or availability of Plan Optical Sales Offices may change.If detect illness and do one or more of the following: you have questions,please call Member Services. • Protect against disease and disability or further Plan Optometrist:An optometrist who is a Plan progression of a disease Provider. • Detect disease in its earliest stages before noticeable Plan Out-of-Pocket Maximum: The total amount of symptoms develop Cost Share you must pay under this EOC in the Primary Care Physicians: Generalists in internal Accumulation Period for certain covered Services that medicine,pediatrics,and family practice,and specialists you receive in the same Accumulation Period.Refer to in obstetrics/gynecology whom the Medical Group the"Cost Share Summary"section to find your Plan Out- designates as Primary Care Physicians.Refer to the of-Pocket Maximum amount and to learn which Services Provider Directory on our website at ky.org/facilities for apply to the Plan Out-of-Pocket Maximum. a list of physicians that are available as Primary Care Plan Pharmacy:A pharmacy owned and operated by Physicians.The directory is updated periodically.The Kaiser Permanente or another pharmacy that we availability of Primary Care Physicians may change.If designate.Refer to the Provider Directory on our website you have questions,please call Member Services. at ku.ora/facilities for locations of Plan Pharmacies.The Primary Care Visits:Evaluations and treatment directory is updated periodically. The availability of Plan provided by Primary Care Physicians and primary care Pharmacies may change.If you have questions,please Plan Providers who are not physicians(such as nurse call Member Services. practitioners). Plan Physician:Any licensed physician who is an Provider Directory:A directory of Plan Physicians and employee of the Medical Group,or any licensed Plan Facilities in your Home Region.This directory is physician who contracts to provide Services to Members available on our website at kmorg/facilities.To obtain a (but not including physicians who contract only to printed copy,call Member Services.The directory is provide referral Services). updated periodically.The availability of Plan Physicians Plan Provider:A Plan Hospital,a Plan Physician,the and Plan Facilities may change.If you have questions, Medical Group,a Plan Pharmacy,or any other health please call Member Services. care provider that Health Plan designates as a Plan Region:A Kaiser Foundation Health Plan organization Provider. or allied plan that conducts a direct-service health care Plan Skilled Nursing Facility:A Skilled Nursing program.Regions may change on January 1 of each year Facility approved by Health Plan. and are currently the District of Columbia and parts of Northern California, Southern California,Colorado, Post-Stabilization Care:Medically Necessary Services Georgia,Hawaii,Maryland,Oregon,Virginia,and related to your Emergency Medical Condition that you Washington.For the current list of Region locations, receive in a hospital(including the emergency please visit our website at ky.org or call Member department),an independent freestanding emergency Services. department,or a skilled nursing facility after your treating physician determines that this condition is Service Area:The ZIP codes below for each county are Stabilized.Post-Stabilization Care also includes durable in our Service Area: medical equipment covered under this EOC,if it is • All ZIP codes in Alameda County are inside our Medically Necessary after discharge from an emergency Northern California Service Area: 94501-02,94505, department and related to the same Emergency Medical 94514,94536-46,94550-52,94555,94557,94560, Condition.For more information about durable medical 94566,94568,94577-80,94586-88,94601-15, equipment covered under this EOC, see"Durable 94617-21,94622-24,94649,94659-62,94666, Medical Equipment("DME")for Home Use"in the 94701-10,94712,94720,95377,95391 "Benefits"section. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 24 • The following ZIP codes in Amador County are 94247-50,94252,94254,94256-59,94261-63, inside our Northern California Service Area: 95640, 94267-69,94271,94273-74,94277-80,94282-85, 95669 94287-91,94293-98,94571,95608-11,95615, • All ZIP codes in Contra Costa County are inside our 95621,95624,95626,95628,95630,95632,95638- Northern California Service Area: 94505-07,94509, 39,95641,95652,95655,95660,95662,95670-71, 94511,94513-14,94516-31,94547-49,94551, 95673,95678,95680,95683,95690,95693,95741- 94553,94556,94561,94563-65,94569-70,94572, 42,95757-59,95763,95811-38,95840-43,95851-53, 94575,94582-83,94595-98,94706-08,94801-08, 95860,95864-67,95894,95899 94820,94850 • All ZIP codes in San Francisco County are inside our • The following ZIP codes in El Dorado County are Northern California Service Area: 94102-05,94107- inside our Northern California Service Area: 95613- 12,94114-34,94137,94139-47,94151,94158-61, 14,95619,95623,95633-35,95651,95664,95667, 94163-64,94172,94177,94188 95672,95682,95762 • All ZIP codes in San Joaquin County are inside our • The following ZIP codes in Fresno County are inside Northern California Service Area: 94514,95201-15, our Northern California Service Area: 93242,93602, 95219-20,95227,95230-31,95234,95236-37, 93606-07,93609,93611-13,93616,93618-19, 95240-42,95253,95258,95267,95269,95296-97, 93624-27,93630-31,93646,93648-52,93654, 95304,95320,95330,95336-37,95361,95366, 93656-57,93660,93662,93667-68,93675,93701- 95376-78,95385,95391,95632,95686,95690 12,93714-18,93720-30,93737,93740-41,93744-45, • All ZIP codes in San Mateo County are inside our 93747,93750,93755,93760-61,93764-65,93771- Northern California Service Area: 94002,94005, 79,93786,93790-94,93844,93888 94010-11,94014-21,94025-28,94030,94037-38, • The following ZIP codes in Kings County are inside 94044,94060-66,94070,94074,94080,94083, our Northern California Service Area: 93230,93232, 94128,94303,94401-04,94497 93242,93631,93656 • The following ZIP codes in Santa Clara County are • The following ZIP codes in Madera County are inside inside our Northern California Service Area: 94022- 24,94035,94039-43,94085-89,94301-06,94309, our Northern California Service Area: 93601-02, 94550,95002,95008-09,95011,95013-15,95020- 93604,93614,93623,93626,93636-39,93643-45, 21,95026,95030-33,95035-38,95042,95044, 93653,93669,93720 95046,95050-56,95070-71,95076,95101,95103, • All ZIP codes in Marin County are inside our 95106,95108-13,95115-36,95138-41,95148, Northern California Service Area: 94901,94903-04, 95150-61,95164,95170,95172-73,95190-94,95196 94912-15,94920,94924-25,94929-30,94933, • All ZIP codes in Santa Cruz County are inside our 94937-42,94945-50,94952,94956-57,94960, 94963-66,94970-71,94973-74,94976-79 Northern California Service Area: 95001,95003, 95005-7,95010,95017-19,95033,95041,95060-67, • The following ZIP codes in Mariposa County are 95073,95076-77 inside our Northern California Service Area: 93 60 1, • All ZIP codes in Solano County are inside our 93623,93653 Northern California Service Area: 94503,94510, • The following ZIP codes in Monterey County are 94512,94533-35,94571,94585,94589-92,95616, inside our Northern California Service Area: 93 90 1, 95618,95620,95625,95687-88,95690,95694, 93902,93905,93906,93907,93912,93915,93933, 95696 93955,93962,95004,95012,95039,95076 • The following ZIP codes in Sonoma County are • All ZIP codes in Napa County are inside our Northern inside our Northern California Service Area: 94515, California Service Area: 94503,94508,94515, 94922-23, 94926-28,94931,94951-55,94972, 94558-59,94562,94567,94573-74,94576,94581, 94975,94999,95401-07,95409,95416,95419, 94599,95476 95421,95425,95430-31,95433,95436,95439, • The following ZIP codes in Placer County are inside 95441-42,95444,95446,95448,95450,95452, our Northern California Service Area: 95602-04, 95462,95465,95471-73,95476,95486-87,95492 95610,95626,95648,95650,95658,95661,95663, • All ZIP codes in Stanislaus County are inside our 95668,95677-78,95681,95703,95722,95736, Northern California Service Area: 95230,95304, 95746-47,95765 95307,95313,95316,95319,95322-23,95326, • All ZIP codes in Sacramento County are inside our 95328-29,95350-58,95360-61,95363,95367-68, Northern California Service Area: 94203-09,94211, 95380-82,95385-87,95397 94229-30,94232,94234-37,94239-40,94244-45, Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 25 • The following ZIP codes in Sutter County are inside Stabilize: To provide the medical treatment of the our Northern California Service Area: 95626,95645, Emergency Medical Condition that is necessary to 95659,95668,95674,95676,95692,95836-7 assure,within reasonable medical probability,that no • The following ZIP codes in Tulare County are inside material deterioration of the condition is likely to result our Northern California Service Area: 93618,93 63 1, from or occur during the transfer of the person from the 93646,93654,93666,93673 facility.With respect to a pregnant person who is having contractions,when there is inadequate time to safely • The following ZIP codes in Yolo County are inside transfer them to another hospital before delivery(or the our Northern California Service Area: 95605,95607, transfer may pose a threat to the health or safety of the 95612,95615-18,95620,95645,95691,95694-95, pregnant person or unborn child),"Stabilize"means to 95697-98,95776,95798-99 deliver(including the placenta). • The following ZIP codes in Yuba County are inside Subscriber:A Member who is eligible for membership our Northern California Service Area: 95692,95903, on their own behalf and not by virtue of Dependent 95961 status and who meets the eligibility requirements as a For each ZIP code listed for a county,our Service Area Subscriber(for Subscriber eligibility requirements,see includes only the part of that ZIP code that is in that "Who Is Eligible"in the"Premiums,Eligibility,and county.When a ZIP code spans more than one county, Enrollment"section). the part of that ZIP code that is in another county is not Surrogacy Arrangement:An arrangement in which an inside our Service Area unless that other county is listed individual agrees to become pregnant and to surrender above and that ZIP code is also listed for that other the baby(or babies)to another person or persons who county. intend to raise the child(or children).The person may be If you have a question about whether a ZIP code is in our impregnated in any manner including,but not limited to, Service Area,please call Member Services. artificial insemination,intrauterine insemination,in vitro fertilization,or through the surgical implantation of a Note:We may expand our Service Area at any time by fertilized egg of another person.For the purposes of this giving written notice to your Group.ZIP codes are EOC,"Surrogacy Arrangements"includes all types of subject to change by the U.S.Postal Service. surrogacy arrangements,including traditional surrogacy Services:Health care services or items("health care" arrangements and gestational surrogacy arrangements. includes physical health care,mental health care,and Telehealth Visits:Interactive video visits and scheduled substance use disorder treatment),and Behavioral Health telephone visits between you and your provider. Treatment for Autism Spectrum Disorder covered under "Mental Health Services"in the"Benefits"section. Urgent Care:Medically Necessary Services for a condition that requires prompt medical attention but is Skilled Nursing Facility:A facility that provides not an Emergency Medical Condition. inpatient skilled nursing care,rehabilitation services,or other related health services and is licensed by the state of California.The facility's primary business must be the provision of 24-hour-a-day licensed skilled nursing care. Premiums, Eligibility, a n d The term"Skilled Nursing Facility"does not include Enrollment convalescent nursing homes,rest facilities,or facilities for the aged,if those facilities furnish primarily custodial Premiums care,including training in routines of daily living.A "Skilled Nursing Facility"may also be a unit or section Your Group is responsible for paying Full Premiums, within another facility(for example,a hospital)as long except that you are responsible for paying Full Premiums as it continues to meet this definition. as described in the"Continuation of Membership" Spouse: The person to whom the Subscriber is legally section if you have Cal-COBRA coverage under this married under applicable law.For the purposes of this EOC.If you are responsible for any contribution to the EOC,the term"Spouse"includes the Subscriber's Premiums that your Group pays,your Group will tell you domestic partner."Domestic partners"are two people the amount,when Premiums are effective,and how to who are registered and legally recognized as domestic pay your Group(through payroll deduction,for partners by California(if your Group allows enrollment example). of domestic partners not legally recognized as domestic partners by California,"Spouse"also includes the Subscriber's domestic partner who meets your Group's eligibility requirements for domestic partners). Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 26 Who Is Eligible For more information about the service areas of the other Regions,please call Member Services. To enroll and to continue enrollment,you must meet all of the eligibility requirements described in this"Who Is Eligibility as a Subscriber Eligible"section,including your Group's eligibility You may be eligible to enroll and continue enrollment as requirements and our Service Area eligibility a Subscriber if you are: requirements. • An employee of your Group Group eligibility requirements • A proprietor or partner of your Group You must meet your Group's eligibility requirements, • Otherwise entitled to coverage under a trust such as the minimum number of hours that employees agreement,retirement benefit program,or must work.Your Group is required to inform Subscribers employment contract(unless the Internal Revenue of its eligibility requirements. Service considers you self-employed) Service Area eligibility requirements Eligibility as a Dependent The"Definitions"section describes our Service Area and how it may change. Enrolling a Dependent Dependent eligibility is subject to your Group's Subscribers must live or work inside our Service Area at eligibility requirements,which are not described in this the time they enroll.If after enrollment the Subscriber no EOC.You can obtain your Group's eligibility longer lives or works inside our Service Area,the requirements directly from your Group.If you are a Subscriber can continue membership unless(1)they live Subscriber under this EOC and if your Group allows inside or move to the service area of another Region and enrollment of Dependents,Health Plan allows the do not work inside our Service Area,or(2)your Group following persons to enroll as your Dependents under does not allow continued enrollment of Subscribers who this EOC: do not live or work inside our Service Area. • Your Spouse • Your or your Spouse's Dependent children,who meet Dependent children of the Subscriber or of the the requirements described under the limit of Subscriber's Spouse may live anywhere inside or outside Dependent children,"if they are any of the following: our Service Area. Other Dependents may live anywhere, except that they are not eligible to enroll or to continue ♦ biological children enrollment if they live in or move to the service area of ♦ stepchildren another Region. ♦ adopted children ♦ children placed with you for adoption If you are not eligible to continue enrollment because you live in or move to the service area of another ♦ foster children if you or your Spouse have the Region,please contact your Group to learn about your legal authority to direct their care Group health care options: ♦ children for whom you or your Spouse is the • Regions outside California.You maybe able to court-appointed guardian(or was when the childreached age 18) enroll in the service area of another Region if there is an agreement between your Group and that Region, • Children whose parent is a Dependent child under but the plan,including coverage,premiums,and your family coverage(including adopted children and eligibility requirements,might not be the same as children placed with your Dependent child for under this EOC adoption or foster care),if they meet all of the • Southern California Region's service area.Your following requirements: Group may have an arrangement with us that permits ♦ they are not married and do not have a domestic membership in the Southern California Region,but partner(for the purposes of this requirement only, the plan,including coverage,premiums,and "domestic partner"means someone who is eligibility requirements,might not be the same as registered and legally recognized as a domestic under this EOC.All terms and conditions in your partner by California) application for enrollment in the Northern California ♦ they meet the requirements described under"Age Region,including the Arbitration Agreement,will limit of Dependent children" continue to apply if the Subscriber does not submit a new enrollment form Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 27 ♦ they receive all of their support and maintenance us documentation of the Dependent's incapacity and from you or your Spouse dependency within 60 days of receipt of our notice ♦ they permanently reside with you or your Spouse and we determine that the Dependent is eligible as a disabled dependent. If the Subscriber provides us this If you have a baby documentation in the specified time period and we do If you have a baby while enrolled under this EOC,the not make a determination about eligibility before the baby is not automatically enrolled in this plan.The termination date,coverage will continue until we Subscriber must request enrollment of the baby as make a determination.If we determine that the described under"Special enrollment"in the"How to Dependent does not meet the eligibility requirements Enroll and When Coverage Begins"section below.If the as a disabled dependent,we will notify the Subscriber Subscriber does not request enrollment within this that the Dependent is not eligible and let the special enrollment period,the baby will only be covered Subscriber know the membership termination date.If under this plan for 31 days(including the date of birth). we determine that the Dependent is eligible as a disabled dependent,there will be no lapse in Age limit of Dependent children coverage.Also,starting two years after the date that Children must be under age 26 as of the effective date of the Dependent reached the age limit,the Subscriber this EOC to enroll as a Dependent under your plan. must provide us documentation of the Dependent's incapacity and dependency annually within 60 days after we request it so that we can determine if the Dependent children are eligible to remain on the plan Dependent continues to be eligible as a disabled through the end of the month in which they reach the age dependent limit. • If the child is not a Member because you are changing Dependent children of the Subscriber or Spouse coverage,you must give us proof,within 60 days (including adopted children and children placed with you after we request it,of the child's incapacity and for adoption,but not including children placed with you dependency as well as proof of the child's coverage for foster care)who reach the age limit may continue under your prior coverage.In the future,you must coverage under this EOC if all of the following provide proof of the child's continued incapacity and conditions are met: dependency within 60 days after you receive our request,but not more frequently than annually • They meet all requirements to be a Dependent except for the age limit If the Subscriber is enrolled under a Kaiser • Your Group permits enrollment of Dependents Permanente Medicare plan • They are incapable of self-sustaining employment The dependent eligibility rules described in the because of a physically-or mentally-disabling injury, "Eligibility as a Dependent"section also apply if you are illness,or condition that occurred before they reached a subscriber under a Kaiser Permanente Medicare plan the age limit for Dependents offered by your Group(please ask your Group about your membership options).All of your dependents who • They receive 50 percent or more of their support and are enrolled under this or any other non-Medicare maintenance from you or your Spouse evidence of coverage offered by your Group must be • If requested,you give us proof of their incapacity and enrolled under the same non-Medicare evidence of dependency within 60 days after receiving our request coverage.A"non-Medicare"evidence of coverage is one (see"Disabled Dependent certification"below in this that does not require members to have Medicare. "Eligibility as a Dependent"section) Persons barred from enrolling Disabled Dependent certification You cannot enroll if you have had your entitlement to Proof may be required for a Dependent to be eligible to receive Services through Health Plan terminated for continue coverage as a disabled Dependent.If we request cause. it,the Subscriber must provide us documentation of the dependent's incapacity and dependency as follows: Members with Medicare and retirees • If the child is a Member,we will send the Subscriber This EOC is not intended for most Medicare a notice of the Dependent's membership termination beneficiaries and some Groups do not offer coverage to due to loss of eligibility at least 90 days before the retirees.If,during the term of this EOC,you are(or date coverage will end due to reaching the age limit. become)eligible for Medicare or you retire,please ask The Dependent's membership will terminate as your Group about your membership options as follows: described in our notice unless the Subscriber provides Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 28 • If a Subscriber who has Medicare Part B retires and Advantage plan applicable when Medicare is secondary the Subscriber's Group has a Kaiser Permanente may also enroll in that plan if it is available. These Senior Advantage plan for retirees,the Subscriber Members receive the benefits and coverage described in should enroll in the plan if eligible this EOC and the Kaiser Permanente Senior Advantage • If the Subscriber has dependents who have Medicare evidence of coverage applicable when Medicare is and your Group has a Kaiser Permanente Senior secondary. Advantage plan(or of one our other plans that require members to have Medicare),the Subscriber may be Medicare late enrollment penalties able to enroll them as dependents under that plan If you become eligible for Medicare Part B and do not enroll,Medicare may require you to pay a late • If the Subscriber retires and your Group does not enrollment penalty if you later enroll in Medicare Part B. offer coverage to retirees,you may be eligible to However,if you delay enrollment in Part B because you continue membership as described in the or your spouse are still working and have coverage "Continuation of Membership"section through an employer group health plan,you may not • If federal law requires that your Group's health care have to pay the penalty.Also,if you are(or become) coverage be primary and Medicare coverage be eligible for Medicare and go without creditable secondary,your coverage under this EOC will be the prescription drug coverage(drug coverage that is at least same as it would be if you had not become eligible for as good as the standard Medicare Part D prescription Medicare.However,you may also be eligible to drug coverage)for a continuous period of 63 days or enroll in Kaiser Permanente Senior Advantage more,you may have to pay a late enrollment penalty if through your Group if you have Medicare Part B you later sign up for Medicare prescription drug • If you are(or become)eligible for Medicare and are coverage.If you are(or become)eligible for Medicare, in a class of beneficiaries for which your Group's your Group is responsible for informing you about health care coverage is secondary to Medicare,you whether your drug coverage under this EOC is creditable should consider enrollment in Kaiser Permanente prescription drug coverage at the times required by the Senior Advantage through your Group if you are Centers for Medicare&Medicaid Services and upon eligible your request. • If none of the above applies to you and you are eligible for Medicare or you retire,please ask your How to Enroll and When Coverage Group about your membership options Begins Note:If you are enrolled in a Medicare plan and lose Your Group is required to inform you when you are Medicare eligibility,you may be able to enroll under this eligible to enroll and what your effective date of EOC if permitted by your Group(please ask your Group coverage is.If you are eligible to enroll as described for details). under"Who Is Eligible"in this"Premiums,Eligibility, and Enrollment"section,enrollment is permitted as When Medicare is primary described below and membership begins at the beginning Your Group's Premiums may increase if you are(or (12:00 a.m.)of the effective date of coverage indicated become)eligible for Medicare Part A or B as primary below,except that your Group may have additional coverage,and you are not enrolled through your Group requirements,which allow enrollment in other situations. in Kaiser Permanente Senior Advantage for any reason (even if you are not eligible to enroll or the plan is not If you are eligible to be a Dependent under this EOC but available to you). the subscriber in your family is enrolled under a Kaiser Permanente Senior Advantage evidence of coverage When Medicare is secondary offered by your Group,the rules for enrollment of Medicare is the primary coverage except when federal Dependents in this"How to Enroll and When Coverage law requires that your Group's health care coverage be Begins"section apply,not the rules for enrollment of primary and Medicare coverage be secondary.Members dependents in the subscriber's evidence of coverage. who have Medicare when Medicare is secondary by law are subject to the same Premiums and receive the same New employees benefits as Members who are under age 65 and do not When your Group informs you that you are eligible to have Medicare.In addition,any such Member for whom enroll as a Subscriber,you may enroll yourself and any Medicare is secondary by law and who meets the eligible Dependents by submitting a Health Plan— eligibility requirements for the Kaiser Permanente Senior approved enrollment application to your Group within 31 days. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 29 Effective date of coverage Subscriber.Enrollments of newly acquired Dependent The effective date of coverage for new employees and children are effective as follows: their eligible family Dependents is determined by your • Enrollments due to birth are effective on the date of Group in accord with waiting period requirements in birth state and federal law.Your Group is required to inform the Subscriber of the date your membership becomes • Enrollments due to adoption are effective on the date effective.For example,if the hire date of an otherwise- of adoption eligible employee is January 19,the waiting period • Enrollments due to placement for adoption or foster begins on January 19 and the effective date of coverage care are effective on the date you or your Spouse have cannot be any later than April 19.Note:If the effective newly assumed a legal right to control health care date of your Group's coverage is always on the first day of the month,in this example the effective date cannot be Special enrollment due to loss of other coverage any later than April 1. You may enroll as a Subscriber(along with any eligible Dependents),and existing Subscribers may add eligible Open enrollment Dependents,if all of the following are true: You may enroll as a Subscriber(along with any eligible • The Subscriber or at least one of the Dependents had Dependents),and existing Subscribers may add eligible other coverage when they previously declined all Dependents,by submitting a Health Plan—approved enrollment application to your Group during your coverage through your Group Group's open enrollment period.Your Group will let you • The loss of the other coverage is due to one of the know when the open enrollment period begins and ends following: and the effective date of coverage. ♦ exhaustion of COBRA coverage ♦ termination of employer contributions for non- Special enrollment COBRA coverage If you do not enroll when you are first eligible and later ♦ loss of eligibility for non-COBRA coverage,but want to enroll,you can enroll only during open not termination for cause or termination from an enrollment unless one of the following is true: individual(nongroup)plan for nonpayment.For • You become eligible because you experience a example,this loss of eligibility may be due to legal qualifying event(sometimes called a"triggering separation or divorce,moving out of the plan's event")as described in this"Special enrollment" service area,reaching the age limit for dependent section children,or the subscriber's death,termination of • You did not enroll in any coverage offered by your employment,or reduction in hours of employment Group when you were first eligible and your Group ♦ loss of eligibility(but not termination for cause) does not give us a written statement that verifies you for coverage through Covered California, signed a document that explained restrictions about Medicaid coverage(known as Medi-Cal in enrolling in the future.The effective date of an California),Children's Health Insurance Program enrollment resulting from this provision is no later coverage,or Medi-Cal Access Program coverage than the first day of the month following the date your ♦ reaching a lifetime maximum on all benefits Group receives a Health Plan—approved enrollment or change of enrollment application from the Subscriber Note:If you are enrolling yourself as a Subscriber along with at least one eligible Dependent,only one of you Special enrollment due to new Dependents must meet the requirements stated above. You may enroll as a Subscriber(along with eligible Dependents),and existing Subscribers may add eligible To request enrollment,the Subscriber must submit a Dependents,within 30 days after marriage,establishment Health Plan—approved enrollment or change of of domestic partnership,birth,adoption,placement for enrollment application to your Group within 30 days adoption,or placement for foster care by submitting to after loss of other coverage,except that the timeframe for your Group a Health Plan—approved enrollment submitting the application is 60 days if you are application. requesting enrollment due to loss of eligibility for coverage through Covered California,Medicaid, The effective date of an enrollment resulting from Children's Health Insurance Program,or Medi-Cal marriage or establishment of domestic partnership is no Access Program coverage.The effective date of an later than the first day of the month following the date enrollment resulting from loss of other coverage is no your Group receives an enrollment application from the later than the first day of the month following the date Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 30 your Group receives an enrollment or change of • You are a Dependent of someone who becomes enrollment application from the Subscriber. entitled to Medicare Special enrollment due to court or administrative order • You become divorced or legally separated Within 30 days after the date of a court or administrative • You are a Dependent of someone who dies order requiring a Subscriber to provide health care • A Health Benefit Exchange(such as Covered coverage for a Spouse or child who meets the eligibility California)determines that one of the following requirements as a Dependent,the Subscriber may add the occurred because of misconduct on the part of a non- Spouse or child as a Dependent by submitting to your Exchange entity that provided enrollment assistance Group a Health Plan—approved enrollment or change of or conducted enrollment activities: enrollment application. ♦ a qualified individual was not enrolled in a qualified health plan The effective date of coverage resulting from a court or ♦ a qualified individual was not enrolled in the administrative order is the first of the month following qualified health plan that the individual selected the date we receive the enrollment request,unless your Group specifies a different effective date(if your Group ♦ a qualified individual is eligible for,but is not specifies a different effective date,the effective date receiving,advance payments of the premium tax cannot be earlier than the date of the order). credit or cost share reductions Special enrollment due to eligibility for premium To request special enrollment,you must submit a Health assistance Plan-approved enrollment application to your Group You may enroll as a Subscriber(along with eligible within 30 days after loss of other coverage.You may be Dependents),and existing Subscribers may add eligible required to provide documentation that you have Dependents,if you or a dependent become eligible for experienced a qualifying event.Membership becomes premium assistance through the Medi-Cal program. effective either on the first day of the next month(for Premium assistance is when the Medi-Cal program pays applications that are received by the fifteenth day of a all or part of premiums for employer group coverage for month)or on the first day of the month following the a Medi-Cal beneficiary.To request enrollment in your next month(for applications that are received after the Group's health care coverage,the Subscriber must fifteenth day of a month). submit a Health Plan—approved enrollment or change of enrollment application to your Group within 60 days Note:If you are enrolling as a Subscriber along with at after you or a dependent become eligible for premium least one eligible Dependent,only one of you must meet assistance.Please contact the California Department of one of the requirements stated above. Health Care Services to find out if premium assistance is available and the eligibility requirements. How to Obtain Services Special enrollment due to reemployment after military service As a Member,you are selecting our medical care If you terminated your health care coverage because you program to provide your health care.You must receive were called to active duty in the military service,you all covered care from Plan Providers inside our Service may be able to reenroll in your Group's health plan if Area,except as described in the sections listed below for required by state or federal law.Please ask your Group the following Services: for more information. • Authorized referrals as described under"Getting a Other special enrollment events Referral"in this"How to Obtain Services"section You may enroll as a Subscriber(along with any eligible • Covered Services received outside of your Home Dependents)if you or your Dependents were not Region Service Area as described under"Receiving previously enrolled,and existing Subscribers may add Care Outside of Your Home Region Service Area"in eligible Dependents not previously enrolled,if any of the this"How to Obtain Services"section following are true: • COVID-19 Services as described under"Outpatient • You lose employment for a reason other than gross Imaging,Laboratory,and Other Diagnostic and misconduct Treatment Services,""Outpatient Prescription Drugs, • Your employment hours are reduced Supplies,and Supplements,"and"Preventive Services"in the`Benefits"section Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 31 • Emergency ambulance Services as described under days a week.Here are some of the ways they can help "Ambulance Services"in the"Benefits"section you: • Emergency Services,Post-Stabilization Care,and • They can answer questions about a health concern, Out-of-Area Urgent Care as described in the and instruct you on self-care at home if appropriate "Emergency Services and Urgent Care"section • They can advise you about whether you should get • Hospice care as described under"Hospice Care"in medical care,and how and where to get care(for the`Benefits"section example,if you are not sure whether your condition is an Emergency Medical Condition,they can help you Our medical care program gives you access to all of the decide whether you need Emergency Services or covered Services you may need,such as routine care Urgent Care,and how and where to get that care) with your own personal Plan Physician,hospital • They can tell you what to do if you need care and a Services,laboratory and pharmacy Services,Emergency Plan Medical Office is closed or you are outside our Services,Urgent Care,and other benefits described in Service Area this EOC. You can reach one of these licensed health care Routine Care professionals by calling the appointment or advice phone number(for phone numbers,refer to our Provider If you need the following Services,you should schedule Directory or call Member Services).When you call,a an appointment: trained support person may ask you questions to help determine how to direct your call. • Preventive Services • Periodic follow-up care(regularly scheduled follow- up care,such as visits to monitor a chronic condition) Your Personal Plan Physician • Other care that is not Urgent Care Personal Plan Physicians provide primary care and play an important role in coordinating care,including hospital To request a non-urgent appointment,you can call your stays and referrals to specialists. local Plan Facility or request the appointment online.For appointment phone numbers,refer to our Provider We encourage you to choose a personal Plan Physician. Directory or call Member Services.To request an You may choose any available personal Plan Physician. appointment online,go to our website at kp•org. Parents may choose a pediatrician as the personal Plan Physician for their child. Most personal Plan Physicians are Primary Care Physicians(generalists in internal Urgent Care medicine,pediatrics,or family practice,or specialists in An Urgent Care need is one that requires prompt medical obstetrics/gynecology whom the Medical Group attention but is not an Emergency Medical Condition.If designates as Primary Care Physicians). Some specialists you think you may need Urgent Care,call the who are not designated as Primary Care Physicians but appropriate appointment or advice phone number at a who also provide primary care may be available as Plan Facility.For phone numbers,refer to our Provider personal Plan Physicians.For example,some specialists Directory or call Member Services. in internal medicine and obstetrics/gynecology who are not designated as Primary Care Physicians may be For information about Out-of-Area Urgent Care,refer to available as personal Plan Physicians.However,if you "Urgent Care"in the"Emergency Services and Urgent choose a specialist who is not designated as a Primary Care"section. Care Physician as your personal Plan Physician,the Cost Share for a Physician Specialist Visit will apply to all visits with the specialist except for routine preventive Not Sure What Kind of Care You Need? visits listed under"Preventive Services"in the "Benefits"section. Sometimes it's difficult to know what kind of care you need,so we have licensed health care professionals To learn how to select or change to a different personal available to assist you by phone 24 hours a day,seven Plan Physician,visit our website at kp•org or call Member Services.Refer to our Provider Directory for a list of physicians that are available as Primary Care Physicians.The directory is updated periodically.The availability of Primary Care Physicians may change.If Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 32 you have questions,please call Member Services.You be covered("prior authorization"means that the Medical can change your personal Plan Physician at any time for Group must approve the Services in advance): any reason. • Durable medical equipment • Ostomy and urological supplies Getting a Referral . Services not available from Plan Providers Referrals to Plan Providers • Transplants A Plan Physician must refer you before you can receive care from specialists,such as specialists in surgery, Utilization Management("UM")is a process that orthopedics,cardiology,oncology,dermatology,and determines whether a Service recommended by your physical,occupational,and speech therapies.Also,a treating provider is Medically Necessary for you.Prior Plan Physician must refer you before you can get authorization is a UM process that determines whether Behavioral Health Treatment for Autism Spectrum the requested services are Medically Necessary before Disorder covered under"Mental Health Services"in the care is provided.If it is Medically Necessary,then you "Benefits"section.However,you do not need a referral will receive authorization to obtain that care in a or prior authorization to receive most care from any of clinically appropriate place consistent with the terms of the following Plan Providers: your health coverage.Decisions regarding requests for • Your personal Plan Physician authorization will be made only by licensed physicians or other appropriately licensed medical professionals. • Generalists in internal medicine,pediatrics,and family practice For the complete list of Services that require prior • Specialists in optometry,mental health Services, authorization,and the criteria that are used to make substance use disorder treatment,and authorization decisions,please visit our website at obstetrics/gynecology kp.ore/UM or call Member Services to request a printed copy. A Plan Physician must refer you before you can get care from a specialist in urology except that you do not need a Refer to"Post-Stabilization Care"under"Emergency referral to receive Services related to sexual or Services"in the"Emergency Services and Urgent Care" reproductive health,such as a vasectomy. section for authorization requirements that apply to Post- Stabilization Care from Non—Plan Providers. Although a referral or prior authorization is not required to receive most care from these providers,a referral may Additional information about prior authorization for be required in the following situations: durable medical equipment and ostomy and urological • The provider may have to get prior authorization for supplies certain Services in accord with"Medical Group The prior authorization process for durable medical authorization procedure for certain referrals"in this equipment and ostomy and urological supplies includes "Getting a Referral"section the use of formulary guidelines.These guidelines were developed by a multidisciplinary clinical and operational • The provider may have to refer you to a specialist work group with review and input from Plan Physicians who has a clinical background related to your illness and medical professionals with clinical expertise. The or condition formulary guidelines are periodically updated to keep pace with changes in medical technology and clinical Standing referrals practice. If a Plan Physician refers you to a specialist,the referral will be for a specific treatment plan.Your treatment plan If your Plan Physician prescribes one of these items,they may include a standing referral if ongoing care from the will submit a written referral in accord with the UM specialist is prescribed.For example,if you have a life- process described in this"Medical Group authorization threatening,degenerative,or disabling condition,you can procedure for certain referrals"section. If the formulary get a standing referral to a specialist if ongoing care from guidelines do not specify that the prescribed item is the specialist is required. appropriate for your medical condition,the referral will be submitted to the Medical Group's designee Plan Medical Group authorization procedure for Physician,who will make an authorization decision as certain referrals described under"Medical Group's decision time frames" The following are examples of Services that require prior in this"Medical Group authorization procedure for authorization by the Medical Group for the Services to certain referrals"section. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 33 Additional information about utilization review for limited coverage of that Non—Plan Provider's determination criteria for mental health Services or Services. substance use disorder treatment Utilization review determination criteria and any Terminated provider education program materials for individuals making If you are currently receiving covered Services in one of authorization decisions related to mental health Services the cases listed below under"Eligibility"from a Plan or substance use disorder treatment are available at Hospital or a Plan Physician(or certain other providers) kp•or2 at no cost. when our contract with the provider ends(for reasons other than medical disciplinary cause or criminal Medical Group's decision time frames activity),you may be eligible for limited coverage of that The applicable Medical Group designee will make the terminated provider's Services. authorization decision within the time frame appropriate for your condition,but no later than five business days Eligibility after receiving all of the information(including The cases that are subject to this completion of Services additional examination and test results)reasonably provision are: necessary to make the decision,except that decisions . Acute conditions,which are medical conditions that about urgent Services will be made no later than 72 involve a sudden onset of symptoms due to an illness, hours after receipt of the information reasonably injury,or other medical problem that requires prompt necessary to make the decision.If the Medical Group medical attention and has a limited duration.We may needs more time to make the decision because it doesn't cover these Services until the acute condition ends have information reasonably necessary to make the decision,or because it has requested consultation by a • Serious chronic conditions until the earlier of(1) 12 particular specialist,you and your treating physician will months from your effective date of coverage if you be informed about the additional information,testing,or are a new Member,(2) 12 months from the specialist that is needed,and the date that the Medical termination date of the terminated provider,or(3)the Group expects to make a decision. first day after a course of treatment is complete when it would be safe to transfer your care to a Plan Your treating physician will be informed of the decision Provider,as determined by Kaiser Permanente after within 24 hours after the decision is made.If the Services consultation with the Member and Non—Plan Provider are authorized,your physician will be informed of the and consistent with good professional practice. scope of the authorized Services.If the Medical Group Serious chronic conditions are illnesses or other does not authorize all of the Services,Health Plan will medical conditions that are serious,if one of the send you a written decision and explanation within two following is true about the condition: business days after the decision is made.Any written ♦ it persists without full cure criteria that the Medical Group uses to make the decision ♦ it worsens over an extended period of time to authorize,modify,delay,or deny the request for authorization will be made available to you upon request. ♦ it requires ongoing treatment maintain remission or prevent deterioration If the Medical Group does not authorize all of the • Pregnancy and immediate postpartum care.We may Services requested and you want to appeal the decision, cover these Services for the duration of the pregnancy you can file a grievance as described under"Grievances" and immediate postpartum care in the"Dispute Resolution"section. o Mental health conditions in pregnant Members that occur,or can impact the Member,during pregnancy For these referral Services,you pay the Cost Share or during the postpartum period including,but not required for Services provided by a Plan Provider as limited to,postpartum depression.We may cover described in this EOC. completion of these Services for up to 12 months from the mental health diagnosis or from the end of Completion of Services from Non—Plan pregnancy,whichever occurs later Providers • Terminal illnesses,which are incurable or irreversible New Member illnesses that have a high probability of causing death If you are currently receiving Services from a Non—Plan within a year or less.We may cover completion of Provider in one of the cases listed below under these Services for the duration of the illness "Eligibility"and your prior plan's coverage of the • Children under age 3.We may cover completion of provider's Services has ended or will end when your these Services until the earlier of(1) 12 months from coverage with us becomes effective,you may be eligible Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 34 the child's effective date of coverage if the child is a Travel and Lodging for Certain Services new Member,(2) 12 months from the termination date of the terminated provider,or(3)the child's third The following are examples of when we will arrange or birthday provide reimbursement for certain travel and lodging • Surgery or another procedure that is documented as expenses in accord with our Travel and Lodging part of a course of treatment and has been Program Description: recommended and documented by the provider to • If Medical Group refers you to a provider that is more occur within 180 days of your effective date of than 50 miles from where you live for certain coverage if you are a new Member or within 180 days specialty Services such as bariatric surgery,complex of the termination date of the terminated provider thoracic surgery,transplant nephrectomy,or inpatient chemotherapy for leukemia and lymphoma To qualify for this completion of Services coverage,all . If Medical Group refers you to a provider that is of the following requirements must be met: outside your Home Region Service Area for certain • Your Health Plan coverage is in effect on the date you specialty Services such as a transplant or transgender receive the Services surgery • For new Members,your prior plan's coverage of the • If you are outside of California and you need an provider's Services has ended or will end when your abortion on an emergency or urgent basis,and the coverage with us becomes effective abortion can't be obtained in a timely manner due to a • You are receiving Services in one of the cases listed near total or total ban on health care providers' ability above from a Non—Plan Provider on your effective to provide such Services date of coverage if you are a new Member,or from the terminated Plan Provider on the provider's For the complete list of specialty Services for which we termination date will arrange or provide reimbursement for travel and lodging expenses,the amount of reimbursement, • For new Members,when you enrolled in Health Plan, limitations and exclusions,and how to request you did not have the option to continue with your reimbursement,refer to the Travel and Lodging Program previous health plan or to choose another plan Description.The Travel and Lodging Program (including an out-of-network option)that would cover Description is available online at kp.org/specialty- the Services of your current Non—Plan Provider care/travel-reimbursements or by calling Member • The provider agrees to our standard contractual terms Services. and conditions, such as conditions pertaining to payment and to providing Services inside our Service Second Opinions Area(the requirement that the provider agree to providing Services inside our Service Area doesn't If you want a second opinion,you can ask Member apply if you were receiving covered Services from the Services to help you arrange one with a Plan Physician provider outside our Service Area when the who is an appropriately qualified medical professional provider's contract terminated) for your condition.If there isn't a Plan Physician who is • The Services to be provided to you would be covered an appropriately qualified medical professional for your Services under this EOC if provided by a Plan condition,Member Services will help you arrange a Provider consultation with a Non—Plan Physician for a second • You request completion of Services within 30 days opinion.For purposes of this"Second Opinions" (or as soon as reasonably possible)from your provision,an"appropriately qualified medical effective date of coverage if you are a new Member professional"is a physician who is acting within their or from the termination date of the Plan Provider scope of practice and who possesses a clinical background,including training and expertise,related to For completion of Services,you pay the Cost Share the illness or condition associated with the request for a required for Services provided by a Plan Provider as second medical opinion. described in this EOC. Here are some examples of when a second opinion may More information be provided or authorized: For more information about this provision,or to request • Your Plan Physician has recommended a procedure the Services or a copy of our"Completion of Covered and you are unsure about whether the procedure is Services"policy,please call Member Services. reasonable or necessary Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 35 • You question a diagnosis or plan of care for a to receive Services from a terminated provider;refer to condition that threatens substantial impairment or loss "Completion of Services from Non—Plan Providers" of life,limb,or bodily functions under"Getting a Referral"in this"How to Obtain • The clinical indications are not clear or are complex Services"section. and confusing Provider groups and hospitals • A diagnosis is in doubt due to conflicting test results If you are assigned to a provider group or hospital whose • The Plan Physician is unable to diagnose the contract with us terminates,or if you live within 15 miles condition of a hospital whose contract with us terminates,we will • The treatment plan in progress is not improving your give you written notice at least 60 days before the medical condition within an appropriate period of termination(or as soon as reasonably possible). time,given the diagnosis and plan of care • You have concerns about the diagnosis or plan of care Receiving Care Outside of Your Home Region Service Area An authorization or denial of your request for a second opinion will be provided in an expeditious manner,as For information about your coverage when you are away appropriate for your condition.If your request for a from home,visit our website at kp.org/travel.You can second opinion is denied,you will be notified in writing also call the Away from Home Travel Line at of the reasons for the denial and of your right to file a 1-951-268-3900 24 hours a day,seven days a week grievance as described under"Grievances"in the (closed holidays). "Dispute Resolution"section. Receiving care in another Kaiser Permanente For these referral Services,you pay the Cost Share service area required for Services provided by a Plan Provider as If you are visiting in another Kaiser Permanente service described in this EOC. area,you may receive certain covered Services from designated providers in that other Kaiser Permanente service area,subject to exclusions,limitations,prior Contracts with Plan Providers authorization or approval requirements,and reductions. How Plan Providers are paid For more information about receiving covered Services in another Kaiser Permanente service area,including Health Plan and Plan Providers are independent provider and facility locations,please visit kp.orE/travel contractors.Plan Providers are paid in a number of ways, or call our Away from Home Travel Line at 1-951-268- such as salary,capitation,per diem rates,case rates,fee 3900 24 hours a day,seven days a week(closed for service,and incentive payments. To learn more about holidays). how Plan Physicians are paid to provide or arrange medical and hospital Services for Members,please visit For covered Services you receive in another Kaiser our website at kp.or2 or call Member Services. Permanente service area,you pay the Cost Share required for Services provided by a Plan Provider inside Financial liability our Service Area as described in this EOC. Our contracts with Plan Providers provide that you are not liable for any amounts we owe.However,you may Receiving care outside of any Kaiser have to pay the full price of noncovered Services you Permanente service area obtain from Plan Providers or Non—Plan Providers. If you are traveling outside of any Kaiser Permanente service area,we cover Emergency Services and Urgent When you are referred to a Plan Provider for covered Care as described in the"Emergency Services and Services,you pay the Cost Share required for Services Urgent Care"section. from that provider as described in this EOC. Termination of a Plan Provider's contract Your ID Card If our contract with any Plan Provider terminates while you are under the care of that provider,we will retain Each Member's Kaiser Permanente ID card has a financial responsibility for the covered Services you medical record number on it,which you will need when receive from that provider until we make arrangements you call for advice,make an appointment,or go to a for the Services to be provided by another Plan Provider provider for covered care.When you get care,please and notify you of the arrangements.You may be eligible bring your ID card and a photo ID.Your medical record Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 36 number is used to identify your medical records and Timely access to telephone assistance membership information.Your medical record number DMHC developed the following standards for answering should never change.Please call Member Services if we telephone questions: ever inadvertently issue you more than one medical . For telephone advice about whether you need to get record number or if you need to replace your ID card. care and where to get care:within 30 minutes,24 Your ID card is for identification only.To receive hours a day,seven days a week covered Services,you must be a current Member. • For general questions:within 10 minutes during Anyone who is not a Member will be billed as a non- normal business hours Member for any Services they receive.If you let someone else use your ID card,we may keep your ID Interpreter services card and terminate your membership as described under If you need interpreter services when you call us or when "Termination for Cause"in the"Termination of you get covered Services,please let us know.Interpreter Membership"section. services,including sign language,are available during all business hours at no cost to you.For more information on the interpreter services we offer,please call Member Timely Access to Care Services. Standards for appointment availability Access to mental health Services and substance The California Department of Managed Health Care use disorder treatment ("DMHC")developed the following standards for appointment availability. This information can help you State law requires evidence of coverage documents to include the following notice: know what to expect when you request an appointment. • Urgent care appointment:within 48 hours You have a right to receive timely and • Routine(non-urgent)primary care appointment geographically accessible Mental (including adult/internal medicine,pediatrics,and Health/Substance Use Disorder(MH/SUD) family medicine):within 10 business days services when you need them. If Health Plan • Routine(non-urgent)specialty care appointment with fails to arrange those services for you with a physician:within 15 business days an appropriate provider who is in the health • Routine(non-urgent)mental health care or substance plan's network,the health plan must cover use disorder treatment appointment with a practitioner other than a physician:within 10 business days and arrange needed services for you from an out-of-network provider. If that happens, • Follow-up(non-urgent)mental health care or substance use disorder treatment appointment with a you do not have to pay anything other than practitioner other than a physician,for those your ordinary in-network cost-sharing. undergoing a course of treatment for an ongoing mental health or substance use disorder condition: If you do not need the services urgently, within 10 business days your health plan must offer an appointment If you prefer to wait for a later appointment that will for you that is no more than 10 business days better fit your schedule or to see the Plan Provider of from when you requested the services from your choice,we will respect your preference.In some the health plan. If you urgently need the cases,your wait may be longer than the time listed if a services,your health plan must offer you an licensed health care professional decides that a later appointment within 48 hours of your request appointment won't have a negative effect on your health. (if the health plan does not require prior The standards for appointment availability do not apply authorization for the appointment) or within to Preventive Services.Your Plan Provider may 96 hours (if the health plan does require recommend a specific schedule for Preventive Services, prior authorization). depending on your needs.Except as specified above for mental health care and substance use disorder treatment, If your health plan does not arrange for you the standards also do not apply to periodic follow-up care to receive services within these timeframes for ongoing conditions or standing referrals to and within geographic access standards,you specialists. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 37 can arrange to receive services from any Visit Member Services office at a Plan Facility(for licensed provider, even if the provider is not addresses,refer to our Provider Directory or in your health plan's network. To be covered call Member Services) by your health plan,your first appointment Write Member Services office at a Plan Facility(for with the provider must be within 90 addresses,refer to our Provider Directory or calendar days of the date you first asked the call Member Services) plan for the MH/SUD services. Website kp.org If you have questions about how to obtain Cost Share estimates For information about estimates,see"Getting an MH/SUD services or are having difficulty estimate of your Cost Share"under"Your Cost Share"in obtaining services you can: 1) call your the`Benefits"section. health plan at the telephone number on the back of your health plan identification card; 2) call the California Department of Plan Facilities I Managed Care's Help Center at 1-888-466- 2219; or 3) contact the California Plan Medical Offices and Plan Hospitals are listed in the Department of Managed Health Care Provider Directory for your Home Region.The directory through its website at describes the types of covered Services that are available from each Plan Facility,because some facilities provide http://www.healthhelp.ca.2ov to request only specific types of covered Services.This directory is assistance in obtaining MH/SUD services. available on our website at kp.om/facilities.To obtain a printed copy,call Member Services.The directory is updated periodically.The availability of Plan Facilities Getting Assistance may change. If you have questions,please call Member Services. We want you to be satisfied with the health care you receive from Kaiser Permanente.If you have any At most of our Plan Facilities,you can usually receive all questions or concerns,please discuss them with your of the covered Services you need,including specialty personal Plan Physician or with other Plan Providers care,pharmacy,and lab work.You are not restricted to a who are treating you.They are committed to your particular Plan Facility,and we encourage you to use the satisfaction and want to help you with your questions. facility that will be most convenient for you: Member Services • All Plan Hospitals provide inpatient Services and are Member Services representatives can answer any open 24 hours a day, seven days a week questions you have about your benefits,available • Emergency Services are available from Plan Hospital Services,and the facilities where you can receive care. emergency departments(for emergency department For example,they can explain the following: locations,refer to our Provider Directory or call • Your Health Plan benefits Member Services) • How to make your first medical appointment • Same-day Urgent Care appointments are available at many locations(for Urgent Care locations,refer to • What to do if you move our Provider Directory or call Member Services) • How to replace your Kaiser Permanente ID card . Many Plan Medical Offices have evening and weekend appointments You can reach Member Services in the following ways: o Many Plan Facilities have a Member Services office Call 1-800-464-4000(English and more than 150 (for locations,refer to our Provider Directory or call languages using interpreter services) Member Services) 1-800-788-0616(Spanish) 1-800-757-7585(Chinese dialects) Note: State law requires evidence of coverage documents TTY users call 711 to include the following notice: 24 hours a day,seven days a week(closed Some hospitals and other providers do not holidays) provide one or more of the following services Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 38 that may be covered under your plan Cigna Healthcare PPO Network facility for an contract and that you or your family Emergency Medical Condition,Cigna Payer member might need: family planning; Solutions is responsible for authorizing any Post- Stabilization Care contraceptive services,including emergency Post-Stabilization Care authorization from other contraception; sterilization,including tubal Non-Plan Providers(including Cigna Healthcare ligation at the time of labor and delivery; PPO Network facilities inside a Kaiser infertility treatments; or abortion. You Permanente State): To request prior authorization, should obtain more information before you the Non—Plan Provider must call 1-800-225-8883 or enroll. Call your prospective doctor, medical the notification phone number on your Kaiser group,independent practice association, or Permanente ID card before you receive the care. We will discuss your condition with the Non—Plan clinic, or call Kaiser Permanente Member Provider.If we determine that you require Post- Services,to ensure that you can obtain the Stabilization Care and that this care is part of your health care services that you need. covered benefits,we will authorize your care from the Non—Plan Provider or arrange to have a Plan Provider Please be aware that if a Service is covered but not (or other designated provider)provide the care.If we available at a particular Plan Facility,we will make it decide to have a Plan Hospital,Plan Skilled Nursing available to you at another facility. Facility,or designated Non—Plan Provider provide your care,we may authorize special transportation services that are medically required to get you to the provider.This may include transportation that is Emergency Services and Urgent otherwise not covered Care Be sure to ask the Non—Plan Provider to tell you what Emergency Services care(including any transportation)we have authorized because we will not cover Post- If you have an Emergency Medical Condition,call 911 Stabilization Care or related transportation provided (where available)or go to the nearest emergency by Non—Plan Providers that has not been authorized. department.You do not need prior authorization for If you receive care from a Non—Plan Provider that we Emergency Services.When you have an Emergency have not authorized,you may have to pay the full cost Medical Condition,we cover Emergency Services you of that care.If you are admitted to a Non—Plan receive from Plan Providers or Non—Plan Providers Hospital or independent freestanding emergency anywhere in the world. department,please notify us as soon as possible by calling 1-800-225-8883 or the notification phone Emergency Services are available from Plan Hospital number on your ID card emergency departments 24 hours a day,seven days a week. When you receive Post-Stabilization Care from a Non- Plan Provider that is not a Cigna Healthcare PPO Post-Stabilization Care Network provider outside of California After you receive Emergency Services from Non-Plan When you receive Post-Stabilization Care from a Non- Providers and your condition is Stabilized,Post- Plan Provider inside of California,or from a Cigna Stabilization Care is considered Emergency Services Healthcare PPO Network facility outside of a Kaiser under federal law if either of the following are true: Permanente State • Y When you receive Emergency Services,we cover Post- Your treating physician determines that you are not Stabilization Care from a Non—Plan Provider only if able to travel using nonemergency transportation to prior authorization for the care is obtained as described an available Plan Provider located within a reasonable below,or if otherwise required by applicable law("prior travel distance,taking into account your medical authorization"means that the Services must be approved condition;or in advance). • Your treating physician,using appropriate medical • Post-Stabilization Care authorization at a Cigna judgment,determines that you are not in a condition Healthcare PPO Network facility outside of a to receive,and/or to provide consent to,the Non-Plan Kaiser Permanente State:If you are outside of a Provider's notice and consent form,in accordance Kaiser Permanente state and you were treated at a with applicable state informed consent law Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 39 If the Post-Stabilization Care is considered Emergency Urgent Care Services under the criteria above,prior authorization for Post-Stabilization Care at a Non-Plan Provider will not Inside our Service Area be required. An Urgent Care need is one that requires prompt medical attention but is not an Emergency Medical Condition.If If the Post-Stabilization Care is not considered you think you may need Urgent Care,call the Emergency Services,the Services are not covered unless appropriate appointment or advice phone number at a you have received prior authorization from Health Plan Plan Facility.For appointment and advice phone as described under"Post-Stabilization Care authorization numbers,refer to our Provider Directory or call Member from other Non-Plan Providers(including Cigna Services. Healthcare PPO Network facilities inside a Kaiser Permanente State)"above.Non-Plan Providers outside of Out-of-Area Urgent Care California may provide notice and seek your consent to If you need Urgent Care due to an unforeseen illness, waive your balance billing protections under the federal unforeseen injury,or unforeseen complication of an No Surprises Act,if such consent is permissible under existing condition(including pregnancy),we cover applicable state informed consent law.If you consent to Medically Necessary Services to prevent serious waive your balance billing protections and receive deterioration of your(or your unborn child's)health Services from the Non-Plan Provider,you will have to from a Non—Plan Provider if all of the following are true: pay the full cost of the Services. • You receive the Services from Non—Plan Providers Your Cost Share while you are temporarily outside our Service Area Your Cost Share for covered Emergency Services and • A reasonable person would have believed that your Post-Stabilization Care is described in the"Cost Share (or your unborn child's)health would seriously Summary"section of this EOC.Your Cost Share is the deteriorate if you delayed treatment until you returned same whether you receive the Services from a Plan to our Service Area Provider or a Non—Plan Provider.For example: • If you receive Emergency Services in the emergency You do not need prior authorization for Out-of-Area Urgent Care.We cover Out-of-Area Urgent Care you department of a Non—Plan Hospital,you pay the Cost receive from Non—Plan Providers if the Services would Share for an emergency department visit as described have been covered under this EOC if you had received in the"Cost Share Summary"under"Emergency them from Plan Providers. Services and Urgent Care" • If we gave prior authorization for inpatient Post- To obtain follow-up care from a Plan Provider,call the Stabilization Care in a Non—Plan Hospital,you pay appointment or advice phone number at a Plan Facility. the Cost Share for hospital inpatient Services as For phone numbers,refer to our Provider Directory or described in the"Cost Share Summary"under call Member Services.We do not cover follow-up care "Hospital inpatient Services" from Non—Plan Providers after you no longer need • If we gave prior authorization for durable medical Urgent Care,except for durable medical equipment equipment after discharge from a Non—Plan Hospital, covered under this EOC.For more information about you pay the Cost Share for durable medical durable medical equipment covered under this EOC,see equipment as described in the"Cost Share Summary" "Durable Medical Equipment("DME")for Home Use" under"Durable Medical Equipment("DME")for in the"Benefits"section.If you require durable medical home use" equipment related to your Urgent Care after receiving • If you receive COVID-19 laboratory testing or Out-of-Area Urgent Care,your provider must obtain prior authorization as described under Getting a immunizations in the emergency department,you pay Referral"in the"How to Obtain Services"section. the Cost Share for an emergency department visit as described in the"Cost Share Summary"under Your Cost Share "Emergency Services and Urgent Care" Your Cost Share for covered Urgent Care is the Cost • If you obtain a prescription in the emergency Share required for Services provided by Plan Providers department related to your Emergency Medical as described in the"Cost Share Summary"section of this Condition,you pay the Cost Share for"Most items" EOC.For example: in the"Cost Share Summary"under"Outpatient • If you receive an Urgent Care evaluation as part of prescription drugs,supplies,and supplements"in covered Out-of-Area Urgent Care from a Non—Plan addition to the Cost Share for the emergency Provider,you pay the Cost Share for Urgent Care department visit Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 40 consultations,evaluations,and treatment as described For information on how to file a claim,please see the in the"Cost Share Summary"under"Emergency "Post-Service Claims and Appeals"section. Services and Urgent Care" • If the Out-of-Area Urgent Care you receive includes an X-ray,you pay the Cost Share for an X-ray as Benefits described in the"Cost Share Summary"under "Outpatient imaging,laboratory,and other diagnostic This section describes the Services that are covered and treatment Services,"in addition to the Cost Share under this EOC. for the Urgent Care evaluation • If the Out-of-Area Urgent Care you receive includes a Services are covered under this EOC as specifically COVID-19 test,you may have to pay the Cost Share described in this EOC. Services that are not specifically for a COVID-19 test as described in the"Cost Share described in this EOC are not covered,except as required Summary"under"Outpatient imaging,laboratory, by state or federal law. Services are subject to exclusions and other diagnostic and treatment Services,"in and limitations described in the"Exclusions,Limitations, addition to the Cost Share for the Urgent Care Coordination of Benefits,and Reductions"section. evaluation Except as otherwise described in this EOC,all of the • If you obtain a prescription as part of an Out-of-Area following conditions must be satisfied: Urgent Care visit related to the condition for which • You are a Member on the date that you receive the you obtained Urgent Care,you pay the Cost Share for Services "Most items"in the"Cost Share Summary"under • The Services are Medically Necessary "Outpatient prescription drugs,supplies,and supplements"in addition to the Cost Share for the • The Services are one of the following: Urgent Care evaluation ♦ Preventive Services • If we gave prior authorization for durable medical ♦ health care items and services for diagnosis, equipment provided as part of Out-of-Area Urgent assessment,or treatment Care,you pay the Cost Share for durable medical ♦ health education covered under"Health equipment as described in the"Cost Share Summary" Education"in this"Benefits"section under"Durable Medical Equipment("DME")for ♦ other health care items and services home use" • The Services are provided,prescribed,authorized,or Note:If you receive Urgent Care in an emergency directed by a Plan Physician,except for: department,you pay the Cost Share for an emergency ♦ covered Services received outside of your Home department visit as described in the"Cost Share Region Service Area,as described under Summary"under"Emergency Services and Urgent "Receiving Care Outside of Your Home Region Care." Service Area"in the"How to Obtain Services" section Payment and Reimbursement ♦ COVID-19 Services from Non-Plan Providers as described under"Outpatient Imaging,Laboratory, If you receive Emergency Services Post-Stabilization and Other Diagnostic and Treatment Services," y g y Care,or Out-of--Area Urgent Care from allon—Plan "Outpatient Prescription Drugs, Supplies,and Provider as described in this"Emergency Services and Supplements,"and"Preventive Services"below Urgent Care"section,or emergency ambulance Services ♦ drugs prescribed by dentists,as described under described under"Ambulance Services"in the"Benefits" "Outpatient Prescription Drugs, Supplies,and section,you are not responsible for any amounts beyond Supplements"below your Cost Share for covered Services.However,if the ♦ emergency ambulance Services,as described provider does not agree to bill us,you may have to pay under"Ambulance Services"below for the Services and file a claim for reimbursement.Also, ♦ Emergency Services,Post-Stabilization Care,and you may be required to pay and file a claim for any Out-of-Area Urgent Care,as described in the Services prescribed by a Non—Plan Provider as part of "Emergency Services and Urgent Care"section covered Emergency Services,Post-Stabilization Care, Non— and Out-of--Area Urgent Care even if you receive the ♦ eyeglasses and contact lenses prescribed by Non— Services from a Plan Provider,such as a Plan Pharmacy. Plan Providers,as described under"Vision Services for Adult Members"and"Vision Services for Pediatric Members"below Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 41 • You receive the Services from Plan Providers inside Refer to the"Cost Share Summary"section of this EOC our Service Area,except for: for the amount you will pay for Services. ♦ authorized referrals,as described under"Getting a Referral"in the"How to Obtain Services"section General rules, examples, and exceptions ♦ covered Services received outside of your Home Your Cost Share for covered Services will be the Cost Region Service Area,as described under Share in effect on the date you receive the Services, "Receiving Care Outside of Your Home Region except as follows: Service Area"in the"How to Obtain Services" • If you are receiving covered hospital inpatient or section Skilled Nursing Facility Services on the effective date ♦ COVID-19 Services from Non-Plan Providers as of this EOC,you pay the Cost Share in effect on your described under"Outpatient Imaging,Laboratory, admission date until you are discharged if the and Other Diagnostic and Treatment Services," Services were covered under your prior Health Plan "Outpatient Prescription Drugs, Supplies,and evidence of coverage and there has been no break in Supplements,"and"Preventive Services"below coverage.However,if the Services were not covered ♦ emergency ambulance Services,as described under your prior Health Plan evidence of coverage,or under"Ambulance Services"below if there has been a break in coverage,you pay the Cost Share in effect on the date you receive the ♦ Emergency Services,Post-Stabilization Care,and Services Out-of-Area Urgent Care,as described in the "Emergency Services and Urgent Care"section • For items ordered in advance,you pay the Cost Share in effect on the order date(although we will not cover ♦ hospice care,as described under"Hospice Care" the item unless you still have coverage for it on the below date you receive it)and you may be required to pay • The Medical Group has given prior authorization for the Cost Share when the item is ordered.For the Services,if required,as described under"Medical outpatient prescription drugs,the order date is the Group authorization procedure for certain referrals" date that the pharmacy processes the order after in the"How to Obtain Services"section receiving all of the information they need to fill the prescription Please also refer to: • The"Emergency Services and Urgent Care"section Cost Share for Services received by newborn children for information about how to obtain covered of a Member Emergency Services,Post-Stabilization Care,and During the 31 days of automatic coverage for newborn Out-of-Area Urgent Care children described under"If you have a baby"under "Who Is Eligible"in the"Premiums,Eligibility,and • Our Provider Directory for the types of covered Enrollment"section,the parent or guardian of the Services that are available from each Plan Facility, newborn must pay the Cost Share indicated in the"Cost because some facilities provide only specific types of Share Summary"section of this EOC for any Services covered Services that the newborn receives,whether or not the newborn is enrolled.When the"Cost Share Summary"indicates the Your Cost Share Services are subject to the Plan Deductible,the Cost Share for those Services will be Charges if the newborn Your Cost Share is the amount you are required to pay has not met the Plan Deductible. for covered Services.For example,your Cost Share may be a Copayment or Coinsurance. Payment toward your Cost Share(and when you may be billed) If your coverage includes a Plan Deductible and you In most cases,your provider will ask you to make a receive Services that are subject to the Plan Deductible, payment toward your Cost Share at the time you receive your Cost Share for those Services will be Charges until Services.If you receive more than one type of Services you reach the Plan Deductible. Similarly,if your (such as a routine physical maintenance exam and coverage includes a Drug Deductible,and you receive laboratory tests),you may be required to pay separate Services that are subject to the Drug Deductible,your Cost Share for each of those Services.Keep in mind that Cost Share for those Services will be Charges until you your payment toward your Cost Share may cover only a reach the Drug Deductible. portion of your total Cost Share for the Services you receive,and you will be billed for any additional amounts that are due.The following are examples of when you may be asked to pay(or you may be billed for) Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 42 Cost Share amounts in addition to the amount you pay at Charges for Services. That could be because your check-in: payment was recorded before the Charges for the • You receive non-preventive Services during a Services were processed.If so,the Charges will appear preventive visit.For example,you go in for a routine on a future bill.Also,you may receive more than one bill physical maintenance exam,and at check-in you pay for a single outpatient visit or inpatient stay.For your Cost Share for the preventive exam(your Cost example,you may receive a bill for physician services Share may be"no charge").However,during your and a separate bill for hospital services.If you don't see preventive exam your provider finds a problem with all the Charges for Services on one bill,they will appear your health and orders non-preventive Services to on a future bill.If we determine that you overpaid and diagnose your problem(such as laboratory tests).You are due a refund,then we will send a refund to you may be asked to pay(or you will be billed for)your within four weeks after we make that determination.If Cost Share for these additional non-preventive you have questions about a bill,please call the phone diagnostic Services number on the bill. • You receive diagnostic Services during a treatment In some cases,a Non—Plan Provider may be involved in visit.For example,you go in for treatment of an the provision of covered Services at a Plan Facility or a existing health condition,and at check-in you pay contracted facility where we have authorized you to your Cost Share for a treatment visit.However, receive care.You are not responsible for any amounts during the visit your provider finds a new problem beyond your Cost Share for the covered Services you with your health and performs or orders diagnostic receive at Plan Facilities or at contracted facilities where Services(such as laboratory tests).You may be asked we have authorized you to receive care.However,if the to pay(or you will be billed for)your Cost Share for provider does not agree to bill us,you may have to pay these additional diagnostic Services for the Services and file a claim for reimbursement.For • You receive treatment Services during a diagnostic information on how to file a claim,please see the"Post- visit.For example,you go in for a diagnostic exam, Service Claims and Appeals"section. and at check-in you pay your Cost Share for a diagnostic exam.However,during the diagnostic Please refer to the"Emergency Services and Urgent exam your provider confirms a problem with your Care"section for more information about when you may health and performs treatment Services(such as an be billed for Emergency Services,Post-Stabilization outpatient procedure).You may be asked to pay(or Care,and Out-of-Area Urgent Care. you will be billed for)your Cost Share for these additional treatment Services Reimbursement for COVID-19 Services from Non-Plan • You receive Services from a second provider during Providers your visit.For example,you go in for a diagnostic If you receive covered COVID-19 Services from Non- exam,and at check-in you pay your Cost Share for a Plan Providers as described under"Outpatient Imaging, diagnostic exam.However,during the diagnostic Laboratory,and Other Diagnostic and Treatment exam your provider requests a consultation with a Services,""Outpatient Prescription Drugs,Supplies,and specialist.You may be asked to pay(or you will be Supplements,"and"Preventive Services"in the billed for)your Cost Share for the consultation with "Benefits"section,you may have to pay for the Services the specialist and file a claim for reimbursement.For information on how to file a claim,please see"Initial Claims"in the In some cases,your provider will not ask you to make a "the"Post-Service Claims and Appeals"section. payment at the time you receive Services,and you will be billed for your Cost Share(for example,some Primary Care Visits,Non-Physician Specialist Visits, Laboratory Departments are not able to collect Cost and Physician Specialist Visits Share,or your Plan Provider is not able to collect Cost The Cost Share for a Primary Care Visit applies to Share,if any,for Telehealth Visits you receive at home). evaluations and treatment provided by generalists in internal medicine,pediatrics,or family practice,and by When we send you a bill,it will list Charges for the specialists in obstetrics/gynecology whom the Medical Services you received,payments and credits applied to Group designates as Primary Care Physicians. Some your account,and any amounts you still owe.Your physician specialists provide primary care in addition to current bill may not always reflect your most recent specialty care but are not designated as Primary Care Charges and payments.Any Charges and payments that Physicians.If you receive Services from one of these are not on the current bill will appear on a future bill. specialists,the Cost Share for a Physician Specialist Visit Sometimes,you may see a payment but not the related will apply to all consultations,evaluations,and treatment Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 43 provided by the specialist except for routine preventive call 711)Monday through Friday 6 a.m.to 5 p.m. counseling and exams listed under"Preventive Services" Refer to the"Cost Share Summary"section of this in this"Benefits"section.For example,if your personal EOC to find out if you have a Plan Deductible Plan Physician is a specialist in internal medicine or • For all other Cost Share estimates,please call 1-800- obstetrics/gynecology who is not a Primary Care 464-4000(TTY users call 711)24 hours a day,seven Physician,you will pay the Cost Share for a Physician days a week(closed holidays) Specialist Visit for all consultations,evaluations,and treatment by the specialist except routine preventive Cost Share estimates are based on your benefits and the counseling and exams listed under"Preventive Services" Services you expect to receive. They are a prediction of in this"Benefits"section.The Non-Physician Specialist cost and not a guarantee of the final cost of Services. Visit Cost Share applies to consultations,evaluations, Your final cost may be higher or lower than the estimate and treatment provided by non-physician specialists since not everything about your care can be known in (such as nurse practitioners,physician assistants, advance. optometrists,podiatrists,and audiologists). Noncovered Services Drug Deductible If you receive Services that are not covered under this This EOC does not include a Drug Deductible. EOC,you may have to pay the full price of those Plan Deductible Services.Payments you make for noncovered Services do not apply to any deductible or out-of-pocket This EOC does not include a Plan Deductible. maximum. Copayments and Coinsurance Benefit limits The Copayment or Coinsurance you must pay for each Some benefits may include a limit on the number of covered Service,after you meet any applicable visits,days,treatment cycles,or dollar amount that will deductible,is described in this EOC. be covered under your plan during a specified time period.If a benefit includes a limit,this will be indicated Note:If Charges for Services are less than the in the"Cost Share Summary"section of this EOC. The Copayment described in this EOC,you will pay the time period associated with a benefit limit may not be the lesser amount,subject to any applicable deductible or same as the term of this EOC.We will count all Services out-of-pocket maximum. you receive during the benefit limit period toward the benefit limit,including Services you received under a Plan Out-of-Pocket Maximum prior Health Plan EOC(as long as you have continuous There is a limit to the total amount of Cost Share you coverage with Health Plan).Note:We will not count must pay under this EOC in the Accumulation Period for Services you received under a prior Health Plan EOC covered Services that you receive in the same when you first enroll in individual plan coverage or a Accumulation Period. The Services that apply to the Plan new employer group's plan,when you move from group Out-of-Pocket Maximum are described under the to individual plan coverage(or vice versa),or when you "Payments that count toward the Plan Out-of-Pocket received Services under a Kaiser Permanente Senior Maximum"section below.Refer to the"Cost Share Advantage evidence of coverage.If you are enrolled in Summary"section of this EOC for your applicable Plan the Kaiser Permanente POS Plan,refer to your KPIC Out-of-Pocket Maximum amounts. Certificate of Insurance and Schedule of Coverage for benefit limits that apply to your separate indemnity If you are a Member in a Family of two or more coverage provided by the Kaiser Permanente Insurance Members,you reach the Plan Out-of-Pocket Maximum Company("KPIC"). either when you reach the maximum for any one Member,or when your Family reaches the Family Getting an estimate of your Cost Share maximum.For example,suppose you have reached the If you have questions about the Cost Share for specific Plan Out-of-Pocket Maximum for any one Member.For Services that you expect to receive or that your provider Services subject to the Plan Out-of-Pocket Maximum, orders during a visit or procedure,please visit our you will not pay any more Cost Share during the website at kp•org to use our cost estimate tool or call remainder of the Accumulation Period,but every other Member Services. Member in your Family must continue to pay Cost Share • If you have a Plan Deductible and would like an during the remainder of the Accumulation Period until either they reach the maximum for any one Member or estimate for Services that are subject to the Plan your Family reaches the Family maximum. Deductible,please call 1-800-390-3507(TTY users Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 44 Payments that count toward the Plan Out-of-Pocket and they are administered to you in a Plan Facility or Maximum during home visits. Any payments you make toward the Plan Deductible or Drug Deductible,if applicable,apply toward the Certain administered drugs are Preventive Services. maximum. Refer to"Reproductive Health Services"for information about administered contraceptives and refer to Most Copayments and Coinsurance you pay for covered "Preventive Services"for information on immunizations. Services apply to the maximum,however some may not. To find out whether a Copayment or Coinsurance for a covered Service will apply to the maximum refer to the Ambulance Services "Cost Share Summary"section of this EOC. Emergency If your plan includes pediatric dental Services described We cover Services of a licensed ambulance anywhere in in a Pediatric Dental Services Amendment to this EOC, the world without prior authorization(including those Services will apply toward the maximum. If your transportation through the 911 emergency response plan has a Pediatric Dental Services Amendment,it will system where available)in the following situations: be attached to this EOC,and it will be listed in the • You reasonably believed that the medical condition EOC's Table of Contents. was an Emergency Medical Condition which required ambulance Services Accrual toward deductibles and out-of-pocket • Your treating physician determines that you must be maximums transported to another facility because your To see how close you are to reaching your deductibles,if Emergency Medical Condition is not Stabilized and any,and out-of-pocket maximums,use our online Out- the care you need is not available at the treating of-Pocket Summary tool at kp•ora or call Member facility Services.We will provide you with accrual balance information for every month that you receive Services If you receive emergency ambulance Services that are until you reach your individual out-of-pocket maximums not ordered by a Plan Provider,you are not responsible or your Family reaches the Family out-of-pocket for any amounts beyond your Cost Share for covered maximums. emergency ambulance Services.However,if the provider does not agree to bill us,you may have to pay for the We will provide accrual balance information by mail Services and file a claim for reimbursement.For unless you have opted to receive notices electronically. information on how to file a claim,please see the"Post- You can change your document delivery preferences at Service Claims and Appeals"section. any time at kp•org or by calling Member Services. Nonemergency Administered Drugs and Products Inside our Service Area,we cover nonemergency ambulance and psychiatric transport van Services if a Administered drugs and products are medications and Plan Physician determines that your condition requires products that require administration or observation by the use of Services that only a licensed ambulance(or medical personnel,such as: psychiatric transport van)can provide and that the use of other means of transportation would endanger your • Whole blood,red blood cells,plasma,and platelets health.These Services are covered only when the vehicle • Allergy antigens(including administration) transports you to or from covered Services. • Cancer chemotherapy drugs and adjuncts Ambulance Services exclusions • Drugs and products that are administered via • Transportation by car,taxi,bus,gurney van, intravenous therapy or injection that are not for cancer chemotherapy,including blood factor products wheelchair van,and any other type of transportation and biological products("biologics")derived from (other than a licensed ambulance or psychiatric tissue,cells,or blood transport van),even if it is the only way to travel to a Plan Provider • Other administered drugs and products We cover these items when prescribed by a Plan Provider,in accord with our drug formulary guidelines, Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 45 Bariatric Surgery certain referrals"under"Getting a Referral"in the"How to Obtain Services"section). We cover hospital inpatient Services related to bariatric surgical procedures(including room and board,imaging, Dental Services for transplants laboratory,other diagnostic and treatment Services,and We cover dental services that are Medically Necessary to Plan Physician Services)when performed to treat obesity free the mouth from infection in order to prepare for a by modification of the gastrointestinal tract to reduce transplant covered under"Transplant Services"in this nutrient intake and absorption,if all of the following `Benefits"section,if a Plan Physician provides the requirements are met: Services or if the Medical Group authorizes a referral to • You complete the Medical Group—approved pre- a dentist for those Services(as described in"Medical surgical educational preparatory program regarding Group authorization procedure for certain referrals" lifestyle changes necessary for long term bariatric under"Getting a Referral"in the"How to Obtain surgery success Services"section). • A Plan Physician who is a specialist in bariatric care Dental anesthesia determines that the surgery is Medically Necessary For dental procedures at a Plan Facility,we provide For covered Services related to bariatric surgical general anesthesia and the facility's Services associated procedures that you receive,you will pay the Cost Share with the anesthesia if all of the following are true: you would pay if the Services were not related to a • You are under age 7,or you are developmentally bariatric surgical procedure.For example,see"Hospital disabled,or your health is compromised inpatient Services"in the"Cost Share Summary"section • Your clinical status or underlying medical condition of this EOC for the Cost Share that applies for hospital requires that the dental procedure be provided in a inpatient Services. hospital or outpatient surgery center For the following Services, refer to these • The dental procedure would not ordinarily require sections general anesthesia • Outpatient prescription drugs(refer to"Outpatient We do not cover any other Services related to the dental Prescription Drugs, Supplies,and Supplements") procedure,such as the dentist's Services. • Outpatient administered drugs(refer to"Administered Drugs and Products") Dental and orthodontic Services for cleft palate We cover dental extractions,dental procedures necessary to prepare the mouth for an extraction,and orthodontic Dental and Orthodontic Services Services,if they meet all of the following requirements: We do not cover most dental and orthodontic Services • The Services are an integral part of a reconstructive under this EOC,but we do cover some dental and surgery for cleft palate that we are covering under orthodontic Services as described in this"Dental and "Reconstructive Surgery"in this"Benefits"section Orthodontic Services"section. ("cleft palate"includes cleft palate,cleft lip,or other craniofacial anomalies associated with cleft palate) For covered dental and orthodontic procedures that you • A Plan Provider provides the Services or the Medical may receive,you will pay the Cost Share you would pay Group authorizes a referral to a Non—Plan Provider if the Services were not related to dental and orthodontic who is a dentist or orthodontist(as described in Services.For example,see"Hospital inpatient Services" "Medical Group authorization procedure for certain in the"Cost Share Summary"section of this EOC for the referrals"under"Getting a Referral"in the"How to Cost Share that applies for hospital inpatient Services. Obtain Services"section) Dental Services for radiation treatment For the following Services, refer to these We cover dental evaluation,X-rays,fluoride treatment, sections and extractions necessary to prepare your jaw for o Accidental injury to teeth(refer to"Injury to Teeth") radiation therapy of cancer in your head or neck if a Plan Physician provides the Services or if the Medical Group • Office visits not described in the"Dental and authorizes a referral to a dentist for those Services(as Orthodontic Services"section(refer to"Office described in"Medical Group authorization procedure for Visits") Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 46 • Outpatient imaging,laboratory,and other diagnostic • Outpatient administered drugs(refer to"Administered and treatment Services(refer to"Outpatient Imaging, Drugs and Products") Laboratory,and Other Diagnostic and Treatment . Telehealth Visits(refer to"Telehealth Visits") Services") • Outpatient administered drugs(refer to"Administered Dialysis care exclusions Drugs and Products"),except that we cover outpatient . Comfort convenience or lux 'equipment,supplies e ui ment lies administered drugs under"Dental anesthesia"in this and features "Dental and Orthodontic Services"section • Outpatient prescription drugs(refer to"Outpatient • Nonmedical items,such as generators or accessories Prescription Drugs, Supplies,and Supplements") to make home dialysis equipment portable for travel • Telehealth Visits(refer to"Telehealth Visits") Durable Medical Equipment ("DME") for Dialysis Care Home Use DME coverage rules We cover acute and chronic dialysis Services if all of the DME for home use is an item that meets the following following requirements are met: criteria: • The Services are provided inside our Service Area . The item is intended for repeated use • You satisfy all medical criteria developed by the • The item is primarily and customarily used to serve a Medical Group and by the facility providing the medical purpose dialysis • The item is generally useful only to an individual • A Plan Physician provides a written referral for care with an illness or injury at the facility • The item is appropriate for use in the home After you receive appropriate training at a dialysis facility we designate,we also cover equipment and For a DME item to be covered,all of the following medical supplies required for home hemodialysis and requirements must be met: home peritoneal dialysis inside our Service Area. o Your EOC includes coverage for the requested DME Coverage is limited to the standard item of equipment or item supplies that adequately meets your medical needs.We . A Plan Physician has prescribed the DME item for decide whether to rent or purchase the equipment and supplies,and we select the vendor.You must return the your medical condition equipment and any unused supplies to us or pay us the • The item has been approved for you through the fair market price of the equipment and any unused Plan's prior authorization process,as described in supply when we are no longer covering them. "Medical Group authorization procedure for certain referrals"under"Getting a Referral"in the"How to For the following Services, refer to these Obtain Services"section sections • The Services are provided inside our Service Area • Durable medical equipment for home use(refer to "Durable Medical Equipment("DME")for Home Coverage is limited to the standard item of equipment Use") that adequately meets your medical needs.We decide • Hospital inpatient Services(refer to"Hospital whether to rent or purchase the equipment,and we select Inpatient Services") the vendor.You must return the equipment to us or pay us the fair market price of the equipment when we are no • Office visits not described in the"Dialysis Care" longer covering it. section(refer to"Office Visits") • Outpatient laboratory(refer to"Outpatient Imaging, Base DME Items Laboratory,and Other Diagnostic and Treatment We cover Base DME Items(including repair or Services") replacement of covered equipment)if all of the • Outpatient prescription drugs(refer to"Outpatient requirements described under"DME coverage rules"in Prescription Drugs, Supplies,and Supplements") this"Durable Medical Equipment("DME")for Home Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 47 Use"section are met. "Base DME Items"means the • Blood glucose monitors for diabetes blood testing and following items: their supplies(such as blood glucose monitor test • Blood glucose monitors for diabetes blood testing and strips,lancets,and lancet devices)from a Plan their supplies(such as blood glucose monitor test Pharmacy strips,lancets,and lancet devices) • Canes(standard curved handle) • Bone stimulator • Crutches(standard) • Canes(standard curved handle or quad)and • Insulin pumps and supplies to operate the pump,after replacement supplies completion of training and education on the use of the • Cervical traction(over door) PUMP • Crutches(standard or forearm)and replacement • Nebulizers and their supplies for the treatment of supplies pediatric asthma • Dry pressure pad for a mattress • Peak flow meters from a Plan Pharmacy • Infusion pumps(such as insulin pumps)and supplies For the following Services, refer to these to operate the pump sections • IV pole e Dialysis equipment and supplies required for home • Nebulizer and supplies hemodialysis and home peritoneal dialysis(refer to • Peak flow meters "Dialysis Care") • Phototherapy blankets for treatment of jaundice in • Diabetes urine testing supplies and insulin- newborns administration devices other than insulin pumps(refer to"Outpatient Prescription Drugs, Supplies,and Supplemental DME items Supplements") We cover DME that is not described under"Base DME • Durable medical equipment related to an Emergency Items"or"Lactation supplies,"including repair and Medical Condition or Urgent Care episode(refer to replacement of covered equipment,if all of the "Post-Stabilization Care"and"Out-of-Area Urgent requirements described under"DME coverage rules"in Care") this"Durable Medical Equipment("DME")for Home • Durable medical equipment related to the terminal Use"section are met. illness for Members who are receiving covered hospice care(refer to"Hospice Care") Lactation supplies . Insulin and any other drugs administered with an We cover one retail-grade milk pump(also known as a infusion pump(refer to"Outpatient Prescription breast pump)per pregnancy and associated supplies,as Drugs,Supplies,and Supplements") listed on our website at ky.orWyrevention.We will decide whether to rent or purchase the item and we DME for home use exclusions choose the vendor.We cover this pump for convenience purposes.The pump is not subject to prior authorization • Comfort,convenience,or luxury equipment or requirements. features except for retail-grade milk pumps as described under"Lactation supplies"in this"Durable If you or your baby has a medical condition that requires Medical Equipment("DME")for Home Use"section the use of a milk pump,we cover a hospital-grade milk . Items not intended for maintaining normal activities pump and the necessary supplies to operate it,in accord of daily living,such as exercise equipment(including with the coverage rules described under"DME coverage devices intended to provide additional support for rules"in this"Durable Medical Equipment("DME")for recreational or sports activities) Home Use"section. • Hygiene equipment Outside our Service Area • Nonmedical items,such as sauna baths or elevators We do not cover most DME for home use outside our . Modifications to your home or car Service Area.However,if you live outside our Service • Devices for testing blood or other body substances Area,we cover the following DME(subject to the Cost Share and all other coverage requirements that apply to (except diabetes blood glucose monitors and their DME for home use inside our Service Area)when the supplies) item is dispensed at a Plan Facility: Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 48 • Electronic monitors of the heart or lungs except infant • Outpatient surgery and outpatient procedures apnea monitors • Outpatient imaging and laboratory Services • Repair or replacement of equipment due to loss,theft, • Outpatient administered drugs that require or misuse administration or observation by medical personnel. We cover these items when they are prescribed by a Emergency Services and Urgent Care Plan Provider,in accord with our drug formulary guidelines,and they are administered to you in a Plan We cover the following Services: Facility • Emergency department visits • Hospital inpatient stays directly related to diagnosis • Urgent Care consultations,evaluations,and treatment and treatment of Infertility For the following Services, refer to these Assisted reproductive technology("ART")Services sections ART Services such as in vitro fertilization("IVF"), • Abortion and abortion-related Services(refer to gamete intra-fallopian transfer("GIFT"),or zygote "Reproductive Health Services") intrafallopian transfer("ZIFT")are not covered under this EOC. Fertility Services For the following Services, refer to these "Fertility Services"means treatments and procedures to sections help you become pregnant. • Fertility preservation Services for iatrogenic Infertility(refer to"Fertility Preservation Services for Before starting or continuing a course of fertility Iatrogenic Infertility") Services,you may be required to pay initial and • Diagnostic Services provided by Plan Providers who subsequent deposits toward your Cost Share for some or are not physicians,such as EKGs and EEGs(refer to all of the entire course of Services,along with any past- "Outpatient Imaging,Laboratory,and Other due fertility-related Cost Share.Any unused portion of Diagnostic and Treatment Services") your deposit will be returned to you.When a deposit is not required,you must pay the Cost Share for the • Outpatient drugs,supplies,and supplements(refer to procedure,along with any past-due fertility-related Cost "Outpatient Prescription Drugs, Supplies,and Share,before you can schedule a fertility procedure. Supplements") Diagnosis and treatment of Infertility Fertility Services exclusions We cover the following Services for the diagnosis and • Reversal of surgical sterilization originally performed treatment of Infertility: for family planning purposes • Office visits • Semen and eggs(and Services related to their • Outpatient surgery and outpatient procedures procurement and storage) • Outpatient imaging and laboratory Services • ART Services,such as ovum transplants,GIFT,IVF, and ZIFT • Outpatient administered drugs that require administration or observation by medical personnel. We cover these items when they are prescribed by a Fertility Preservation Services for Plan Provider,in accord with our drug formulary Iatrogenic Infertility guidelines,and they are administered to you in a Plan Facility Standard fertility preservation Services are covered for • Hospital inpatient stay directly related to diagnosis Members undergoing treatment or receiving covered and treatment of Infertility Services that may directly or indirectly cause iatrogenic Infertility.Fertility preservation Services do not include Artificial insemination diagnosis or treatment of Infertility. We cover the following Services for artificial For covered fertility preservation Services that you insemination: receive,you will pay the Cost Share you would pay if the • Office visits Services were not related to fertility preservation.For Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 49 example,see"Outpatient surgery and outpatient and models of hearing aids furnished by the provider or procedures"in the"Cost Share Summary"section of this vendor. EOC for the Cost Share that applies for outpatient procedures. For the following Services, refer to these sections Health Education • Routine hearing screenings when performed as part of a routine physical maintenance exam(refer to We cover a variety of health education counseling, "Preventive Services") programs,and materials that your personal Plan Physician or other Plan Providers provide during a visit • Services related to the ear or hearing other than those covered under another part of this EOC. described in this section, such as outpatient care to treat an ear infection or outpatient prescription drugs, We also cover a variety of health education counseling, supplies,and supplements(refer to the applicable programs,and materials to help you take an active role in heading in this"Benefits"section) protecting and improving your health,including • Cochlear implants and osseointegrated hearing programs for tobacco cessation,stress management,and devices(refer to"Prosthetic and Orthotic Devices") chronic conditions(such as diabetes and asthma).Kaiser Permanente also offers health education counseling, Hearing Services exclusions programs,and materials that are not covered,and you • Internally implanted hearing aids may be required to pay a fee. • Replacement parts and batteries,repair of hearing For more information about our health education aids,and replacement of lost or broken hearing aids counseling,programs,and materials,please contact a (the manufacturer warranty may cover some of these) Health Education Department or Member Services or go to our website at kp.m. Home Health Care Hearing Services "Home health care"means Services provided in the home by nurses,medical social workers,home health We cover the following: aides,and physical,occupational,and speech therapists. • Hearing exams with an audiologist to determine the need for hearing correction We cover home health care only if all of the following are true: • Physician Specialist Visits to diagnose and treat . You are substantially confined to your home(or a hearing problems friend's or relative's home) Hearing aids • Your condition requires the Services of a nurse, We provide an Allowance for each ear toward the physical therapist,occupational therapist,or speech purchase price of a hearing aid(including fitting, therapist(home health aide Services are not covered counseling,adjustment,cleaning,and inspection)when unless you are also getting covered home health care prescribed by a Plan Physician or by a Plan Provider who from a nurse,physical therapist,occupational is an audiologist.We will cover hearing aids for both therapist,or speech therapist that only a licensed ears only if both aids are required to provide significant provider can provide) improvement that is not obtainable with only one hearing • A Plan Physician determines that it is feasible to aid.We will not provide the Allowance if we have maintain effective supervision and control of your provided an Allowance toward(or otherwise covered)a care in your home and that the Services can be safely hearing aid within the previous 36 months.Also,the and effectively provided in your home Allowance can only be used at the initial point of sale.If you do not use all of your Allowance at the initial point • The Services are provided inside our Service Area of sale,you cannot use it later.Refer to"Hearing Services"in the"Cost Share Summary"section of this We cover only part-time or intermittent home health EOC for your Allowance amount. care,as follows: • Up to two hours per visit for visits by a nurse, We select the provider or vendor that will furnish the medical social worker,or physical,occupational,or covered hearing aids.Coverage is limited to the types speech therapist,and up to four hours per visit for visits by a home health aide Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 50 • Up to three visits per day(counting all home health discomforts of a Member experiencing the last phases of visits) life due to a terminal illness.It also provides support to • Up to 100 visits per Accumulation Period(counting the primary caregiver and the Member's family.A all home health visits) Member who chooses hospice care is choosing to receive palliative care for pain and other symptoms associated Note:If a visit by a nurse,medical social worker,or with the terminal illness,but not to receive care to try to physical,occupational,or speech therapist lasts longer cure the terminal illness.You may change your decision than two hours,then each additional increment of two to receive hospice care benefits at any time. hours counts as a separate visit.If a visit by a home health aide lasts longer than four hours,then each We cover the hospice Services listed below only if all of additional increment of four hours counts as a separate the following requirements are met: visit.For example,if a nurse comes to your home for • A Plan Physician has diagnosed you with a terminal three hours and then leaves,that counts as two visits. illness and determines that your life expectancy is 12 Also,each person providing Services counts toward months or less these visit limits.For example,if a home health aide and • The Services are provided inside our Service Area or a nurse are both at your home during the same two hours, inside California but within 15 miles or 30 minutes that counts as two visits. from our Service Area(including a friend's or For the following Services, refer to these relative's home even if you live there temporarily) sections • The Services are provided by a licensed hospice agency that is a Plan Provider • Behavioral Health Treatment for Autism Spectrum Disorder(refer to"Mental Health Services") • A Plan Physician determines that the Services are necessary for the palliation and management of your • Dialysis care(refer to"Dialysis Care") terminal illness and related conditions • Durable medical equipment(refer to"Durable Medical Equipment("DME")for Home Use") If all of the above requirements are met,we cover the • Ostomy and urological supplies(refer to"Ostomy and following hospice Services,if necessary for your hospice Urological Supplies") care: • Outpatient drugs,supplies,and supplements(refer to • Plan Physician Services "Outpatient Prescription Drugs, Supplies,and • Skilled nursing care,including assessment, Supplements") evaluation,and case management of nursing needs, • Outpatient physical,occupational,and speech therapy treatment for pain and symptom control,provision of visits(refer to"Rehabilitative and Habilitative emotional support to you and your family,and Services") instruction to caregivers • Prosthetic and orthotic devices(refer to"Prosthetic • Physical,occupational,and speech therapy for and Orthotic Devices") purposes of symptom control or to enable you to maintain activities of daily living Home health care exclusions • Respiratory therapy • Care of a type that an unlicensed family member or • Medical social services other layperson could provide safely and effectively • Home health aide and homemaker services in the home setting after receiving appropriate training.This care is excluded even if we would cover • Palliative drugs prescribed for pain control and the care if it were provided by a qualified medical symptom management of the terminal illness for up to professional in a hospital or a Skilled Nursing Facility a 100-day supply in accord with our drug formulary guidelines.You must obtain these drugs from a Plan • Care in the home if the home is not a safe and Pharmacy.Certain drugs are limited to a maximum effective treatment setting 30-day supply in any 30-day period(your Plan Pharmacy can tell you if a drug you take is one of Hospice Care these drugs) • Durable medical equipment Hospice care is a specialized form of interdisciplinary • Respite care when necessary to relieve your health care designed to provide palliative care and to caregivers.Respite care is occasional short-term alleviate the physical,emotional,and spiritual Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 51 inpatient Services limited to no more than five • Behavioral Health Treatment for Autism Spectrum consecutive days at a time Disorder • Counseling and bereavement services • Respiratory therapy • Dietary counseling • Physical,occupational,and speech therapy(including treatment in our organized,multidisciplinary We also cover the following hospice Services only rehabilitation program) during periods of crisis when they are Medically • Medical social services and discharge planning Necessary to achieve palliation or management of acute medical symptoms: For the following Services, refer to these • Nursing care on a continuous basis for as much as 24 sections hours a day as necessary to maintain you at home • Abortion and abortion-related Services(refer to • Short-term inpatient Services required at a level that "Reproductive Health Services") cannot be provided at home • Bariatric surgical procedures(refer to"Bariatric Surgery") Hospital Inpatient Services • Dental and orthodontic procedures(refer to"Dental and Orthodontic Services") We cover the following inpatient Services in a Plan • Dialysis care(refer to"Dialysis Care") Hospital,when the Services are generally and customarily provided by acute care general hospitals • Fertility preservation Services for iatrogenic inside our Service Area: Infertility(refer to"Fertility Preservation Services for • Room and board,including a private room if Iatrogenic Infertility") Medically Necessary • Services related to diagnosis and treatment of • Specialized care and critical care units Infertility,artificial insemination,or assisted reproductive technology(refer to"Fertility Services") • General and special nursing care • Hospice care(refer to"Hospice Care") • Operating and recovery rooms • Mental health Services(refer to"Mental Health • Services of Plan Physicians,including consultation Services") and treatment by specialists • Prosthetics and orthotics(refer to"Prosthetic and • Anesthesia Orthotic Devices") • Drugs prescribed in accord with our drug formulary . Reconstructive surgery Services(refer to guidelines(for discharge drugs prescribed when you "Reconstructive Surgery") are released from the hospital,refer to"Outpatient Prescription Drugs, Supplies,and Supplements"in • Services in connection with a clinical trial(refer to this"Benefits"section) "Services in Connection with a Clinical Trial") • Radioactive materials used for therapeutic purposes • Skilled inpatient Services in a Plan Skilled Nursing Facility(refer to"Skilled Nursing Facility Care") • Durable medical equipment and medical supplies • Substance use disorder treatment Services(refer to • Imaging,laboratory,and other diagnostic and "Substance Use Disorder Treatment") treatment Services,including MRI,CT,and PET . Transplant Services(refer to"Transplant Services") scans • Whole blood,red blood cells,plasma,platelets,and their administration I n]u ry to Teeth • Obstetrical care and delivery(including cesarean Services for accidental injury to teeth are not covered section).Note: If you are discharged within 48 hours under this EOC. after delivery(or within 96 hours if delivery is by cesarean section),your Plan Physician may order a follow-up visit for you and your newborn to take Mental Health Services place within 48 hours after discharge(for visits after you are released from the hospital,refer to"Office We cover Services specified in this"Mental Health Visits"in this"Benefits"section) Services"section only when the Services are for the prevention,diagnosis,or treatment of Mental Health Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 52 Conditions.A"Mental Health Condition"is a mental accord with our drug formulary guidelines if they are health condition that falls under any of the diagnostic administered to you in the facility by medical categories listed in the mental and behavioral disorders personnel(for discharge drugs prescribed when you chapter of the most recent edition of the International are released from the residential treatment facility, Classification of Diseases or that is listed in the most refer to"Outpatient Prescription Drugs, Supplies,and recent version of the Diagnostic and Statistical Manual Supplements"in this"Benefits"section) of Mental Disorders. • Discharge planning Outpatient mental health Services Gender-affirming Services We cover the following Services when provided by Plan For covered Services you receive for treatment of gender Physicians or other Plan Providers who are licensed dysphoria,you will pay the Cost Share you would pay if health care professionals acting within the scope of their the Services were not related to gender dysphoria.For license: example: • Individual and group mental health evaluation and • See"Administered Drugs"for administered drugs treatment,including treatment of first episode psychosis • See"Office Visits"for consultations for gender dysphoria treatment,such as hormone therapy,and • Psychological testing when necessary to evaluate a hair removal procedures Mental Health Condition • See"Outpatient Laboratory,Imaging,and Other • Outpatient Services for the purpose of monitoring Diagnostic and Treatment Services"for laboratory drug therapy and imaging Services • Behavioral Health Treatment for Autism Spectrum • See"Outpatient Prescription Drugs, Supplies and Disorder Supplements"for drugs,supplies,and supplements • Electroconvulsive therapy • See"Reconstructive Surgery"for surgical Services • Transcranial magnetic stimulation • See"Rehabilitative and Habilitative Services"for speech(voice)therapy Intensive psychiatric treatment programs We cover intensive psychiatric treatment programs at a Inpatient psychiatric hospitalization Plan Facility,such as: We cover inpatient psychiatric hospitalization in a Plan • Partial hospitalization Hospital. Coverage includes room and board,drugs,and • Multidisciplinary treatment in an intensive outpatient Services of Plan Physicians and other Plan Providers or day-treatment program who are licensed health care professionals acting within the scope of their license. • Psychiatric observation for an acute psychiatric crisis Services from Non-Plan Providers Residential treatment If we are not able to offer an appointment with a Plan Inside our Service Area,we cover the following Services Provider within required geographic and timely access when the Services are provided in a licensed residential standards,we will offer to refer you to a Non-Plan treatment facility that provides 24-hour individualized Provider(as described in"Medical Group authorization mental health treatment,the Services are generally and procedure for certain referrals"under"Getting a customarily provided by a mental health residential Referral'in the"How to Obtain Services"section). treatment program in a licensed residential treatment facility,and the Services are above the level of custodial Additionally,we cover Services provided by a 988 care: center,mobile crisis team,or other provider of • Individual and group mental health evaluation and behavioral health crisis services(collectively,"988 treatment Services")for medically necessary treatment of a mental • Medical services health or substance use disorder without prior authorization until the condition is stabilized,as required • Medication monitoring by state law.After the mental health or substance use • Room and board disorder condition has been stabilized,post-stabilization care from Non-Plan Providers is subject to prior • Social services authorization as described under"Post-Stabilization • Drugs prescribed by a Plan Provider as part of your Care"in the"Emergency Services"section. plan of care in the residential treatment facility in Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 53 For these referral Services and 988 Services,you pay the • The item has been approved for you through the Cost Share required for Services provided by a Plan Plan's prior authorization process,as described in Provider as described in this EOC. "Medical Group authorization procedure for certain referrals"under"Getting a Referral"in the"How to For the following Services, refer to these Obtain Services"section sections • The Services are provided inside our Service Area • Behavioral Health Treatment for Autism Spectrum Disorder provided during a covered stay in a Plan Coverage is limited to the standard item of equipment Hospital or Skilled Nursing Facility(refer to that adequately meets your medical needs.We decide "Hospital Inpatient Services"and"Skilled Nursing whether to rent or purchase the equipment,and we select Facility Care") the vendor. • Outpatient drugs,supplies,and supplements(refer to "Outpatient Prescription Drugs, Supplies,and Ostomy and urological supplies exclusions Supplements") • Comfort,convenience,or luxury equipment or • Outpatient laboratory and sleep studies(refer to features "Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services") Outpatient Imaging, Laboratory, and • Outpatient physical,occupational,and speech therapy Other Diagnostic and Treatment visits(refer to"Rehabilitative and Habilitative Services") Services • Telehealth Visits(refer to"Telehealth Visits") We cover the following Services only when part of care covered under other headings in this"Benefits"section. Office Visits The Services must be prescribed by a Plan Provider. • Complex imaging(other than preventive)such as CT We cover the following: scans,MRIs,and PET scans • Primary Care Visits and Non-Physician Specialist • Basic imaging Services,such as diagnostic and Visits therapeutic X-rays,mammograms,and ultrasounds • Physician Specialist Visits • Nuclear medicine • Group appointments • Routine retinal photography screenings • Acupuncture Services(typically provided only for the • Laboratory tests,including tests to monitor the treatment of nausea or as part of a comprehensive effectiveness of dialysis and tests for specific genetic pain management program for the treatment of disorders for which genetic counseling is available chronic pain) • Diagnostic Services provided by Plan Providers who • House calls by a Plan Physician(or a Plan Provider are not physicians(such as EKGs,EEGs,and sleep who is a registered nurse)inside our Service Area studies) when care can best be provided in your home as • Radiation therapy determined by a Plan Physician • Ultraviolet light treatments,including ultraviolet light For the following Services, refer to these therapy equipment for home use,if(1)the equipment sections has been approved for you through the Plans prior authorization process,as described in"Medical Group • Abortion and abortion-related Services(refer to authorization procedure for certain referrals"under "Reproductive Health Services") "Getting a Referral"in the"How to Obtain Services" section and(2)the equipment is provided inside our Service Area.(Coverage for ultraviolet light therapy Ostomy and Urological Supplies equipment is limited to the standard item of We cover ostomy and urological supplies if the equipment that adequately meets your medical needs. following requirements are met: We decide whether to rent or purchase the equipment, and we select the vendor.You must return the • A Plan Physician has prescribed ostomy and equipment to us or pay us the fair market price of the urological supplies for your medical condition equipment when we are no longer covering it.) Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 54 We cover laboratory tests to diagnose or screen for items described in this section when prescribed as COVID-19 from Plan Providers or Non-Plan Providers, follows: including a provider visit for purposes of receiving the . Items prescribed by Plan Providers,within the scope laboratory test. of their licensure and practice We cover up to a total of eight FDA-authorized over-the- • Items prescribed by the following Non—Plan counter COVID-19 tests per calendar month from Plan Providers: Providers or Non-Plan Providers. Over-the-counter tests ♦ Dentists if the drug is for dental care are self-administered tests that deliver results at home ♦ Non—Plan Physicians if the Medical Group and are available without a prescription.For purposes of authorizes a written referral to the Non—Plan this section,"Plan Provider"means a Plan Pharmacy, Physician(in accord with"Medical Group mail order delivery through our website at kp.org,or a authorization procedure for certain referrals" participating retail pharmacy.For purposes of this under"Getting a Referral"in the"How to Obtain section,a"Non-Plan Provider"means a pharmacy or Services"section)and the drug, supply,or online retailer that isn't a Plan Provider. To find out supplement is covered as part of that referral more about coverage and limitations,including the ♦ Non—Plan Physicians if the prescription was current list of Plan Providers,visit our website or call obtained as part of covered Emergency Services, Member Services. Post-Stabilization Care,or Out-of-Area Urgent For the following Services, refer to these Care described in the"Emergency Services and sections Urgent Care"section(if you fill the prescription at a Plan Pharmacy,you may have to pay Charges • Abortion and abortion-related Services(refer to for the item and file a claim for reimbursement as "Reproductive Health Services") described under"Payment and Reimbursement"in • Outpatient imaging and laboratory Services that are the"Emergency Services and Urgent Care" Preventive Services,such as routine mammograms, section) bone density scans,and laboratory screening tests ♦ Non—Plan Providers that are not providers of (refer to"Preventive Services") Emergency Services or Out-of-Area Urgent Care • Outpatient procedures that include imaging and if the prescription is for COVID-19 therapeutics diagnostic Services(refer to"Outpatient Surgery and (if you fill the prescription at a Plan Pharmacy, you may have to pay Charges for the item and file Outpatient Procedures") a claim for reimbursement as described in the • Services related to diagnosis and treatment of "Post-Service Claims and Appeals"section) Infertility,artificial insemination,or assisted reproductive technology("ART")Services(refer to Note:If you obtain a prescription from a Non-Plan "Fertility Services") Provider related to dental care or for COVID-19 therapeutics as described above,we do not cover an Outpatient Imaging, Laboratory, and Other office visit or any other services from the Non-Plan Diagnostic and Treatment Services exclusions Provider. • Ultraviolet light therapy comfort,convenience,or luxury equipment or features How to obtain covered items • Repair or replacement of ultraviolet light therapy You must obtain covered items at a Plan Pharmacy or equipment due to loss,theft,or misuse through our mail-order service unless you obtain the item from a Non-Plan Provider as part of covered Emergency Services,Post-Stabilization Care,or Out-of-Area Urgent Outpatient Prescription Drugs, Supplies, Care described in the"Emergency Services and Urgent and Supplements Care"section or a Non-Plan Provider prescribes COVID- 19 therapeutics for you. We cover outpatient drugs,supplies,and supplements specified in this"Outpatient Prescription Drugs, For the locations of Plan Pharmacies,refer to our Supplies,and Supplements"section,in accord with our Provider Directory or call Member Services. drug formulary guidelines,subject to any applicable exclusions or limitations under this EOC.We cover Refills You may be able to order refills at a Plan Pharmacy, through our mail-order service,or through our website at kp.org/rxrefill.A Plan Pharmacy can give you more Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 55 information about obtaining refills,including the options About the drug formulary available to you for obtaining refills.For example,a few The drug formulary includes a list of drugs that our Plan Pharmacies don't dispense refills and not all drugs Pharmacy and Therapeutics Committee has approved for can be mailed through our mail-order service.Please our Members.Our Pharmacy and Therapeutics check with a Plan Pharmacy if you have a question about Committee,which is primarily composed of Plan whether your prescription can be mailed or obtained at a Physicians and pharmacists,selects drugs for the drug Plan Pharmacy.Items available through our mail-order formulary based on several factors,including safety and service are subject to change at any time without notice. effectiveness as determined from a review of medical literature.The drug formulary is updated monthly based Day supply limit on new information or new drugs that become available. The prescribing physician or dentist determines how To find out which drugs are on the formulary for your much of a drug,supply,item,or supplement to prescribe. plan,please refer to the California Commercial HMO For purposes of day supply coverage limits,Plan formulary on our website at ky.org/formulary.The Physicians determine the amount of an item that formulary also discloses requirements or limitations that constitutes a Medically Necessary 30-or 100-day supply apply to specific drugs,such as whether there is a limit (or 365-day supply if the item is a hormonal on the amount of the drug that can be dispensed and contraceptive)for you.Upon payment of the Cost Share whether the drug must be obtained at certain specialty specified in the"Outpatient prescription drugs,supplies, pharmacies.If you would like to request a copy of this and supplements"section of the"Cost Share Summary," drug formulary,please call Member Services.Note: The you will receive the supply prescribed up to the day presence of a drug on the drug formulary does not supply limit specified in this section or in the drug necessarily mean that it will be prescribed for a particular formulary for your plan(see"About the drug formulary" medical condition. below).The maximum you may receive at one time of a covered item,other than a hormonal contraceptive,is Formulary exception process either one 30-day supply in a 30-day period or one 100- Drug formulary guidelines allow you to obtain a non- day supply in a 100-day period.If you wish to receive formulary prescription drug(those not listed on our drug more than the covered day supply limit,then you must formulary for your condition)if it would otherwise be pay Charges for any prescribed quantities that exceed the covered by your plan,as described above,and it is day supply limit. Medically Necessary.If you disagree with a Health Plan determination that a non-formulary prescription drug is If your plan includes coverage for hormonal not covered,you may file a grievance as described in the contraceptives,the maximum you may receive at one "Dispute Resolution"section. time of contraceptive drugs is a 365-day supply.To obtain a 365-day supply,talk to your prescribing Continuity drugs provider.Refer to the"Cost Share Summary"section of If this EOC is amended to exclude a drug that we have this EOC to find out if your plan includes coverage for been covering and providing to you under this EOC,we hormonal contraceptives. will continue to provide the drug if a prescription is required by law and a Plan Physician continues to If your plan includes coverage for sexual dysfunction prescribe the drug for the same condition and for a use drugs,the maximum you may receive at one time of approved by the federal Food and Drug Administration. episodic drugs prescribed for the treatment of sexual dysfunction disorders is eight doses in any 30-day period About drug tiers or up to 27 doses in any 100-day period.Refer to the Drugs for your plan are categorized into tiers as "Cost Share Summary"section of this EOC to find out if described in the table below(your plan doesn't have a your plan includes coverage for sexual dysfunction Tier 3).Your Cost Share for covered items may vary drugs. based on the tier.Refer to"Outpatient prescription drugs, supplies,and supplements"in the"Cost Share The pharmacy may reduce the day supply dispensed at Summary"section of this EOC for Cost Share for items the Cost Share specified in the"Outpatient prescription covered under this section.Refer to the drug formulary drugs,supplies,and supplements"section of the"Cost to find out which tier a particular drug is on and for the Share Summary"for any drug to a 30-day supply in any definition of"generic drug,""brand-name drug,"and 30-day period if the pharmacy determines that the item is "specialty drug." in limited supply in the market or for specific drugs (your Plan Pharmacy can tell you if a drug you take is one of these drugs). Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 56 Schedule H drugs Tier Description You or the prescribing provider can request that the pharmacy dispense less than the prescribed amount of a Tier 1 Most generic drugs,supplies and covered oral,solid dosage form of a Schedule II drug supplements(also includes certain (your Plan Pharmacy can tell you if a drug you take is brand-name drugs,supplies,and one of these drugs).Your Cost Share will be prorated supplements) based on the amount of the drug that is dispensed.If the pharmacy does not prorate your Cost Share,we will send Tier 2 Most brand-name drugs,supplies, you a refund for the difference. and supplements(also includes certain generic drugs,supplies,and Mail-order service supplements) Prescription refills can be mailed within 3 to 5 days at no extra cost for standard U.S.postage.The appropriate Tier 4 High-cost brand-name or generic Cost Share(according to your drug coverage)will apply drugs,supplies,and supplements and must be charged to a valid credit card. (sometimes called"specialty drugs") You may request mail-order service in the following ways: These tiers apply to formulary and non-formulary drugs, . To order online,visit kp.org/rxrefill(you can register supplies and supplements.If you need help determining for a secure account at kp.m/re0sternow)or use whether a formulary or non-formulary drug,supply,or the KP app from your smartphone or other mobile supplement is categorized as Tier 1,Tier 2,or Tier 4, device please call Member Services.Note:Non-formulary drugs are not covered unless Medically Necessary as described • Call the pharmacy phone number highlighted on your prescription label and select the mail delivery option under"Formulary exception process"in the"About the drug formulary"section above. • On your next visit to a Kaiser Permanente pharmacy, ask our staff how you can have your prescriptions General rules about coverage and your Cost mailed to you Share We cover the following outpatient drugs,supplies,and Note:Restrictions and limitations apply.For example, supplements as described in this"Outpatient Prescription not all drugs can be mailed and we cannot mail drugs to Drugs,Supplies,and Supplements"section: all states. • Drugs for which a prescription is required by law.We Manufacturer coupon program also cover certain over-the-counter drugs and items (drugs and items that do not require a prescription by For outpatient prescription drugs or items that are law)if they are listed on our drug formulary and covered under this"Outpatient Prescription Drugs, prescribed by a Plan Physician,except a prescription Supplies,and Supplements"section and obtained at a is not required for over-the-counter contraceptives Plan Pharmacy,you maybe able to use approved manufacturer coupons as payment for the Cost Share that • Disposable needles and syringes needed for injecting you owe,as allowed under Health Plan's coupon covered drugs and supplements program.You will owe any additional amount if the • Inhaler spacers needed to inhale covered drugs coupon does not cover the entire amount of your Cost Share for your prescription.When you use an approved Note: coupon for payment of your Cost Share,the coupon • If Charges for the drug,supply,or supplement are less amount and any additional payment that you make will accumulate to your out-of-pocket maximum if than the Copayment,you will pay the lesser amount, applicable.Refer to the"Cost Share Summary"section subject to any applicable deductible or out-of-pocket of this EOC to find your applicable out-of-pocket maximum maximum amount and to learn which drugs and items • Items can change tier at any time,in accord with apply to the maximum. Certain health plan coverages are formulary guidelines,which may impact your Cost not eligible for coupons.You can get more information Share(for example,if a brand-name drug is added to regarding the Kaiser Permanente coupon program rules the specialty drug list,you will pay the Cost Share and limitations at k%or2/rxcoup0ns. that applies to drugs on Tier 4,not the Cost Share for drugs on Tier 2) Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 57 Base drugs,supplies,and supplements Outpatient prescription drugs, supplies, and Cost Share for the following items may be different than supplements limitations other drugs,supplies,and supplements.Refer to"Base . When you are prescribed drugs solely for the drugs,supplies,and supplements"in the"Cost Share purposes of losing weight,we may require you to be Summary"section of this EOC: enrolled in a covered comprehensive weight loss • Certain drugs for the treatment of life-threatening program,for a reasonable period of time prior to or ventricular arrhythmia concurrent with receiving the prescription drug • Drugs for the treatment of tuberculosis Outpatient prescription drugs, supplies, and • Elemental dietary enteral formula when used as a supplements exclusions primary therapy for regional enteritis • Any requested packaging(such as dose packaging) • Hematopoietic agents for dialysis other than the dispensing pharmacy's standard • Hematopoietic agents for the treatment of anemia in packaging chronic renal insufficiency • Compounded products unless the drug is listed on our • Human growth hormone for long-term treatment of drug formulary or one of the ingredients requires a pediatric patients with growth failure from lack of prescription by law adequate endogenous growth hormone secretion • Drugs prescribed to shorten the duration of the • Immunosuppressants and ganciclovir and ganciclovir common cold prodrugs for the treatment of cytomegalovirus when • Prescription drugs for which there is an over-the- prescribed in connection with a transplant counter equivalent(the same active ingredient, • Phosphate binders for dialysis patients for the strength,and dosage form as the prescription drug). treatment of hyperphosphatemia in end stage renal This exclusion does not apply to: disease ♦ insulin ♦ over-the-counter drugs covered under"Preventive For the following Services, refer to these Services"in this"Benefits"section(this includes sections tobacco cessation drugs and contraceptive drugs) • Drugs prescribed for abortion or abortion-related ♦ an entire class of prescription drugs when one drug Services(refer to"Reproductive Health Services") within that class becomes available over-the- • Administered contraceptives(refer to"Reproductive counter Health Services") • All drugs,supplies,and supplements related to • Diabetes blood-testing equipment and their supplies, assisted reproductive technology("ART")Services and insulin pumps and their supplies(refer to "Durable Medical Equipment("DME")for Home Use") Outpatient Surgery and Outpatient Procedures • Drugs covered during a covered stay in a Plan Hospital or Skilled Nursing Facility(refer to We cover the following outpatient care Services: "Hospital Inpatient Services"and"Skilled Nursing . Outpatient surgery Facility Care") • Drugs prescribed for pain control and symptom • Outpatient procedures(including imaging and management of the terminal illness for Members who diagnostic Services)when provided in an outpatient are receiving covered hospice care(refer to"Hospice or ambulatory surgery center or in a hospital Care") operating room,or in any setting where a licensed staff member monitors your vital signs as you regain • Durable medical equipment used to administer drugs sensation after receiving drugs to reduce sensation or (refer to"Durable Medical Equipment("DME")for to minimize discomfort Home Use") • Outpatient administered drugs that are not For the following Services, refer to these contraceptives(refer to"Administered Drugs and sections Products") • Fertility preservation Services for iatrogenic Infertility(refer to"Fertility Preservation Services for Iatrogenic Infertility") Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 58 • Outpatient procedures(including imaging and need other care,such as diagnostic or treatment Services. diagnostic Services)that do not require a licensed If you receive any other covered Services that are not staff member to monitor your vital signs(refer to the Preventive Services before,during,or after a visit that section that would otherwise apply for the procedure; includes Preventive Services,you will pay the applicable for example,for radiology procedures that do not Cost Share for those other Services.For example,if require a licensed staff member to monitor your vital laboratory tests or imaging Services ordered during a signs,refer to"Outpatient Imaging,Laboratory,and preventive office visit are not Preventive Services,you Other Diagnostic and Treatment Services") will pay the applicable Cost Share for those Services. For the following Services, refer to these Preventive Services sections We cover a variety of Preventive Services from Plan • Milk pumps and lactation supplies(refer to"Lactation Providers,as listed on our website at kp.org/prevention, supplies"under"Durable Medical Equipment including the following: ("DME")for Home Use") • Services recommended by the United States • Health education programs(refer to"Health Preventive Services Task Force with rating of"A"or Education") "B."The complete list of these services can be found • Outpatient drugs,supplies,and supplements that are at uspreventiveservicestaskforce.org Preventive Services(refer to"Outpatient Prescription • Immunizations recommended by the Advisory Drugs,Supplies,and Supplements") Committee on Immunization Practices of the Centers o Family planning counseling,consultations,and for Disease Control and Prevention.The complete list sterilization Services(refer to"Reproductive Health of recommended immunizations can be found at Services") cdc.gov/vaccines/schedules • Preventive services recommended by the Health Prosthetic and Orthotic Devices Resources and Services Administration and incorporated into the Affordable Care Act.The Prosthetic and orthotic devices coverage rules complete list of these services can be found at We cover the prosthetic and orthotic devices specified in hrsa.gov/womens-guidelines this"Prosthetic and Orthotic Devices"section if all of Note:We cover immunizations to prevent COVID-19 the following requirements are met: that are administered in a Plan Medical Office or by a • The device is in general use,intended for repeated Non-Plan Provider.If you obtain this immunization from use,and primarily and customarily used for medical a Non-Plan Provider(except for providers of Emergency purposes Services or Out-of-Area Urgent Care),we do not cover . The device is the standard device that adequately an office visit or any other services from the Non-Plan meets your medical needs Provider other than administration of the vaccine. . you receive the device from the provider or vendor The list of Preventive Services recommended by the that we select above organizations is subject to change.These • The item has been approved for you through the Preventive Services are subject to all coverage Plan's prior authorization process,as described in requirements described in this"Benefits"section and all "Medical Group authorization procedure for certain provisions in the"Exclusions,Limitations,Coordination referrals"under"Getting a Referral"in the"How to of Benefits,and Reductions"section. Obtain Services"section • The Services are provided inside our Service Area If you are enrolled in a grandfathered plan,certain preventive items listed on our website,such as over-the- Coverage includes fitting and adjustment of these counter drugs,may not be covered.Refer to the"Certain devices,their repair or replacement,and Services to preventive items"table in the"Cost Share Summary" determine whether you need a prosthetic or orthotic section of this EOC for coverage information.If you device. If we cover a replacement device,then you pay have questions about Preventive Services,please call the Cost Share that you would pay for obtaining that Member Services. device. Note:Preventive Services help you stay healthy,before you have symptoms.If you have symptoms,you may Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 59 Base prosthetic and orthotic devices Supplemental prosthetic and orthotic devices If all of the requirements described under"Prosthetic and If all of the requirements described under"Prosthetic and orthotic coverage rules"in this"Prosthetics and Orthotic orthotic coverage rules"in this"Prosthetics and Orthotic Devices"section are met,we cover the items described Devices"section are met,we cover the following items: in this"Base prosthetic and orthotic devices"section. • Prosthetic devices required to replace all or part of an organ or extremity,but only if they also replace the Internally implanted devices function of the organ or extremity We cover prosthetic and orthotic devices such as • Rigid and semi-rigid orthotic devices required to pacemakers,intraocular lenses,cochlear implants, osseointegrated hearing devices,and hip joints,if they support or correct a defective body part are implanted during a surgery that we are covering under another section of this"Benefits"section. For the following Services, refer to these sections For internally implanted prosthetic and orthotic devices, • Eyeglasses and contact lenses,including contact you pay the Cost Share for the procedure to implant the lenses to treat aniridia or aphakia(refer to"Vision device.For example,see"Outpatient Surgery and Services for Adult Members"and"Vision Services Outpatient Procedures"in the"Cost Share Summary" for Pediatric Members") section of this EOC for the Cost Share that applies for • Hearing aids other than internally implanted devices Outpatient Surgery. described in this section(refer to"Hearing Services") External devices • Injectable implants(refer to"Administered Drugs and We cover the following external prosthetic and orthotic Products") devices: Prosthetic and orthotic devices exclusions • Prosthetic devices and installation accessories to restore a method of speaking following the removal • Multifocal intraocular lenses and intraocular lenses to of all or part of the larynx(this coverage does not correct astigmatism include electronic voice-producing machines,which • Nonrigid supplies,such as elastic stockings and wigs, are not prosthetic devices) except as otherwise described above in this • After Medically Necessary removal of all or part of a "Prosthetic and Orthotic Devices"section breast: • Comfort,convenience,or luxury equipment or ♦ prostheses,including custom-made prostheses features when Medically Necessary • Repair or replacement of device due to loss,theft,or ♦ up to three brassieres required to hold a prosthesis misuse in any 12-month period • Shoes,shoe inserts,arch supports,or any other • Podiatric devices(including footwear)to prevent or footwear,even if custom-made,except footwear treat diabetes-related complications when prescribed described above in this"Prosthetic and Orthotic by a Plan Physician or by a Plan Provider who is a Devices"section for diabetes-related complications podiatrist • Prosthetic and orthotic devices not intended for • Compression burn garments and lymphedema wraps maintaining normal activities of daily living and garments (including devices intended to provide additional • Enteral formula for Members who require tube support for recreational or sports activities) feeding in accord with Medicare guidelines • Enteral pump and supplies Reconstructive Surgery • Tracheostomy tube and supplies We cover the following reconstructive surgery Services: • Prostheses to replace all or part of an external facial . Reconstructive surgery to correct or repair abnormal body part that has been removed or impaired as a structures of the body caused by congenital defects, result of disease,injury,or congenital defect developmental abnormalities,trauma,infection, tumors,or disease,if a Plan Physician determines that it is necessary to improve function,or create a normal appearance,to the extent possible Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 60 • Following Medically Necessary removal of all or part We cover the following Services: of a breast,we cover reconstruction of the breast, • Individual outpatient physical,occupational,and surgery and reconstruction of the other breast to speech therapy produce a symmetrical appearance,and treatment of physical complications,including lymphedemas • Group outpatient physical,occupational,and speech therapy For covered Services related to reconstructive surgery • Physical,occupational,and speech therapy provided that you receive,you will pay the Cost Share you would in an organized,multidisciplinary rehabilitation day- pay if the Services were not related to reconstructive treatment program surgery.For example,see"Hospital inpatient Services" in the"Cost Share Summary"section of this EOC for the For the following Services, refer to these Cost Share that applies for hospital inpatient Services, sections and see"Outpatient surgery and outpatient procedures" e Behavioral Health Treatment for Autism Spectrum in the"Cost Share Summary"for the Cost Share that Disorder(refer to"Mental Health Services") applies for outpatient surgery. • Home health care(refer to"Home Health Care") For the following Services, refer to these • Durable medical equipment(refer to"Durable sections Medical Equipment("DME")for Home Use") • Dental and orthodontic Services that are an integral • Ostomy and urological supplies(refer to"Ostomy and part of reconstructive surgery for cleft palate(refer to Urological Supplies") "Dental and Orthodontic Services") • Prosthetic and orthotic devices(refer to"Prosthetic • Office visits not described in the"Reconstructive and Orthotic Devices") Surgery"section(refer to"Office Visits") • Physical,occupational,and speech therapy provided • Outpatient imaging and laboratory(refer to during a covered stay in a Plan Hospital or Skilled "Outpatient Imaging,Laboratory,and Other Nursing Facility(refer to"Hospital Inpatient Diagnostic and Treatment Services") Services"and"Skilled Nursing Facility Care") • Outpatient prescription drugs(refer to"Outpatient Prescription Drugs, Supplies,and Supplements") Rehabilitative and habilitative Services • Outpatient administered drugs(refer to"Administered exclusions Drugs and Products") • Items and services that are not health care items and services(for example,respite care,day care, • Prosthetics and orthotics(refer to"Prosthetic and recreational care,residential treatment,social Orthotic Devices ) services,custodial care,or education services of any • Telehealth Visits(refer to"Telehealth Visits") kind,including vocational training) Reconstructive surgery exclusions • Surgery that,in the judgment of a Plan Physician Reproductive Health Services specializing in reconstructive surgery,offers only a Family planning Services minimal improvement in appearance We cover the following Services when provided for family planning purposes: Rehabilitative and Habilitative Services • Family planning counseling • Injectable contraceptives,internally implanted time- We cover the Services described in this"Rehabilitative release contraceptives or intrauterine devices and requirements ar Services"section if all of the following ("IUDs")and office visits related to their insertion, requirements are met: removal,and management when provided to prevent • The Services are to address a health condition pregnancy • The Services are to help you keep,learn,or improve • Sterilization procedures for Members assigned female skills and functioning for daily living at birth • You receive the Services at a Plan Facility unless a • Sterilization procedures for Members assigned male Plan Physician determines that it is Medically at birth Necessary for you to receive the Services in another location Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 61 Plan Doula services ♦ Clinical or medical Services(such as taking blood If you are pregnant or were pregnant within the last 12 pressure or temperature,fetal heart tone checks, months and want Plan Doula services,talk to your care vaginal examinations,or postpartum clinical care) team.We cover the following Plan Doula services: ♦ Assistance with activities of daily living • One initial visit ♦ Alternative or complementary modalities(such as • Up to eight one-hour visits that maybe provided in aromatherapy,childbirth education,massagetherapy,or placenta encapsulation) any combination of prenatal and postpartum visits • Support during labor and delivery ♦ Yoga ♦ Birthing ceremonies Up to two additional postpartum visits may be available. ♦ Over-the-counter supplies or drugs ♦ Home birth Abortion and abortion-related Services We cover the following Services: Services in Connection with a Clinical • Surgical abortion Trial • Prescription drugs,in accord with our drug formulary guidelines We cover Services you receive in connection with a • Abortion-related Services clinical trial if all of the following requirements are met: • We would have covered the Services if they were not For the following Services, refer to these related to a clinical trial sections • You are eligible to participate in the clinical trial • Fertility preservation Services for iatrogenic according to the trial protocol with respect to Infertility(refer to"Fertility Preservation Services for treatment of cancer or other life-threatening condition Iatrogenic Infertility") (a condition from which the likelihood of death is probable unless the course of the condition is • Services to diagnose or treat Infertility(refer to interrupted),as determined in one of the following "Fertility Services") ways: • Office visits related to injectable contraceptives, ♦ a Plan Provider makes this determination internally implanted time-release contraceptives or intrauterine devices("I[JDs")when provided for ♦ you provide us with medical and scientific medical reasons other than to prevent pregnancy information establishing this determination (refer to"Office Visits") • If any Plan Providers participate in the clinical trial • Outpatient administered drugs that are not and will accept you as a participant in the clinical contraceptives(refer to"Administered Drugs and trial,you must participate in the clinical trial through Products") a Plan Provider unless the clinical trial is outside the state where you live • Outpatient laboratory and imaging services associated . The clinical trial is an Approved Clinical Trial with family planning services(refer to"Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services") "Approved Clinical Trial"means a phase I,phase II, phase Ill,or phase IV clinical trial related to the • Outpatient contraceptive drugs and devices(refer to prevention,detection,or treatment of cancer or other "Outpatient Prescription Drugs, Supplies,and life-threatening condition,and that meets one of the Supplements") following requirements: • Outpatient surgery and outpatient procedures when . The study or investigation is conducted under an provided for medical reasons other than to prevent investigational new drug application reviewed by the pregnancy(refer to"Outpatient Surgery and federal Food and Drug Administration Outpatient Procedures") • The study or investigation is a drug trial that is Reproductive health Services exclusions exempt from having an investigational new drug application • Reversal of surgical sterilization originally performed o The study or investigation is approved or funded by at for family planning purposes least one of the following: • Plan Doula services exclusions: ♦ the National Institutes of Health Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 62 ♦ the Centers for Disease Control and Prevention • Durable medical equipment if Skilled Nursing ♦ the Agency for Health Care Research and Quality Facilities ordinarily furnish the equipment(refer to ♦ the Centers for Medicare&Medicaid Services "Medical Group authorization procedure for certain referrals"under"Getting a Referral"in the"How to ♦ a cooperative group or center of any of the above Obtain Services"section) entities or of the Department of Defense or the Department of Veterans Affairs • Imaging and laboratory Services that Skilled Nursing ♦ a qualified non-governmental research entity Facilities ordinarily provide identified in the guidelines issued by the National • Medical social services Institutes of Health for center support grants • Whole blood,red blood cells,plasma,platelets,and ♦ the Department of Veterans Affairs or the their administration Department of Defense or the Department of • Medical supplies Energy,but only if the study or investigation has been reviewed and approved though a system of • Behavioral Health Treatment for Autism Spectrum peer review that the U.S. Secretary of Health and Disorder Human Services determines meets all of the • Physical,occupational,and speech therapy following requirements: (1)It is comparable to the . Respiratory therapy National Institutes of Health system of peer review of studies and investigations and(2)it assures For the following Services, refer to these unbiased review of the highest scientific standards by qualified people who have no interest in the sections outcome of the review • Outpatient imaging,laboratory,and other diagnostic and treatment Services(refer to"Outpatient Imaging, For covered Services related to a clinical trial,you will Laboratory,and Other Diagnostic and Treatment pay the Cost Share you would pay if the Services were Services") not related to a clinical trial.For example, see"Hospital • Outpatient physical,occupational,and speech therapy inpatient Services"in the"Cost Share Summary"section (refer to"Rehabilitative and Habilitative Services") of this EOC for the Cost Share that applies for hospital inpatient Services. Substance Use Disorder Treatment Services in connection with a clinical trial exclusions We cover Services specified in this"Substance Use • The investigational Service Disorder Treatment"section only when the Services are for the prevention,diagnosis,or treatment of Substance • Services that are provided solely to satisfy data Use Disorders.A"Substance Use Disorder"is a collection and analysis needs and are not used in your substance use disorder that falls under any of the clinical management diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or that is listed Skilled Nursing Facility Care in the most recent version of the Diagnostic and Inside our Service Area,we cover skilled inpatient Statistical Manual of Mental Disorders. Services in a Plan Skilled Nursing Facility. The skilled Outpatient substance use disorder treatment inpatient Services must be customarily provided by a Skilled Nursing Facility,and above the level of custodial We cover the following Services for treatment of substance use disorders: or intermediate care. • Day-treatment programs We cover the following Services: • Individual and group substance use disorder • Physician and nursing Services counseling • Room and board • Intensive outpatient programs • Drugs prescribed by a Plan Physician as part of your • Medical treatment for withdrawal symptoms plan of care in the Plan Skilled Nursing Facility in • Methadone maintenance treatment at a licensed accord with our drug formulary guidelines if they are treatment center approved by Medical Group administered to you in the Plan Skilled Nursing Facility by medical personnel Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 63 Residential treatment For these referral Services and 988 Services,you pay the Inside our Service Area,we cover the following Services Cost Share required for Services provided by a Plan when the Services are provided in a licensed residential Provider as described in this EOC. treatment facility that provides 24-hour individualized substance use disorder treatment,the Services are For the following Services, refer to these generally and customarily provided by a substance use sections disorder residential treatment program in a licensed • Outpatient laboratory,including drug testing(refer to residential treatment facility,and the Services are above "Outpatient Imaging,Laboratory,and Other the level of custodial care: Diagnostic and Treatment Services") • Individual and group substance use disorder • Outpatient self-administered drugs(refer to counseling "Outpatient Prescription Drugs, Supplies,and • Medical services Supplements") • Medication monitoring • Telehealth Visits(refer to"Telehealth Visits") • Room and board • Social services Telehealth Visits • Drugs prescribed by a Plan Provider as part of your Telehealth Visits are intended to make it more plan of care in the residential treatment facility in convenient for you to receive covered Services,when a accord with our drug formulary guidelines if they are Plan Provider determines it is medically appropriate for administered to you in the facility by medical your medical condition.You may receive covered personnel(for discharge drugs prescribed when you Services via Telehealth Visits,when available and if the are released from the residential treatment facility, Services would have been covered under this EOC if refer to"Outpatient Prescription Drugs, Supplies,and provided in person.You are not required to use Supplements"in this"Benefits"section) Telehealth Visits,and you may choose to receive in- • Discharge planning person Services from a Plan Provider instead. Some Plan Providers offer Services exclusively through a telehealth Inpatient detoxification technology platform and have no physical location at We cover hospitalization in a Plan Hospital only for which you can receive Services.If you receive covered medical management of withdrawal symptoms,including Services from these Plan Providers,you may access your room and board,Plan Physician Services,drugs, medical record of the Telehealth Visit and,unless you dependency recovery Services,education,and object,such information will be added to your Health counseling. Plan electronic medical record and shared with your Primary Care Physician. Services from Non-Plan Providers If we are not able to offer an appointment with a Plan We cover the following types of Telehealth Visits with Provider within required geographic and timely access Primary Care Physicians,Non-Physician Specialists,and standards,we will offer to refer you to a Non-Plan Physician Specialists: Provider(as described in"Medical Group authorization • Interactive video visits procedure for certain referrals"under"Getting a • Scheduled telephone visits Referral'in the"How to Obtain Services"section). Additionally,we cover Services provided by a 988 Transplant Services center,mobile crisis team,or other provider of behavioral health crisis services(collectively,"988 We cover transplants of organs,tissue,or bone marrow if Services")for medically necessary treatment of a mental the Medical Group provides a written referral for care to health or substance use disorder without prior a transplant facility as described in"Medical Group authorization until the condition is stabilized,as required authorization procedure for certain referrals"under by state law.After the mental health or substance use "Getting a Referral'in the"How to Obtain Services" disorder condition has been stabilized,post-stabilization section. care from Non-Plan Providers is subject to prior authorization as described under"Post-Stabilization Care"in the"Emergency Services"section. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 64 After the referral to a transplant facility,the following We cover the following for Adult Members: applies: • Routine eye exams with a Plan Optometrist to • If either the Medical Group or the referral facility determine the need for vision correction(including determines that you do not satisfy its respective dilation Services when Medically Necessary)and to criteria for a transplant,we will only cover Services provide a prescription for eyeglass lenses you receive before that determination is made • Physician Specialist Visits to diagnose and treat • Health Plan,Plan Hospitals,the Medical Group,and injuries or diseases of the eye Plan Physicians are not responsible for finding, • Non-Physician Specialist Visits to diagnose and treat furnishing,or ensuring the availability of an organ, injuries or diseases of the eye tissue,or bone marrow donor • In accord with our guidelines for Services for living Optical Services transplant donors,we provide certain donation-related We cover the Services described in this"Optical Services for a donor,or an individual identified by the Services"section when received from Plan Medical Medical Group as a potential donor,whether or not Offices or Plan Optical Sales Offices. the donor is a Member. These Services must be directly related to a covered transplant for you,which The date we provide an Allowance toward(or otherwise may include certain Services for harvesting the organ, cover)an item described in this"Optical Services" tissue,or bone marrow and for treatment of section is the date on which you order the item.For complications.Please call Member Services for example,if we last provided an Allowance toward an questions about donor Services item you ordered on May 1,2023,and if we provide an Allowance not more than once every 24 months for that For covered transplant Services that you receive,you type of item,then we would not provide another will pay the Cost Share you would pay if the Services Allowance toward that type of item until on or after May were not related to a transplant.For example,see 1,2025.You can use the Allowances under this"Optical "Hospital inpatient Services"in the"Cost Share Services"section only when you first order an item.If Summary"section of this EOC for the Cost Share that you use part but not all of an Allowance when you first applies for hospital inpatient Services.We provide or pay order an item,you cannot use the rest of that Allowance for donation-related Services for actual or potential later. donors(whether or not they are Members)in accord with our guidelines for donor Services at no charge. Special contact lenses For the following Services, refer to these We cover the following: sections • For aniridia(missing iris),we cover up to two Medically Necessary contact lenses per eye • Dental Services that are Medically Necessary to (including fitting and dispensing)in any 12-month prepare for a transplant(refer to"Dental and period when prescribed by a Plan Physician or Plan Orthodontic Services") Optometrist • Outpatient imaging and laboratory(refer to • For aphakia(absence of the crystalline lens of the "Outpatient Imaging,Laboratory,and Other eye),we cover up to six Medically Necessary aphakic Diagnostic and Treatment Services") contact lenses per eye(including fitting and • Outpatient prescription drugs(refer to"Outpatient dispensing)in any 12-month period when prescribed Prescription Drugs, Supplies,and Supplements") by a Plan Physician or Plan Optometrist • Outpatient administered drugs(refer to"Administered • For other specialty contact lenses that will provide a Drugs and Products") significant improvement in your vision not obtainable with eyeglass lenses,we cover either one pair of contact lenses(including fitting and dispensing)or an Vision Services for Adult Members initial supply of disposable contact lenses(up to six months,including fitting and dispensing)in any 24- For the purpose of this"Vision Services for Adult month period Members"section,an"Adult Member"is a Member who is age 19 or older and is not a Pediatric Member,as Eyeglasses and contact lenses defined under"Vision Services for Pediatric Members" We provide a single Allowance toward the purchase in this"Benefits"section.For example,if you turn 19 on price of any or all of the following not more than once June 25,you will be an Adult Member starting July 1. every 24 months when a physician or optometrist Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 65 prescribes an eyeglass lens(for eyeglass lenses and • Items that do not require a prescription by law(other frames)or contact lens(for contact lenses).Refer to than eyeglass frames),such as eyeglass holders, "Vision Services for Adult Members"in the"Cost Share eyeglass cases,and repair kits Summary"section of this EOC for your Allowance • Lenses and sunglasses without refractive value, amount. except as described in this"Vision Services for Adult • Eyeglass lenses when a Plan Provider puts the lenses Members"section into a frame • Low vision devices ♦ we cover a clear balance lens when only one eye o Replacement of lost,broken,or damaged contact needs correction ♦ we cover tinted lenses when Medically Necessary lenses,eyeglass lenses,and frames to treat macular degeneration or retinitis pigmentosa Vision Services for Pediatric Members • Eyeglass frames when a Plan Provider puts two lenses (at least one of which must have refractive value)into For the purpose of this"Vision Services for Pediatric the frame Members"section,a"Pediatric Member"is a Member • Contact lenses,fitting,and dispensing from birth through the end of the month of their 19th birthday.For example,if you turn 19 on June 25,you We will not provide the Allowance if we have provided will be an Adult Member starting July 1 and your last an Allowance toward(or otherwise covered)eyeglass minute as a Pediatric Member will be 11:59 p.m. on June lenses or frames within the previous 24 months. 30. Replacement lenses We cover the following for Pediatric Members: If you have a change in prescription of at least.50 • Routine eye exams with a Plan Optometrist to diopter in one or both eyes within 12 months of the determine the need for vision correction(including initial point of sale of an eyeglass lens or contact lens dilation Services when Medically Necessary)and to that we provided an Allowance toward(or otherwise provide a prescription for eyeglass lenses covered)we will provide an Allowance toward the • Physician Specialist Visits to diagnose and treat purchase price of a replacement item of the same type injuries or diseases of the eye (eyeglass lens,or contact lens,fitting,and dispensing) • Non-Physician Specialist Visits to diagnose and treat for the eye that had the .50 diopter change.Refer to "Vision Services for Adult Members"in the"Cost Share injuries or diseases of the eye Summary"section of this EOC for your Allowance Optical Services amount. We cover the Services described in this"Optical Low vision devices Services"section when received from Plan Medical Low vision devices(including fitting and dispensing)are Offices or Plan Optical Sales Offices. not covered under this EOC. Special contact lenses For the following Services, refer to these We cover the following: sections • For aniridia(missing iris),we cover up to two • Routine vision screenings when performed as part of Medically Necessary contact lenses per eye a routine physical exam(refer to"Preventive (including fitting and dispensing)in any 12-month Services") period when prescribed by a Plan Physician or Plan • Services related to the eye or vision other than Optometrist Services covered under this"Vision Services for • For aphakia(absence of the crystalline lens of the Adult Members"section,such as outpatient surgery eye),we cover up to six Medically Necessary aphakic and outpatient prescription drugs,supplies,and contact lenses per eye(including fitting and supplements(refer to the applicable heading in this dispensing)in any 12-month period when prescribed "Benefits"section) by a Plan Physician or Plan Optometrist • For other specialty contact lenses that will provide a Vision Services for Adult Members exclusions significant improvement in your vision not obtainable • Eyeglass or contact lens adornment,such as with eyeglass lenses,we cover either one pair of engraving,faceting,or jeweling contact lenses(including fitting and dispensing)or an Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 66 initial supply of disposable contact lenses(up to six Vision Services for Pediatric Members months,including fitting and dispensing)in any 24- exclusions month period e Eyeglass or contact lens adornment,such as Eyeglasses and contact lenses engraving,faceting,or jeweling We provide a single Allowance toward the purchase • Items that do not require a prescription by law(other price of any or all of the following not more than once than eyeglass frames),such as eyeglass holders, every 24 months when a physician or optometrist eyeglass cases,and repair kits prescribes an eyeglass lens(for eyeglass lenses and • Lenses and sunglasses without refractive value, frames)or contact lens(for contact lenses).Refer to except as described in this"Vision Services for "Vision Services for Pediatric Members"in the"Cost Pediatric Members"section Share Summary"section of this EOC for your • Low vision devices Allowance amount. • Replacement of lost,broken,or damaged contact • Eyeglass lenses when a Plan Provider puts the lenses lenses,eyeglass lenses,and frames into a frame ♦ we cover a clear balance lens when only one eye needs correction ♦ we cover tinted lenses when Medically Necessary EXC�USIOnS, Limitations, to treat macular degeneration or retinitis Coordination Of Benefits, and pigmentosa Reductions • Eyeglass frames when a Plan Provider puts two lenses (at least one of which must have refractive value)into Exclusions the frame • Contact lenses,fitting,and dispensing The items and services listed in this"Exclusions"section are excluded from coverage.These exclusions apply to We will not provide the Allowance if we have provided all Services that would otherwise be covered under this an Allowance toward(or otherwise covered)eyeglass EOC regardless of whether the services are within the lenses or frames within the previous 24 months. scope of a provider's license or certificate.These exclusions or limitations do not apply to Services that are Replacement lenses Medically Necessary to treat mental health conditions or substance use disorders that fall under any of the If you have a change in prescription of at least.50 diagnostic categories listed in the mental and behavioral diopter in one or both eyes at least 12 months after the disorders chapter of the most recent edition of the date we dispensed eyeglass lenses of the type described International Classification of Diseases or that are listed in this"Vision Services for Pediatric Members"section, in the most recent version of the Diagnostic and we will cover a replacement Regular Eyeglass Lens for Statistical Manual of Mental Disorders. the eye that had the .50 diopter change. Low vision devices Certain exams and Services Routine physical exams and other Services that are not Low vision devices(including fitting and dispensing)are Medically Necessary,such as when required(1)for not covered under this EOC. obtaining or maintaining employment or participation in For the following Services, refer to these employee programs,(2)for insurance,credentialing or sections licensing,(3)for travel,or(4)by court order or for parole or probation. • Routine vision screenings when performed as part of a routine physical exam(refer to"Preventive Chiropractic Services Services") Chiropractic Services and the Services of a chiropractor, • Services related to the eye or vision other than unless you have coverage for supplemental chiropractic Services covered under this"Vision Services for Services as described in an amendment to this EOC. Pediatric Members"section,such as outpatient surgery and outpatient prescription drugs,supplies, Cosmetic Services and supplements(refer to the applicable heading in Services that are intended primarily to change or this"Benefits"section) maintain your appearance,including cosmetic surgery (surgery that is performed to alter or reshape normal Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 67 structures of the body in order to improve appearance), Experimental or investigational Services except that this exclusion does not apply to any of the A Service is experimental or investigational if we,in following: consultation with the Medical Group,determine that one • Services covered under"Reconstructive Surgery"in of the following is true: the"Benefits"section • Generally accepted medical standards do not • The following devices covered under"Prosthetic and recognize it as safe and effective for treating the Orthotic Devices"in the`Benefits"section:testicular condition in question(even if it has been authorized implants implanted as part of a covered reconstructive by law for use in testing or other studies on human surgery,breast prostheses needed after removal of all patients) or part of a breast,and prostheses to replace all or part • It requires government approval that has not been of an external facial body part obtained when the Service is to be provided Custodial care This exclusion does not apply to any of the following: Assistance with activities of daily living(for example: . Experimental or investigational Services when an walking,getting in and out of bed,bathing,dressing, investigational application has been filed with the feeding,toileting,and taking medicine). federal Food and Drug Administration("FDA")and the manufacturer or other source makes the Services This exclusion does not apply to assistance with available to you or Kaiser Permanente through an activities of daily living that is provided as part of FDA-authorized procedure,except that we do not covered hospice, Skilled Nursing Facility,or hospital cover Services that are customarily provided by inpatient Services. research sponsors free of charge to enrollees in a Dental and orthodontic Services clinical trial or other investigational treatment protocol Dental and orthodontic Services such as X-rays, appliances,implants, Services provided by dentists or • Services covered under Services in Connection with orthodontists,dental Services following accidental injury a Clinical Trial"in the"Benefits"section to teeth,and dental Services resulting from medical treatment such as surgery on the jawbone and radiation Refer to the"Dispute Resolution"section for information treatment. about Independent Medical Review related to denied requests for experimental or investigational Services. This exclusion does not apply to the following Services: Hair loss or growth treatment • Services covered under"Dental and Orthodontic Items and services for the promotion,prevention or Services"in the"Benefits"section other treatment of hair loss or hair growth. • Service described under"Injury to Teeth"in the "Benefits"section Intermediate care • Pediatric dental Services described in a Pediatric Care in a licensed intermediate care facility.This Dental Services Amendment to this EOC,if any.If exclusion does not apply to Services covered under your plan has a Pediatric Dental Services "Durable Medical Equipment("DME")for Home Use," Amendment,it will be attached to this EOC,and it "Home Health Care,"and"Hospice Care"in the will be listed in the EOC's Table of Contents "Benefits"section. Disposable supplies Items and services that are not health care items Disposable supplies for home use,such as bandages, and services gauze,tape,antiseptics,dressings,Ace-type bandages, For example,we do not cover: and diapers,underpads,and other incontinence supplies. • Teaching manners and etiquette • Teaching and support services to develop planning This exclusion does not apply to disposable supplies skills such as daily activity planning and project or covered under"Durable Medical Equipment("DME") for Home Use,""Home Health Care,""Hospice Care," task planning "Ostomy and Urological Supplies,"and"Outpatient • Items and services for the purpose of increasing Prescription Drugs, Supplies,and Supplements"in the academic knowledge or skills "Benefits"section. • Teaching and support services to increase intelligence Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 68 • Academic coaching or tutoring for skills such as Routine foot care items and services grammar,math,and time management Routine foot care items and services that are not • Teaching you how to read,whether or not you have Medically Necessary. dyslexia Services not approved by the federal Food and • Educational testing Drug Administration • Teaching art,dance,horse riding,music,play or Drugs,supplements,tests,vaccines,devices,radioactive swimming materials,and any other Services that by law require • Teaching skills for employment or vocational federal Food and Drug Administration("FDA")approval purposes in order to be sold in the U.S.but are not approved by the FDA.This exclusion applies to Services provided • Vocational training or teaching vocational skills anywhere,even outside the U.S. • Professional growth courses • Training for a specific job or employment counseling This exclusion does not apply to any of the following: • Aquatic therapy and other water therapy,except that • Services covered under the"Emergency Services and this exclusion for aquatic therapy and other water Urgent Care"section that you receive outside the U.S. therapy does not apply to therapy Services that are • Experimental or investigational Services when an part of a physical therapy treatment plan and covered investigational application has been filed with the under"Home Health Care,""Hospice Services," FDA and the manufacturer or other source makes the "Hospital Inpatient Services,""Rehabilitative and Services available to you or Kaiser Permanente Habilitative Services,"or"Skilled Nursing Facility through an FDA-authorized procedure,except that we Care"in the"Benefits"section do not cover Services that are customarily provided by research sponsors free of charge to enrollees in a Items and services to correct refractive defects clinical trial or other investigational treatment of the eye protocol Items and services(such as eye surgery or contact lenses • Services covered under"Services in Connection with to reshape the eye)for the purpose of correcting a Clinical Trial"in the`Benefits"section refractive defects of the eye such as myopia,hyperopia, or astigmatism. • COVID-19 Services granted emergency use authorization by the FDA(COVID-19 laboratory Massage therapy tests,therapeutics,and immunizations must be Massage therapy,and services of massage therapists. prescribed or furnished by a licensed health care provider acting within their scope of practice and the Oral nutrition and weight loss aids standard of care) Outpatient oral nutrition, such as dietary supplements, Refer to the"Dispute Resolution"section for information herbal supplements,formulas,food,and weight loss aids. about Independent Medical Review related to denied This exclusion does not apply to any of the following: requests for experimental or investigational Services. • Amino acid—modified products and elemental dietary Services performed by unlicensed people enteral formula covered under"Outpatient Services that are performed safely and effectively by Prescription Drugs, Supplies,and Supplements"in people who do not require licenses or certificates by the the"Benefits"section state to provide health care services and where the • Enteral formula covered under"Prosthetic and Member's condition does not require that the services be Orthotic Devices"in the"Benefits"section provided by a licensed health care provider. Residential care This exclusion does not apply to covered Plan Doula Care in a facility where you stay overnight,except that services. this exclusion does not apply when the overnight stay is part of covered care in a hospital,a Skilled Nursing Services related to a noncovered Service Facility,or inpatient respite care covered in the"Hospice When a Service is not covered,all Services related to the Care"section. noncovered Service are excluded, except for Services we would otherwise cover to treat complications of the noncovered Service.For example,if you have a Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 69 noncovered cosmetic surgery,we would not cover Department of Managed Health Care.Those rules are Services you receive in preparation for the surgery or for incorporated into this EOC. follow-up care. If you later suffer a life-threatening complication such as a serious infection,this exclusion If both the other coverage and we cover the same would not apply and we would cover any Services that Service,the other coverage and we will see that up to we would otherwise cover to treat that complication. 100 percent of your covered medical expenses are paid for that Service.The coordination of benefits rules Surrogacy determine which coverage pays first,or is"primary,"and Services for anyone in connection with a Surrogacy which coverage pays second,or is"secondary."The Arrangement,except for otherwise-covered Services secondary coverage may reduce its payment to take into provided to a Member who is a surrogate.Refer to account payment by the primary coverage.You must "Surrogacy Arrangements"under"Reductions"in this give us any information we request to help us coordinate "Exclusions,Limitations,Coordination of Benefits,and benefits. Reductions"section for information about your obligations to us in connection with a Surrogacy If your coverage under this EOC is secondary,we may Arrangement,including your obligations to reimburse us be able to establish a Benefit Reserve Account for you. for any Services we cover and to provide information You may draw on the Benefit Reserve Account during a about anyone who may be financially responsible for calendar year to pay for your out-of-pocket expenses for Services the baby(or babies)receive. Services that are partially covered by either your other coverage or us during that calendar year.If you are Travel and lodging expenses entitled to a Benefit Reserve Account,we will provide Travel and lodging expenses,except as described in our you with detailed information about this account. Travel and Lodging Program Description.The Travel and Lodging Program Description is available online at If you have any questions about coordination of benefits, ko.or2/specialty-care/travel-reimbursements or by please call Member Services. calling Member Services. Medicare coverage If you have Medicare coverage,we will coordinate Limitations benefits with the Medicare coverage under Medicare We will make a good faith effort to provide or arrange rules.Medicare rules determine which coverage pays for covered Services within the remaining availability of first or is"primary,"and which coverage pays second, or is"secondary."You must give us any information we facilities or personnel in the event of unusual request to help us coordinate benefits.Please call circumstances that delay or render impractical the Member Services to find out which Medicare rules apply provision of Services under this EOC,such as a major to your situation,and how payment will be handled. disaster,epidemic,war,riot,civil insurrection,disability of a large share of personnel at a Plan Facility,complete or partial destruction of facilities,and labor dispute. Reductions Under these circumstances,if you have an Emergency Medical Condition,call 911 or go to the nearest Employer responsibility emergency department as described under"Emergency For any Services that the law requires an employer to Services"in the"Emergency Services and Urgent Care" provide,we will not pay the employer,and when we section,and we will provide coverage and cover any such Services we may recover the value of the reimbursement as described in that section. Services from the employer. Government agency responsibility Coordination of Benefits For any Services that the law requires be provided only The Services covered under this EOC are subject to by or received only from a government agency,we will coordination of benefits rules. not pay the government agency,and when we cover any such Services we may recover the value of the Services Coverage other than Medicare coverage from the government agency. If you have medical or dental coverage under another Injuries or illnesses alleged to be caused by plan that is subject to coordination of benefits,we will coordinate benefits with the other coverage under the other parties coordination of benefits rules of the California If you obtain a judgment or settlement from or on behalf of another party who allegedly caused an injury or illness Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 70 for which you received covered Services,you must If your estate,parent,guardian,or conservator asserts a reimburse us to the maximum extent allowed under claim against another party based on your injury or California Civil Code Section 3040.The reimbursement illness,your estate,parent,guardian,or conservator and due to us is not limited by or subject to the Plan Out-of- any settlement or judgment recovered by the estate, Pocket Maximum.Note: This"Injuries or illnesses parent,guardian,or conservator shall be subject to our alleged to be caused by other parties"section does not liens and other rights to the same extent as if you had affect your obligation to pay your Cost Share for these asserted the claim against the other party.We may assign Services. our rights to enforce our liens and other rights. To the extent permitted or required by law,we have the If you have Medicare,Medicare law may apply with option of becoming subrogated to all claims,causes of respect to Services covered by Medicare. action,and other rights you may have against another party or an insurer,government program,or other source Surrogacy Arrangements of coverage for monetary damages,compensation,or If you enter into a Surrogacy Arrangement and you or indemnification on account of the injury or illness any other payee are entitled to receive monetary allegedly caused by the other party.We will be so compensation under the Surrogacy Arrangement,you subrogated as of the time we mail or deliver a written must reimburse us for covered Services you receive notice of our exercise of this option to you or your related to conception,pregnancy,delivery,or postpartum attorney. care in connection with that arrangement("Surrogacy Health Services")to the maximum extent allowed under To secure our rights,we will have a lien and California Civil Code Section 3040.Note:This reimbursement rights to the proceeds of any judgment or "Surrogacy Arrangements"section does not affect your settlement you or we obtain(1)against another party, obligation to pay your Cost Share for these Services. and/or(2)from other types of coverage or sources of After you surrender a baby to the legal parents,you are payment that include but are not limited to: liability, not obligated to reimburse us for any Services that the uninsured motorist,underinsured motorist,personal baby receives(the legal parents are financially umbrella,workers' compensation,and/or personal injury responsible for any Services that the baby receives). coverages,any other types of medical payments and all other first party types of coverages or sources of By accepting Surrogacy Health Services,you payment.The proceeds of any judgment or settlement automatically assign to us your right to receive payments that you or we obtain and/or payments that you receive that are payable to you or any other payee under the shall first be applied to satisfy our lien,regardless of Surrogacy Arrangement,regardless of whether those whether you are made whole and regardless of whether payments are characterized as being for medical the total amount of the proceeds is less than the actual expenses.To secure our rights,we will also have a lien losses and damages you incurred. on those payments and on any escrow account,trust,or any other account that holds those payments. Those Within 30 days after submitting or filing a claim or legal payments(and amounts in any escrow account,trust,or action against another party,you must send written other account that holds those payments)shall first be notice of the claim or legal action to: applied to satisfy our lien. The assignment and our lien will not exceed the total amount of your obligation to us The Rawlings Company under the preceding paragraph. One Eden Parkway P.O.Box 2000 Within 30 days after entering into a Surrogacy LaGrange,KY 40031-2000 Arrangement,you must send written notice of the Fax: 502-214-1137 arrangement,including all of the following information: • Names,addresses,and phone numbers of the other In order for us to determine the existence of any rights parties to the arrangement we may have and to satisfy those rights,you must complete and send us all consents,releases, • Names,addresses,and phone numbers of any escrow authorizations,assignments,and other documents, agent or trustee including lien forms directing your attorney,the other • Names,addresses,and phone numbers of the intended party,and the other party's liability insurer to pay us parents and any other parties who are financially directly.You may not agree to waive,release,or reduce responsible for Services the baby(or babies)receive, our rights under this provision without our prior,written including names,addresses,and phone numbers for consent. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 71 any health insurance that will cover Services that the recover the value of any covered Services from the baby(or babies)receive following sources: • A signed copy of any contracts and other documents • From any source providing a Financial Benefit or explaining the arrangement from whom a Financial Benefit is due • Any other information we request in order to satisfy • From you,to the extent that a Financial Benefit is our rights provided or payable or would have been required to be provided or payable if you had diligently sought to You must send this information to: establish your rights to the Financial Benefit under any workers' compensation or employer's liability The Rawlings Company law One Eden Parkway P.O.Box 2000 LaGrange,KY 40031-2000 Post-Service Claims and Appeals Fax: 502-214-1137 You must complete and send us all consents,releases, This"Post-Service Claims and Appeals"section explains authorizations,lien forms,and other documents that are how to file a claim for payment or reimbursement for reasonably necessary for us to determine the existence of Services that you have already received.Please use the any rights we may have under this"Surrogacy procedures in this section in the following situations: Arrangements"section and to satisfy those rights.You • You have received Emergency Services,Post- may not agree to waive,release,or reduce our rights Stabilization Care,Out-of-Area Urgent Care, under this"Surrogacy Arrangements"section without emergency ambulance Services,or COVID-19 our prior,written consent. testing,therapeutics,or immunization Services from a Non—Plan Provider and you want us to pay for the If your estate,parent,guardian,or conservator asserts a Services claim against another party based on the Surrogacy • You have received Services from a Non—Plan Arrangement,your estate,parent,guardian,or Provider that we did not authorize(other than conservator and any settlement or judgment recovered by Emergency Services,Post-Stabilization Care,Out-of- the estate,parent,guardian,or conservator shall be Area Urgent Care,emergency ambulance Services,or subject to our liens and other rights to the same extent as COVID-19 testing,therapeutics,or immunization if you had asserted the claim against the other party.We Services)and you want us to pay for the Services may assign our rights to enforce our liens and other . You want to appeal a denial of an initial claim for rights. payment If you have questions about your obligations under this provision please call Member Services. Please follow the procedures under"Grievances"in the "Dispute Resolution"section in the following situations: U.S. Department of Veterans Affairs • You want us to cover Services that you have not yet For any Services for conditions arising from military received service that the law requires the Department of Veterans • You want us to continue to cover an ongoing course Affairs to provide,we will not pay the Department of of covered treatment Veterans Affairs,and when we cover any such Services • You want to appeal a written denial of a request for we may recover the value of the Services from the Department of Veterans Affairs. Services that require prior authorization(as described under"Medical Group authorization procedure for Workers' compensation or employer's liability certain referrals") benefits You may be eligible for payments or other benefits, Who May File including amounts received as a settlement(collectively referred to as"Financial Benefit"),under workers' The following people may file claims: compensation or employer's liability law.We will • You may file for yourself provide covered Services even if it is unclear whether you are entitled to a Financial Benefit,but we may • You can ask a friend,relative,attorney,or any other individual to file a claim for you by appointing them in writing as your authorized representative Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 72 • A parent may file for their child under age 18,except • In person from any Member Services office at a Plan that the child must appoint the parent as authorized Facility and from Plan Providers(for addresses,refer representative if the child has the legal right to control to our Provider Directory or call Member Services) release of information that is relevant to the claim • By calling Member Services at 1-800-464-4000(TTY • A court-appointed guardian may file for their ward, users call 711) except that the ward must appoint the court-appointed guardian as authorized representative if the ward has Other supporting information the legal right to control release of information that is When you file a claim,please include any information relevant to the claim that clarifies or supports your position.For example,if • A court-appointed conservator may file for their you have paid for Services,please include any bills and conservatee receipts that support your claim.To request that we pay a Non—Plan Provider for Services,include any bills from • An agent under a currently effective health care the Non—Plan Provider.If the Non—Plan Provider states proxy,to the extent provided under state law,may file that they will file the claim,you are still responsible for for their principal making sure that we receive everything we need to process the request for payment.When appropriate,we Authorized representatives must be appointed in writing will request medical records from Plan Providers on your using either our authorization form or some other form of behalf.If you tell us that you have consulted with a Non— written notification. The authorization form is available Plan Provider and are unable to provide copies of from the Member Services office at a Plan Facility,on relevant medical records,we will contact the provider to our website at kp.org,or by calling Member Services. request a copy of your relevant medical records.We will Your written authorization must accompany the claim. ask you to provide us a written authorization so that we You must pay the cost of anyone you hire to represent or can request your records. help you. If you want to review the information that we have Supporting Documents collected regarding your claim,you may request,and we will provide without charge,copies of all relevant You can request payment or reimbursement orally or in documents,records,and other information.You also writing.Your request for payment or reimbursement,and have the right to request any diagnosis and treatment any related documents that you give us,constitute your codes and their meanings that are the subject of your claim. claim.To make a request,you should follow the steps in the written notice sent to you about your claim. Claim forms for Emergency Services, Post- Stabilization Care, Out-of-Area Urgent Care, emergency ambulance Services, and COVID-19 Initial Claims Services To request that we pay a provider(or reimburse you)for To file a claim in writing for Emergency Services,Post- Services that you have already received,you must file a Stabilization Care,Out-of-Area Urgent Care,emergency claim.If you have any questions about the claims ambulance Services,or COVID-19 testing,therapeutics, process,please call Member Services. or immunization Services,please use our claim form. You can obtain a claim form in the following ways: Submitting a claim for Emergency Services, • By visiting our website at kp.org Post-Stabilization Care, Out-of-Area Urgent • In person from any Member Services office at a Plan Care, emergency ambulance Services, andCOVID-19 Services Facility and from Plan Providers(for addresses,refer to our Provider Directory or call Member Services) You may file a claim(request for payment/reimbursement): • By calling Member Services at 1-800-464-4000(TTY • By visiting kp•org,completing an electronic form users call 711) and uploading supporting documentation; Claims forms for all other Services • By mailing a paper form that can be obtained by To file a claim in writing for all other Services,you may visiting kp•org or calling Member Services;or use our grievance form.You can obtain this form in the • If you are unable access the electronic form(or obtain following ways: the paper form),by mailing the minimum amount of • By visiting our website at kp•org information we need to process your claim: Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 73 ♦ Member/Patient Name and Medical/Health Record decision period.We will send our written decision no Number later than 15 days after the date we receive the ♦ The date you received the Services additional information.If we do not receive the ♦ Where you received the Services necessary information within the timeframe specified in our letter,we will make our decision based on the ♦ Who provided the Services information we have within 15 days after the end of ♦ Why you think we should pay for the Services that timeframe ♦ A copy of the bill,your medical record(s)for these Services,and your receipt if you paid for the If we pay any part of your claim,we will subtract Services applicable Cost Share from any payment we make to you or the Non—Plan Provider.You are not responsible for Mailing address to submit your claim to Kaiser any amounts beyond your Cost Share for covered Permanente: Emergency Services.If we deny your claim(if we do not agree to pay for all the Services you requested other than Kaiser Permanente the applicable Cost Share),our letter will explain why Claims Administration-NCAL we denied your claim and how you can appeal. P.O.Box 12923 Oakland,CA 94604-2923 If you later receive any bills from the Non—Plan Provider for covered Services(other than bills for your Cost Please call Member Services if you need help filing your Share),please call Member Services for assistance. claim. Submitting a claim for all other Services Appeals If you have received any other Services from a Non—Plan Claims for Emergency Services, Post- Provider that we did not authorize,then as soon as Stabilization Care, Out-of-Area Urgent Care, possible after you receive the Services,you must file emergency ambulance Services, or COVID-19 your claim in one of the following ways: Services from a Non—Plan Provider • By delivering your claim to a Member Services office If we did not decide fully in your favor and you want to at a Plan Facility(for addresses,refer to our Provider appeal our decision,you may submit your appeal in one Directory or call Member Services) of the following ways: • By mailing your claim to a Member Services office at • By mailing your appeal to the Claims Department at a Plan Facility(for addresses,refer to our Provider the following address: Directory or call Member Services) Kaiser Foundation Health Plan,Inc. • By calling Member Services at 1-800-464-4000(TTY Special Services Unit users call 711) P.O.Box 23280 Oakland,CA 94623 • By visiting our website at kp.org • By calling Member Services at 1-800-464-4000(TTY Please call Member Services if you need help filing your users call 711) claim. By visiting our website at k1p.org After we receive your claim Claims for all other Services from a Non-Plan Provider that we did not authorize We will send you an acknowledgment letter within five days after we receive your claim. If we did not decide fully in your favor and you want to appeal our decision,you may submit your appeal in one After we review your claim,we will respond as follows: of the following ways: • If we have all the information we need we will send • By visiting our website at kp.org you a written decision within 30 days after we receive • By mailing your appeal to any Member Services your claim.We may extend the time for making a office at a Plan Facility(for addresses,refer to our decision for an additional 15 days if circumstances Provider Directory or call Member Services) beyond our control delay our decision,if we notify • In person at any Member Services office at a Plan you within 30 days after we receive your claim Facility or any Plan Provider(for addresses,refer to • If we need more information,we will ask you for the our Provider Directory or call Member Services) information before the end of the initial 30-day Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 74 • By calling Member Services at 1-800-464-4000(TTY We will send you a resolution letter within 30 days after users call 711) we receive your appeal.If we do not decide in your favor,our letter will explain why and describe your When you file an appeal,please include any information further appeal rights. that clarifies or supports your position.If you want to review the information that we have collected regarding your claim,you may request,and we will provide External Review without charge,copies of all relevant documents, You must exhaust our internal claims and appeals records,and other information.To make a request,you procedures before you may request external review should call Member Services. unless we have failed to comply with the claims and Additional information regarding claims for all appeals procedures described in this"Post-Service other Services from a Non—Plan Provider that Claims and Appeals"section.For information about the we did not authorize external review process,see"Independent Medical Review("IMR")"in the"Dispute Resolution"section. If we initially denied your request,you must file your appeal within 180 days after the date you received our denial letter.You may send us information including Additional Review comments,documents,and medical records that you believe support your claim. If we asked for additional You may have certain additional rights if you remain information and you did not provide it before we made dissatisfied after you have exhausted our internal claims our initial decision about your claim,then you may still and appeals procedure,and if applicable,external send us the additional information so that we may review: include it as part of our review of your appeal.Please • If your Group's benefit plan is subject to the send all additional information to the address or fax Employee Retirement Income Security Act mentioned in your denial letter. ("ERISA"),you may file a civil action under section 502(a)of ERISA. To understand these rights,you Also,you may give testimony in writing or by phone. should check with your Group or contact the Please send your written testimony to the address Employee Benefits Security Administration(part of mentioned in our acknowledgment letter,sent to you the U.S.Department of Labor)at 1-866-444-EBSA within five days after we receive your appeal.To arrange (1-866-444-3272) to give testimony by phone,you should call the phone . If your Group's benefit plan is not subject to ERISA number mentioned in our acknowledgment letter. (for example,most state or local government plans We will add the information that you provide through and church plans),you may have a right to request testimony or other means to your appeal file and we will review in state court review it without regard to whether this information was filed or considered in our initial decision regarding your request for Services.You have the right to request any Dispute Resolution diagnosis and treatment codes and their meanings that are the subject of your claim. We are committed to providing you with quality care and with a timely response to your concerns.You can discuss We will share any additional information that we collect your concerns with our Member Services representatives in the course of our review and we will send it to you.If at most Plan Facilities,or you can call Member Services. we believe that your request should not be granted, before we issue our final decision letter,we will also share with you any new or additional reasons for that Grievances decision.We will send you a letter explaining the additional information and/or reasons. Our letters about This"Grievances"section describes our grievance additional information and new or additional rationales procedure.A grievance is any expression of will tell you how you can respond to the information dissatisfaction expressed by you or your authorized provided if you choose to do so.If you do not respond representative through the grievance process.If you want before we must issue our final decision letter,that to make a claim for payment or reimbursement for decision will be based on the information in your appeal Services that you have already received from a Non—Plan file. Provider,please follow the procedure in the"Post- Service Claims and Appeals"section. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 75 Here are some examples of reasons you might file a • Your physician may act as your authorized grievance: representative with your verbal consent to request an • You are not satisfied with the quality of care you urgent grievance as described under"Urgent received procedure"in this"Grievances"section • You received a written denial of Services that require Authorized representatives must be appointed in writing prior authorization from the Medical Group and you using either our authorization form or some other form of want us to cover the Services written notification.The authorization form is available • You received a written denial for a second opinion or from the Member Services office at a Plan Facility,on we did not respond to your request for a second our website at kp.org,or by calling Member Services. opinion in an expeditious manner,as appropriate for Your written authorization must accompany the your condition grievance.You must pay the cost of anyone you hire to • Your treating physician has said that Services are not represent or help you. Medically Necessary and you want us to cover the How to file Services You can file a grievance orally or in writing.Your • You were told that Services are not covered and you grievance must explain your issue,such as the reasons believe that the Services should be covered why you believe a decision was in error or why you are • You want us to continue to cover an ongoing course dissatisfied with the Services you received. of covered treatment • You are dissatisfied with how long it took to get Standard Procedure Services,including getting an appointment,in the To file a grievance electronically,use the grievance form waiting room,or in the exam room on kp.org. • You want to report unsatisfactory behavior by To file a grievance orally,call Member Services toll free providers or staff,or dissatisfaction with the condition at 1-800-464-4000(TTY users call 711). of a facility • You believe you have faced discrimination from To file a grievance in writing,please use our grievance providers,staff,or Health Plan form,which is available on kp•org under"Forms& • We terminated your membership and you disagree Publications,"in person from any Member Services with that termination office at a Plan Facility,or from Plan Providers(for addresses,refer to our Provider Directory or call Member Who may file Services).You can submit the form in the following The following people may file a grievance: ways: You may file for yourself • In person at any Member Services office at a Plan •• You can ask a friend,relative,attorney,or any other Facility individual to file a grievance for you by appointing • By mail to any Member Services office at a Plan them in writing as your authorized representative Facility • A parent may file for their child under age 18,except You must file your grievance within 180 days following that the child must appoint the parent as authorized the incident or action that is subject to your representative if the child has the legal right to control dissatisfaction.You may send us information including release of information that is relevant to the grievance comments,documents,and medical records that you • A court-appointed guardian may file for their ward, believe support your grievance. except that the ward must appoint the court-appointed guardian as authorized representative if the ward has Please call Member Services if you need help filing a the legal right to control release of information that is grievance. relevant to the grievance • A court-appointed conservator may file for their If your grievance involves a request to obtain a non- conservatee formulary prescription drug,we will notify you of our decision within 72 hours.If we do not decide in your • An agent under a currently effective health care favor,our letter will explain why and describe your proxy,to the extent provided under state law,may file further appeal rights.For information on how to request for their principal a review by an independent review organization,see Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 76 "Independent Review Organization for Non-Formulary • Using the standard procedure would,in the opinion of Prescription Drug Requests"in this"Dispute Resolution" a physician with knowledge of your medical section. condition,subject you to severe pain that cannot be adequately managed without extending your course of For all other grievances,we will send you an covered treatment acknowledgment letter within five days after we receive . A physician with knowledge of your medical your grievance.We will send you a resolution letter condition determines that your grievance is urgent within 30 days after we receive your grievance.If you are requesting Services,and we do not decide in your • You have received Emergency Services but have not favor,our letter will explain why and describe your been discharged from a facility and your request further appeal rights. involves admissions,continued stay,or other health care Services If you want to review the information that we have • You are undergoing a current course of treatment collected regarding your grievance,you may request,and using a non-formulary prescription drug and your we will provide without charge,copies of all relevant grievance involves a request to refill a non-formulary documents,records,and other information. To make a prescription drug request,you should call Member Services. For most grievances that we respond to on an urgent Urgent procedure basis,we will give you oral notice of our decision as If you want us to consider your grievance on an urgent soon as your clinical condition requires,but no later than basis,please tell us that when you file your grievance. 72 hours after we received your grievance.We will send Note:Urgent is sometimes referred to as"exigent."If you a written confirmation of our decision within three exigent circumstances exist,your grievance may be days after we received your grievance. reviewed using the urgent procedure described in this section. If your grievance involves a request to obtain a non- formulary prescription drug and we respond to your You must file your urgent grievance in one of the request on an urgent basis,we will notify you of our following ways: decision within 24 hours of your request.For information • By calling our Expedited Review Unit toll free at on how to request a review by an independent review 1-888-987-7247(TTY users call 711) organization,see"Independent Review Organization for Non-Formulary Prescription Drug Requests"in this • By mailing a written request to: "Dispute Resolution"section. Kaiser Foundation Health Plan,Inc. Expedited Review Unit If we do not decide in your favor,our letter will explain P.O.Box 1809 why and describe your further appeal rights. Pleasanton,CA 94566 • By faxing a written request to our Expedited Review Note:If you have an issue that involves an imminent and Unit toll free at 1-888-987-2252 serious threat to your health(such as severe pain or potential loss of life,limb,or major bodily function),you • By visiting a Member Services office at a Plan can contact the California Department of Managed Facility(for addresses,refer to our Provider Directory Health Care at any time at 1-888-466-2219(TDD 1-877- or call Member Services) 688-9891)without first filing a grievance with us. • By completing the grievance form on our website at ky.om If you want to review the information that we have collected regarding your grievance,you may request,and We will decide whether your grievance is urgent or non- we will provide without charge,copies of all relevant urgent unless your attending health care provider tells us documents,records,and other information. To make a your grievance is urgent.If we determine that your request,you should call Member Services. grievance is not urgent,we will use the procedure described under"Standard procedure"in this Additional information regarding pre-service requests "Grievances"section.Generally,a grievance is urgent for Medically Necessary Services only if one of the following is true: You may give testimony in writing or by phone.Please • Using the standard procedure could seriously send your written testimony to the address mentioned in jeopardize your life,health,or ability to regain our acknowledgment letter.To arrange to give testimony maximum function Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 77 by phone,you should call the phone number mentioned decision letter,that decision will be based on the in our acknowledgment letter. information in your appeal file. We will add the information that you provide through Additional information about utilization review testimony or other means to your grievance file and we determination criteria for mental health Services or will consider it in our decision regarding your pre- substance use disorder treatment service request for Medically Necessary Services. Utilization review determination criteria and any education program materials for individuals making We will share any additional information that we collect authorization decisions related to mental health Services in the course of our review and we will send it to you.If or substance use disorder treatment are available at we believe that your request should not be granted, kp•or2 at no cost. before we issue our decision letter,we will also share with you any new or additional reasons for that decision. We will send you a letter explaining the additional Independent Review Organization for information and/or reasons. Our letters about additional Non-Formulary Prescription Drug information and new or additional rationales will tell you Requests how you can respond to the information provided if you choose to do so.If your grievance is urgent,the If you filed a grievance to obtain a non-formulary information will be provided to you orally and followed prescription drug and we did not decide in your favor, in writing.If you do not respond before we must issue you may submit a request for a review of your grievance our final decision letter,that decision will be based on by an independent review organization("IRO").You the information in your grievance file. must submit your request for IRO review within 180 days of the receipt of our decision letter. Additional information regarding appeals of written denials for Services that require prior authorization You must file your request for IRO review in one of the You must file your appeal within 180 days after the date following ways: you received our denial letter. • By calling our Expedited Review Unit toll free at 1-888-987-7247(TTY users call 711) You have the right to request any diagnosis and treatment codes and their meanings that are the subject of • By mailing a written request to: your appeal. Kaiser Foundation Health Plan,Inc. Expedited Review Unit Also,you may give testimony in writing or by phone. P.O.Box 1809 Please send your written testimony to the address Pleasanton,CA 94566 mentioned in our acknowledgment letter.To arrange to o By faxing a written request to our Expedited Review give testimony by phone,you should call the phone Unit toll free at 1-888-987-2252 number mentioned in our acknowledgment letter. . By visiting a Member Services office at a Plan We will add the information that you provide through Facility(for addresses,refer to our Provider Directory testimony or other means to your appeal file and we will or call Member Services) consider it in our decision regarding your appeal. • By completing the grievance form on our website at kp•or2 We will share any additional information that we collect in the course of our review and we will send it to you.If For urgent IRO reviews,we will forward to you the we believe that your request should not be granted, independent reviewer's decision within 24 hours.For before we issue our decision letter,we will also share non-urgent requests,we will forward the independent with you any new or additional reasons for that decision. reviewer's decision to you within 72 hours.If the We will send you a letter explaining the additional independent reviewer does not decide in your favor,you information and/or reasons. Our letters about additional may submit a complaint to the Department of Managed information and new or additional rationales will tell you Health Care,as described under"Department of how you can respond to the information provided if you Managed Health Care Complaints"in this"Dispute choose to do so.If your appeal is urgent,the information Resolution"section.You may also submit a request for will be provided to you orally and followed in writing.If an Independent Medical Review as described under you do not respond before we must issue our final "Independent Medical Review"in this"Dispute Resolution"section. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 78 Department of Managed Health Care from a provider who determined the Services to be Complaints Medically Necessary ♦ you have been seen by a Plan Provider for the The California Department of Managed Health Care is diagnosis or treatment of your medical condition responsible for regulating health care service plans.If . Your request for payment or Services has been you have a grievance against your health plan,you denied,modified,or delayed based in whole or in part should first telephone your health plan toll free at 1-800-464-4000 (TTY users call 711)and use your N a decision that the Services are not Medically Necessary health plan's grievance process before contacting the department.Utilizing this grievance procedure does not • You have filed a grievance and we have denied it or prohibit any potential legal rights or remedies that may we haven't made a decision about your grievance be available to you.If you need help with a grievance within 30 days(or three days for urgent grievances). involving an emergency,a grievance that has not been The DMHC may waive the requirement that you first satisfactorily resolved by your health plan,or a grievance file a grievance with us in extraordinary and that has remained unresolved for more than 30 days,you compelling cases,such as severe pain or potential loss may call the department for assistance.You may also be of life,limb,or major bodily function.If we have eligible for an Independent Medical Review(IMR).If denied your grievance,you must submit your request you are eligible for IMR,the IMR process will provide for an IMR within six months of the date of our an impartial review of medical decisions made by a written denial.However,the DMHC may accept your health plan related to the medical necessity of a proposed request after six months if they determine that service or treatment,coverage decisions for treatments circumstances prevented timely submission that are experimental or investigational in nature and payment disputes for emergency or urgent medical You may also qualify for IMR if the Service you services.The department also has a toll-free telephone requested has been denied on the basis that it is number(1-888-466-2219)and a TDD line experimental or investigational as described under (1-877-688-9891)for the hearing and speech "Experimental or investigational denials." impaired.The department's Internet website If the DMHC determines that your case is eligible for www.dmhC.Ca.gOV has complaint forms,IMR IMR,it will ask us to send your case to the DMHC's application forms and instructions online. IMR organization.The DMHC will promptly notify you of its decision after it receives the IMR organization's Independent Medical Review ("IMR") determination.If the decision is in your favor,we will contact you to arrange for the Service or payment. Except as described in this"Independent Medical Review("IMR")"section,you must exhaust our internal Experimental or investigational denials grievance procedure before you may request independent If we deny a Service because it is experimental or medical review unless we have failed to comply with the investigational,we will send you our written explanation grievance procedure described under"Grievances"in within three days after we received your request.We will this"Dispute Resolution"section.If you qualify,you or explain why we denied the Service and provide your authorized representative may have your issue additional dispute resolution options.Also,we will reviewed through the IMR process managed by the provide information about your right to request California Department of Managed Health Care Independent Medical Review if we had the following ("DMHC").The DMHC determines which cases qualify information when we made our decision: for IMR.This review is at no cost to you.If you decide . Your treating physician provided us a written not to request an IMR,you may give up the right to statement that you have a life-threatening or seriously pursue some legal actions against us. debilitating condition and that standard therapies have not been effective in improving your condition,or You may qualify for IMR if all of the following are true: that standard therapies would not be appropriate,or • One of these situations applies to you: that there is no more beneficial standard therapy we cover than the therapy being requested."Life- requesting you have a recommendation from a provider threatening"means diseases or conditions where the requesting Medically Necessary Services likelihood of death is high unless the course of the ♦ you have received Emergency Services, disease is interrupted,or diseases or conditions with emergency ambulance Services,or Urgent Care potentially fatal outcomes where the end point of clinical intervention is survival."Seriously Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 79 debilitating"means diseases or conditions that cause 502(a)of ERISA. To understand these rights,you major irreversible morbidity should check with your Group or contact the • If your treating physician is a Plan Physician,they Employee Benefits Security Administration(part of recommended a treatment,drug,device,procedure,or the U.S.Department of Labor)at 1-866-444-EBSA other therapy and certified that the requested therapy (1-866-444-3272) is likely to be more beneficial to you than any • If your Group's benefit plan is not subject to ERISA available standard therapies and included a statement (for example,most state or local government plans of the evidence relied upon by the Plan Physician in and church plans),you may have a right to request certifying their recommendation review in state court • You(or your Non—Plan Physician who is a licensed, and either a board-certified or board-eligible, Binding Arbitration physician qualified in the area of practice appropriate to treat your condition)requested a therapy that, For all claims subject to this`Binding Arbitration" based on two documents from the medical and section,both Claimants and Respondents give up the scientific evidence,as defined in California Health right to a jury or court trial and accept the use of binding and Safety Code Section 1370.4(d),is likely to be arbitration.Insofar as this"Binding Arbitration"section more beneficial for you than any available standard applies to claims asserted by Kaiser Permanente Parties, therapy. The physician's certification included a it shall apply retroactively to all unresolved claims that statement of the evidence relied upon by the accrued before the effective date of this EOC. Such physician in certifying their recommendation.We do retroactive application shall be binding only on the not cover the Services of the Non—Plan Provider Kaiser Permanente Parties. Note:You can request IMR for experimental or Scope of arbitration investigational denials at any time without first filing a Any dispute shall be submitted to binding arbitration if grievance with us. all of the following requirements are met: • The claim arises from or is related to an alleged Office of Civil Rights Complaints violation of any duty incident to or arising out of or relating to this EOC or a Member Party's relationship If you believe that you have been discriminated against to Kaiser Foundation Health Plan,Inc.("Health by a Plan Provider or by us because of your race,color, Plan"),including any claim for medical or hospital national origin,disability,age,sex(including sex malpractice(a claim that medical services or items stereotyping and gender identity),or religion,you may were unnecessary or unauthorized or were file a complaint with the Office of Civil Rights in the improperly,negligently,or incompetently rendered), United States Department of Health and Human Services for premises liability,or relating to the coverage for, ("OCR"). or delivery of,services or items,irrespective of the legal theories upon which the claim is asserted You may file your complaint with the OCR within 180 . The claim is asserted by one or more Member Parties days of when you believe the act of discrimination against one or more Kaiser Permanente Parties or by occurred.However,the OCR may accept your request one or more Kaiser Permanente Parties against one or after six months if they determine that circumstances more Member Parties prevented timely submission.For more information on the OCR and how to file a complaint with the OCR,go • Governing law does not prevent the use of binding to hhs.gov/civil-rights. arbitration to resolve the claim Members enrolled under this EOC thus give up their Additional Review right to a court or jury trial,and instead accept the use of binding arbitration except that the following types of You may have certain additional rights if you remain claims are not subject to binding arbitration: dissatisfied after you have exhausted our internal claims and appeals procedure,and if applicable,external • Claims within the jurisdiction of the Small Claims review: Court • If your Group's benefit plan is subject to the • Claims subject to a Medicare appeal procedure as Employee Retirement Income Security Act applicable to Kaiser Permanente Senior Advantage ("ERISA"),you may file a civil action under section Members Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 80 • Claims that cannot be subject to binding arbitration on the same incident,transaction,or related under governing law circumstances. As referred to in this"Binding Arbitration"section, Serving Demand for Arbitration "Member Parties"include: Health Plan,Kaiser Foundation Hospitals,The • A Member Permanente Medical Group,Inc., Southern California Permanente Medical Group,The Permanente Federation, • A Member's heir,relative,or personal representative LLC,and The Permanente Company,LLC,shall be • Any person claiming that a duty to them arises from a served with a Demand for Arbitration by mailing the Member's relationship to one or more Kaiser Demand for Arbitration addressed to that Respondent in Permanente Parties care of: Kaiser Foundation Health Plan,Inc. "Kaiser Permanente Parties"include: Legal Department,Professional&Public Liability • Kaiser Foundation Health Plan,Inc. 1 Kaiser Plaza, 191h Floor • Kaiser Foundation Hospitals Oakland,CA 94612 • The Permanente Medical Group,Inc. Service on that Respondent shall be deemed completed • Southern California Permanente Medical Group when received.All other Respondents,including individuals,must be served as required by the California • The Permanente Federation,LLC Code of Civil Procedure for a civil action. • The Permanente Company,LLC • Any Southern California Permanente Medical Group Filing fee or The Permanente Medical Group physician The Claimants shall pay a single,nonrefundable filing fee of$150 per arbitration payable to"Arbitration • Any individual or organization whose contract with Account"regardless of the number of claims asserted in any of the organizations identified above requires the Demand for Arbitration or the number of Claimants arbitration of claims brought by one or more Member or Respondents named in the Demand for Arbitration. Parties • Any employee or agent of any of the foregoing Any Claimant who claims extreme hardship may request that the Office of the Independent Administrator waive "Claimant"refers to a Member Party or a Kaiser the filing fee and the neutral arbitrator's fees and Permanente Party who asserts a claim as described expenses.A Claimant who seeks such waivers shall above."Respondent"refers to a Member Party or a complete the Fee Waiver Form and submit it to the Kaiser Permanente Party against whom a claim is Office of the Independent Administrator and asserted. simultaneously serve it upon the Respondents.The Fee Waiver Form sets forth the criteria for waiving fees and Rules of Procedure is available by calling Member Services. Arbitrations shall be conducted according to the Rules for Kaiser Permanente Member Arbitrations Overseen Number of arbitrators by the Office of the Independent Administrator("Rules The number of arbitrators may affect the Claimants' of Procedure")developed by the Office of the responsibility for paying the neutral arbitrator's fees and Independent Administrator in consultation with Kaiser expenses(see the Rules of Procedure). Permanente and the Arbitration Oversight Board. Copies of the Rules of Procedure may be obtained from Member If the Demand for Arbitration seeks total damages of Services. $200,000 or less,the dispute shall be heard and determined by one neutral arbitrator,unless the parties Initiating arbitration otherwise agree in writing after a dispute has arisen and a Claimants shall initiate arbitration by serving a Demand request for binding arbitration has been submitted that for Arbitration. The Demand for Arbitration shall include the arbitration shall be heard by two party arbitrators and the basis of the claim against the Respondents;the one neutral arbitrator.The neutral arbitrator shall not amount of damages the Claimants seek in the arbitration; have authority to award monetary damages that are the names,addresses,and phone numbers of the greater than$200,000. Claimants and their attorney,if any;and the names of all Respondents. Claimants shall include in the Demand for If the Demand for Arbitration seeks total damages of Arbitration all claims against Respondents that are based more than$200,000,the dispute shall be heard and Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 81 determined by one neutral arbitrator and two party future damages conformed to periodic payments,shall arbitrators,one jointly appointed by all Claimants and apply to any claims for professional negligence or any one jointly appointed by all Respondents.Parties who are other claims as permitted or required by law. entitled to select a party arbitrator may agree to waive this right.If all parties agree,these arbitrations will be Arbitrations shall be governed by this"Binding heard by a single neutral arbitrator. Arbitration"section, Section 2 of the Federal Arbitration Act,and the California Code of Civil Procedure Payment of arbitrators'fees and expenses provisions relating to arbitration that are in effect at the Health Plan will pay the fees and expenses of the neutral time the statute is applied,together with the Rules of arbitrator under certain conditions as set forth in the Procedure,to the extent not inconsistent with this Rules of Procedure.In all other arbitrations,the fees and "Binding Arbitration"section.In accord with the rule expenses of the neutral arbitrator shall be paid one-half that applies under Sections 3 and 4 of the Federal by the Claimants and one-half by the Respondents. Arbitration Act,the right to arbitration under this "Binding Arbitration"section shall not be denied,stayed, If the parties select party arbitrators,Claimants shall be or otherwise impeded because a dispute between a responsible for paying the fees and expenses of their Member Party and a Kaiser Permanente Party involves party arbitrator and Respondents shall be responsible for both arbitrable and nonarbitrable claims or because one paying the fees and expenses of their party arbitrator. or more parties to the arbitration is also a party to a pending court action with another party that arises out of Costs the same or related transactions and presents a possibility Except for the aforementioned fees and expenses of the of conflicting rulings or findings. neutral arbitrator,and except as otherwise mandated by laws that apply to arbitrations under this"Binding Arbitration"section,each party shall bear the party's Termination of Membership own attorneys' fees,witness fees,and other expenses incurred in prosecuting or defending against a claim Your Group is required to inform the Subscriber of the regardless of the nature of the claim or outcome of the date your membership terminates.Your membership arbitration. termination date is the first day you are not covered(for General provisions example,if your termination date is January 1,2026, your last minute of coverage was at 11:59 p.m.on A claim shall be waived and forever barred if(1)on the December 31,2025).When a Subscriber's membership date the Demand for Arbitration of the claim is served, ends,the memberships of any Dependents end at the the claim,if asserted in a civil action,would be barred as same time.You will be billed as a non-Member for any to the Respondent served by the applicable statute of Services you receive after your membership terminates. limitations,(2)Claimants fail to pursue the arbitration Health Plan and Plan Providers have no further liability claim in accord with the Rules of Procedure with or responsibility under this EOC after your membership reasonable diligence,or(3)the arbitration hearing is not terminates,except as provided under"Payments after commenced within five years after the earlier of(a)the Termination"in this"Termination of Membership" date the Demand for Arbitration was served in accord section. with the procedures prescribed herein,or(b)the date of filing of a civil action based upon the same incident, transaction,or related circumstances involved in the Termination Due to Loss of Eligibility claim.A claim may be dismissed on other grounds by the neutral arbitrator based on a showing of a good cause.If If you no longer meet the eligibility requirements a party fails to attend the arbitration hearing after being described under"Who Is Eligible"in the"Premiums, given due notice thereof,the neutral arbitrator may Eligibility,and Enrollment"section,your Group will proceed to determine the controversy in the party's notify you of the date that your membership will end. absence. Your membership termination date is the first day you are not covered.For example,if your termination date is The California Medical Injury Compensation Reform January 1,2026,your last minute of coverage was at Act of 1975 (including any amendments thereto), 11:59 p.m. on December 31,2025. including sections establishing the right to introduce evidence of any insurance or disability benefit payment to the patient,the limitation on recovery for non- economic losses,and the right to have an award for Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 82 Termination of Agreement Payments after Termination If your Group's Agreement with us terminates for any If we terminate your membership for cause or for reason,your membership ends on the same date.Your nonpayment,we will: Group is required to notify Subscribers in writing if its • Refund any amounts we owe your Group for Agreement with us terminates. Premiums paid after the termination date • Pay you any amounts we have determined that we Termination for Cause owe you for claims during your membership in accord with the"Emergency Services and Urgent If you intentionally commit fraud in connection with Care"and"Dispute Resolution"sections membership,Health Plan,or a Plan Provider,we may terminate your membership by sending written notice to We will deduct any amounts you owe Health Plan or the Subscriber;termination will be effective 30 days Plan Providers from any payment we make to you. from the date we send the notice. Some examples of fraud include: • Misrepresenting eligibility information about you or a State Review of Membership Dependent Termination • Presenting an invalid prescription or physician order If you believe that we have terminated your membership • Misusing a Kaiser Permanente ID card(or letting because of your ill health or your need for care,you may someone else use it) request a review of the termination by the California • Giving us incorrect or incomplete material Department of Managed Health Care(please see information.For example,you have entered into a "Department of Managed Health Care Complaints"in Surrogacy Arrangement and you fail to send us the the"Dispute Resolution"section). information we require under"Surrogacy Arrangements"under"Reductions"in the "Exclusions,Limitations,Coordination of Benefits, Continuation Of Membership and Reductions"section • Failing to notify us of changes in family status or If your membership under this EOC ends,you may be Medicare coverage that may affect your eligibility or eligible to continue Health Plan membership without a benefits break in coverage.You may be able to continue Group coverage under this EOC as described under If we terminate your membership for cause,you will not "Continuation of Group Coverage."Also,you may be be allowed to enroll in Health Plan in the future.We may able to continue membership under an individual plan as also report criminal fraud and other illegal acts to the described under"Continuation of Coverage under an authorities for prosecution. Individual Plan."If at any time you become entitled to continuation of Group coverage,please examine your coverage options carefully before declining this Termination of a Product or all Products coverage.Individual plan premiums and coverage will be different from the premiums and coverage under your We may terminate a particular product or all products Group plan. offered in the group market as permitted or required by law.If we discontinue offering a particular product in the group market,we will terminate just the particular Continuation of Group Coverage product by sending you written notice at least 90 days before the product terminates.If we discontinue offering COBRA all products in the group market,we may terminate your You may be able to continue your coverage under this Group's Agreement by sending you written notice at EOC for a limited time after you would otherwise lose least 180 days before the Agreement terminates. eligibility,if required by the federal Consolidated Omnibus Budget Reconciliation Act("COBRA"). COBRA applies to most employees(and most of their covered family Dependents)of most employers with 20 or more employees. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 83 If your Group is subject to COBRA and you are eligible must send us the Premium payment by the due date on for COBRA coverage,in order to enroll you must submit the bill to be enrolled in Cal-COBRA. a COBRA election form to your Group within the COBRA election period.Please ask your Group for After that first payment,your Premium payment for the details about COBRA coverage,such as how to elect upcoming coverage month is due on the last day of the coverage,how much you must pay for coverage,when preceding month. The Premiums will not exceed 110 coverage and Premiums may change,and where to send percent of the applicable Premiums charged to a your Premium payments. similarly situated individual under the Group benefit plan except that Premiums for disabled individuals after 18 If you enroll in COBRA and exhaust the time limit for months of COBRA coverage will not exceed 150 percent COBRA coverage,you may be able to continue Group instead of 110 percent.Returned checks or insufficient coverage under state law as described under"Cal- funds on electronic payments may be subject to a fee. COBRA"in this"Continuation of Group Coverage" section. If you have selected Ancillary Coverage provided under any other program,the Premium for that Ancillary Cal-COBRA Coverage will be billed together with required Premiums If you are eligible for coverage under the California for coverage under this EOC.Full Premiums will then Continuation Benefits Replacement Act("Cal- also include Premium for Ancillary Coverage. This COBRA"),you can continue coverage as described in means if you do not pay the Full Premiums owed by the this"Cal-COBRA"section if you apply for coverage in due date,we may terminate your membership under this compliance with Cal-COBRA law and pay applicable EOC and any Ancillary Coverage,as described in the Premiums. "Termination for nonpayment of Cal-COBRA Premiums"section. Eligibility and effective date of coverage for Cal- COBRA after COBRA Changes to Cal-COBRA coverage and Premiums If your group is subject to COBRA and your COBRA Your Cal-COBRA coverage is the same as for any coverage ends,you may be able to continue Group similarly situated individual under your Group's coverage effective the date your COBRA coverage ends Agreement,and your Cal-COBRA coverage and if all of the following are true: Premiums will change at the same time that coverage or Premiums change in your Group's Agreement.Your • Your effective date of COBRA coverage was on or Group's coverage and Premiums will change on the after January 1,2003 renewal date of its Agreement(January 1),and may also • You have exhausted the time limit for COBRA change at other times if your Group's Agreement is coverage and that time limit was 18 or 29 months amended.Your monthly invoice will reflect the current • You do not have Medicare Premiums that are due for Cal-COBRA coverage, including any changes.For example,if your Group You must request an enrollment application by calling makes a change that affects Premiums retroactively,the Member Services within 60 days of the date of when amount we bill you will be adjusted to reflect the your COBRA coverage ends. retroactive adjustment in Premiums.Your Group can tell you whether this EOC is still in effect and give you a Cal-COBRA enrollment and Premiums current one if this EOC has expired or been amended. Within 10 days of your request for an enrollment You can also request one from Member Services. application,we will send you our application,which will include Premium and billing information.You must Cal-COBRA open enrollment or termination of another return your completed application within 63 days of the health plan date of our termination letter or of your membership If you previously elected Cal-COBRA coverage through termination date(whichever date is later). another health plan available through your Group,you may be eligible to enroll in Kaiser Permanente during If we approve your enrollment application,we will send your Group's annual open enrollment period,or if your you billing information within 30 days after we receive Group terminates its agreement with the health plan you your application.You must pay Full Premiums within 45 are enrolled in.You will be entitled to Cal-COBRA days after the date we issue the bill. The first Premium coverage only for the remainder,if any,of the coverage payment will include coverage from your Cal-COBRA period prescribed by Cal-COBRA.Please ask your effective date through our current billing cycle.You Group for information about health plans available to Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 84 you either at open enrollment or if your Group terminates when the memberships of the Subscriber and all a health plan's agreement. Dependents will terminate if the required Premiums are not paid.Your coverage will continue during this grace In order for you to switch from another health plan and period.If we do not receive Full Premium payment by continue your Cal-COBRA coverage with us,we must the end of the grace period,we will mail a termination receive your enrollment application during your Group's notice to the Subscriber's address of record.After open enrollment period,or within 63 days of receiving termination of your membership for nonpayment of Cal- the Group's termination notice described under"Group COBRA Premiums,you are still responsible for paying responsibilities."To request an application,please call all amounts due,including Premiums for the grace Member Services.We will send you our enrollment period. application and you must return your completed application before open enrollment ends or within 63 Reinstatement of your membership after termination days of receiving the termination notice described under for nonpayment of Cal-COBRA Premiums "Group responsibilities."If we approve your enrollment If we terminate your membership for nonpayment of application,we will send you billing information within Premiums,we will permit reinstatement of your 30 days after we receive your application.You must pay membership three times during any 12-month period if the bill within 45 days after the date we issue the bill. we receive the amounts owed within 15 days of the date You must send us the Premium payment by the due date of the Termination Notice.We will not reinstate your on the bill to be enrolled in Cal-COBRA_ membership if you do not obtain reinstatement of your terminated membership within the required 15 days,or if How you may terminate your Cal-COBRA coverage we terminate your membership for nonpayment of You may terminate your Cal-COBRA coverage by Premiums more than three times in a 12-month period. sending written notice,signed by the Subscriber,to the address below.Your membership will terminate at 11:59 Termination of Cal-COBRA coverage p.m.on the last day of the month in which we receive Cal-COBRA coverage continues only upon payment of your notice.Also,you must include with your notice all applicable monthly Premiums to us at the time we amounts payable related to your Cal-COBRA coverage, specify,and terminates on the earliest of- including Premiums,for the period prior to your . The date your Group's Agreement with us terminates termination date. (you may still be eligible for Cal-COBRA through Kaiser Foundation Health Plan,Inc. another Group health plan) California Service Center • The date you get Medicare P.O.Box 23127 • The date your coverage begins under any other group San Diego,CA 92193-3127 health plan that does not contain any exclusion or limitation with respect to any pre-existing condition Termination for nonpayment of Cal-COBRA Premiums you may have(or that does contain such an exclusion If you do not pay Full Premiums by the due date,we may or limitation,but it has been satisfied) terminate your membership as described in this • The date that is 36 months after your original "Termination for nonpayment of Cal-COBRA COBRA effective date(under this or any other plan) Premiums"section.If you intend to terminate your membership,be sure to notify us as described under • The date your membership is terminated for "How you may terminate your Cal-COBRA coverage"in nonpayment of Premiums as described under this"Cal-COBRA"section,as you will be responsible "Termination for nonpayment of Cal-COBRA for any Premiums billed to you unless you let us know Premiums"in this"Continuation of Membership" before the first of the coverage month that you want us to section terminate your coverage. Note:If the Social Security Administration determined Your Premium payment for the upcoming coverage that you were disabled at any time during the first 60 month is due on the last day of the preceding month.If days of COBRA coverage,you must notify your Group we do not receive Full Premium payment by the due within 60 days of receiving the determination from date,we will send a notice of nonreceipt of payment to Social Security.Also,if Social Security issues a final the Subscriber's address of record.You will have a 30- determination that you are no longer disabled in the 35th day grace period to pay the required Premiums before we or 36th month of Group continuation coverage,your Cal- terminate your Cal-COBRA coverage for nonpayment. COBRA coverage will end the later of. (1)expiration of The notice will state when the grace period begins and 36 months after your original COBRA effective date,or (2)the first day of the first month following 31 days after Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 85 Social Security issued its final determination.You must Your coverage will be subject to the terms of this EOC, notify us within 30 days after you receive Social including Cost Share,but we will not cover Services for Security's final determination that you are no longer any condition other than your totally disabling condition. disabled. For Subscribers and adult Dependents,"Totally Group responsibilities Disabled"means that,in the judgment of a Medical If your Group's agreement with a health plan is Group physician,an illness or injury is expected to result terminated,your Group is required to provide written in death or has lasted or is expected to last for a notice at least 30 days before the termination date to the continuous period of at least 12 months,and makes the persons whose Cal-COBRA coverage is terminating. person unable to engage in any employment or This notice must inform Cal-COBRA beneficiaries that occupation,even with training,education,and they can continue Cal-COBRA coverage by enrolling in experience. any health benefit plan offered by your Group.It must also include information about benefits,premiums, For Dependent children,"Totally Disabled"means that, payment instructions,and enrollment forms(including in the judgment of a Medical Group physician,an illness instructions on how to continue Cal-COBRA coverage or injury is expected to result in death or has lasted or is under the new health plan).Your Group is required to expected to last for a continuous period of at least 12 send this information to the person's last known address, months and the illness or injury makes the child unable as provided by the prior health plan.Health Plan is not to substantially engage in any of the normal activities of obligated to provide this information to qualified children in good health of like age. beneficiaries if your Group fails to provide the notice. These persons will be entitled to Cal-COBRA coverage To request continuation of coverage for your disabling only for the remainder,if any,of the coverage period condition,you must call Member Services within 30 prescribed by Cal-COBRA. days after your Group's Agreement with us terminates. USERRA If you are called to active duty in the uniformed services, Continuation of Coverage under an you may be able to continue your coverage under this Individual Plan EOC for a limited time after you would otherwise lose eligibility,if required by the federal Uniformed Services If you want to remain a Health Plan member when your Employment and Reemployment Rights Act Group coverage ends,you might be able to enroll in one ("USERRA").You must submit a USERRA election of our Kaiser Permanente for Individuals and Families form to your Group within 60 days after your call to plans. The premiums and coverage under our individual active duty.Please contact your Group to find out how to plan coverage are different from those under this EOC. elect USERRA coverage and how much you must pay your Group. If you want your individual plan coverage to be effective when your Group coverage ends,you must submit your Coverage for a Disabling Condition application within the special enrollment period for If you became Totally Disabled while you were a enrolling in an individual plan due to loss of other Member under your Group's Agreement with us and coverage.Otherwise,you will have to wait until the next while the Subscriber was employed by your Group,and annual open enrollment period. your Group's Agreement with us terminates and is not renewed,we will cover Services for your totally To request an application to enroll directly with us, disabling condition until the earliest of the following please go to buyky.org or call Member Services.For events occurs: information about plans that are available through Covered California,see"Covered California"below. • 12 months have elapsed since your Group's Agreement with us terminated Covered California • You are no longer Totally Disabled U.S.citizens or legal residents of the U.S.can buy health • Your Group's Agreement with us is replaced by care coverage from Covered California. This is another group health plan without limitation as to the California's health benefit exchange("the Exchange"). disabling condition You may apply for help to pay for premiums and copayments but only if you buy coverage through Covered California.This financial assistance may be available if you meet certain income guidelines. To learn more about coverage that is available through Covered Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 86 California,visit CoveredCA.com or call Covered Assignment California at 1-800-300-1506(TTY users call 711). You may not assign this EOC or any of the rights, interests,claims for money due,benefits,or obligations Miscellaneous Provisions ■ hereunder without our prior written consent. Attorney and Advocate Fees and Administration of Agreement Expenses We may adopt reasonable policies,procedures,and In any dispute between a Member and Health Plan,the interpretations to promote orderly and efficient Medical Group,or Kaiser Foundation Hospitals,each administration of your Group's Agreement, including this EOC. party will bear its own fees and expenses,including attorneys' fees,advocates' fees,and other expenses. Advance Directives Claims Review Authority The California Health Care Decision Law offers several We are responsible for determining whether you are ways for you to control the kind of health care you will entitled to benefits under this EOC and we have the receive if you become very ill or unconscious,including the following: discretionary authority to review and evaluate claims that arise under this EOC.We conduct this evaluation • A Power of Attorney for Health Care lets you name independently by interpreting the provisions of this EOC. someone to make health care decisions for you when We may use medical experts to help us review claims.If you cannot speak for yourself.It also lets you write coverage under this EOC is subject to the Employee down your own views on life support and other Retirement Income Security Act("ERISA")claims treatments procedure regulation(29 CFR 2560.503-1),then we are a • Individual health care instructions let you express "named claims fiduciary"to review claims under this your wishes about receiving life support and other EOC. treatment.You can express these wishes to your doctor and have them documented in your medical chart,or you can put them in writing and have that EOC Binding o n Members included in your medical chart By electing coverage or accepting benefits under this EOC,all Members legally capable of contracting,and To learn more about advance directives,including how the legal representatives of all Members incapable of to obtain forms and instructions,contact the Member contracting,agree to all provisions of this EOC. Services office at a Plan Facility.For more information about advance directives,refer to our website at kp.org or call Member Services. ERISA Notices This"ERISA Notices"section applies only if your Amendment of Agreement Group's health benefit plan is subject to the Employee Retirement Income Security Act("ERISA").We provide Your Group's Agreement with us will change these notices to assist ERISA-covered groups in periodically.If these changes affect this EOC,your complying with ERISA.Coverage for Services described Group is required to inform you in accord with in these notices is subject to all provisions of this EOC. applicable law and your Group's Agreement. Newborns' and Mothers' Health Protection Act Applications and Statements Group health plans and health insurance issuers generally may not,under Federal law,restrict benefits for any You must complete any applications,forms,or hospital length of stay in connection with childbirth for statements that we request in our normal course of the birthing person or newborn child to less than 48 business or as specified in this EOC. hours following a vaginal delivery,or less than 96 hours following a cesarean section.However,Federal law generally does not prohibit the birthing person's or newborn's attending provider,after consulting with the Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 87 birthing person,from discharging the birthing person or Subscriber's address,they should call Member Services their newborn earlier than 48 hours(or 96 hours as to discuss alternate delivery options. applicable).In any case,plans and issuers may not,under Federal law,require that a provider obtain authorization Note:When we tell your Group about changes to this from the plan or the insurance issuer for prescribing a EOC or provide your Group other information that length of stay not in excess of 48 hours(or 96 hours). affects you,your Group is required to notify the Subscriber within 30 days(or five days if we terminate Women's Health and Cancer Rights Act your Group's Agreement)after receiving the information If you have had or are going to have a mastectomy,you from us.The Subscriber is also responsible for notifying may be entitled to certain benefits under the Women's Group of any change in contact information. Health and Cancer Rights Act.For individuals receiving mastectomy-related benefits,coverage will be provided in a manner determined in consultation with the Overpayment Recovery attending physician and the patient,for all stages of We may recover any overpayment we make for Services reconstruction of the breast on which the mastectomy was performed,surgery and reconstruction of the other from anyone who receives such an overpayment or from breast to produce a symmetrical appearance,prostheses, any person or organization obligated to pay for the and treatment of physical complications of the Services. mastectomy,including lymphedemas.These benefits will be provided subject to the same Cost Share applicable to Privacy Practices other medical and surgical benefits provided under this plan. Kaiser Permanente will protect the privacy of your protected health information. We also Governing Law require contracting providers to protect your protected health information. Your protected Except as preempted by federal law,this EOC will be health information is individually-identifiable governed in accord with California law and any provision that is required to be in this EOC by state or information (oral, written, or electronic) about federal law shall bind Members and Health Plan whether your health, health care services you receive, or or not set forth in this EOC. payment for your health care. You may generally see and receive copies of your Group and Members Not Our Agents protected health information, correct or update your protected health information, and ask us Neither your Group nor any Member is the agent or for an accounting of certain disclosures of your representative of Health Plan. protected health information. No Waiver You can request delivery of confidential Our failure to enforce any provision of this EOC will not communication to a location other than your constitute a waiver of that or any other provision,or usual address or by a means of delivery other impair our right thereafter to require your strict than the usual means. You may request performance of any provision. confidential communication by completing a confidential communication request form, Notices Regarding Your Coverage which is available on kmom under"Request for confidential communications forms."Your Our notices to you will be sent to the most recent address request for confidential communication will be we have for the Subscriber.The Subscriber is responsible valid until you submit a revocation or a new for notifying us of any change in address. Subscribers w request for confidential communication. If you who move should call Member Services as soon as possible to give us their new address.If a Member does have questions,please call Member Services. not reside with the Subscriber,or needs to have confidential information sent to an address other than the We may use or disclose your protected health information for treatment, health research, Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 88 payment, and health care operations purposes, Helpful Information such as measuring the quality of Services. We are sometimes required by law to give How to Obtain this EOC in Other protected health information to others, such as Formats government agencies or in judicial actions. In addition,protected health information is shared You can request a copy of this EOC in an alternate format(Braille,audio,electronic text file,or large print) with your Group only with your authorization by calling Member Services. or as otherwise permitted by law. We will not use or disclose your protected Provider Directory health information for any other purpose Refer to the Provider Directory for your Home Region without your(or your representative's) written for the following information: authorization, except as described in our Notice . A list of Plan Physicians Of Privacy Practices (see below). Giving us . The location of Plan Facilities and the types of authorization is at your discretion. covered Services that are available from each facility • Hours of operation This is only a brief summary of some of our Appointments and advice phone numbers key privacy practices. OUR NOTICE OF PRIVACYPRACTICES, WHICH PROVIDES This directory is available on our website at ku.ora.To ADDITIONAL INFORMATION ABOUT obtain a printed copy,call Member Services. The OUR PRIVACY PRACTICES AND YOUR directory is updated periodically.The availability of Plan RIGHTS REGARDING YOUR PROTECTED Physicians and Plan Facilities may change.If you have HEALTH INFORMATION, IS AVAILABLE questions,please call Member Services. AND WILL BE FURNISHED TO YOU UPON REQUEST. To request a copy, please Online Tools and Resources call Member Services. You can also find the Here are some tools and resources available on our notice at a Plan Facility or on our website at website at kp.ore: kp.om. • How to use our Services and make appointments • Tools you can use to email your doctor's office,view Public Policy Participation test results,refill prescriptions,and schedule routine The Kaiser Foundation Health Plan,Inc.,Board of appointments Directors establishes public policy for Health Plan.A list • Health education resources of the Board of Directors is available on our website at • Preventive care guidelines about.kp.ora or from Member Services.If you would . Member rights and responsibilities like to provide input about Health Plan public policy for consideration by the Board,please send written You can also access tools and resources using the KP comments to: app on your smartphone or other mobile device. Kaiser Foundation Health Plan,Inc. Office of Board and Corporate Governance Services Document Delivery Preferences One Kaiser Plaza, 19th Floor Oakland,CA 94612 Many Health Plan documents are available electronically,such as bills,statements,and notices.If you prefer to get documents in electronic format,go to ky.om or call Member Services.You can change delivery preference at any time. To get a copy of a specific Heath Plan document in printed format,call Member Services. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 89 How to Reach Us Call 1-800-464-4000(TTY users call 711) Appointments 24 hours a day,seven days a week(closed If you need to make an appointment,please call us or holidays) visit our website: Website ku.ora Call The appointment phone number at a Plan Away from Home Travel Line Facility(for phone numbers,refer to our Provider Directory or call Member Services) If you have questions about your coverage when you are away from home: Website ky.ore for routine(non-urgent)appointments with your personal Plan Physician or another Call 1-951-268-3900 Primary Care Physician 24 hours a day,seven days a week(closed holidays) Not sure what kind of care you need? Website kn.org/travel If you need advice on whether to get medical care,or how and when to get care,we have licensed health care Authorization for Post-Stabilization Care professionals available to assist you by phone 24 hours a day,seven days a week: To request prior authorization for Post-Stabilization Care as described under"Emergency Services"in the Call The appointment or advice phone number at a "Emergency Services and Urgent Care"section: Plan Facility(for phone numbers,refer to our Provider Directory or call Member Services) Call 1-800-225-8883 or the notification phone number on your Kaiser Permanente ID card Member Services (TTY users call 711) If you have questions or concerns about your coverage, 24 hours a day,seven days a week how to obtain Services,or the facilities where you can receive care,you can reach us in the following ways: Help with claim forms for Emergency Services, Call 1-800-464-4000(English and more than 150 Post-Stabilization Care, Out-of-Area Urgent languages using interpreter services) Care, emergency ambulance Services, and 1-800-788-0616(Spanish) COVID-19 Services 1-800-757-7585(Chinese dialects) If you need a claim form to request payment or TTY users call 711 reimbursement for Services described in the"Emergency Services and Urgent Care"section under"Ambulance 24 hours a day,seven days a week(closed Services"in the"Benefits"section,or COVID-19 holidays) Services under"Outpatient Imaging,Laboratory,and Visit Member Services office at a Plan Facility(for Other Diagnostic and Treatment Services,""Outpatient addresses,refer to our Provider Directory or Prescription Drugs, Supplies,and Supplements,"and call Member Services) "Preventive Services"in the"Benefits"section,or if you need help completing the form,you can reach us by Write Member Services office at a Plan Facility(for calling or by visiting our website. addresses,refer to our Provider Directory or Call 1-800-464-4000(TTY users call 711) call Member Services) Website kU.ore 24 hours a day,seven days a week(closed holidays) Estimates, bills, and statements Website ku.or2 For the following concerns,please call us at the number below: Submitting claims for Emergency Services, • If you have questions about a bill Post-Stabilization Care, Out-of-Area Urgent Care, emergency ambulance Services, and • To find out how much you have paid toward your COVID-19 Services Plan Deductible(if applicable)or Plan Out-of-Pocket If you need to submit a completed claim form for Maximum Services described in the"Emergency Services and • To get an estimate of Charges for Services that are Urgent Care"section,under"Ambulance Services"in subject to the Plan Deductible(if applicable) the"Benefits"section,or COVID-19 Services under "Outpatient Imaging,Laboratory,and Other Diagnostic Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 90 and Treatment Services,""Outpatient Prescription • If you receive Services from Non—Plan Providers that Drugs,Supplies,and Supplements,"and"Preventive we did not authorize(other than Emergency Services, Services"in the"Benefits"section,or if you need to Post-Stabilization Care,Out-of-Area Urgent Care, submit other information that we request about your emergency ambulance Services,or COVID-19 claim,send it to our Claims Department: Services)and you want us to pay for the care,you Write Kaiser Permanente must submit a grievance(refer to"Grievances"in the Claims Administration-NCAL "Dispute Resolution"section) P.O.Box 12923 • If you have coverage with another plan or with Oakland,CA 94604-2923 Medicare,we will coordinate benefits with the other coverage(refer to"Coordination of Benefits"in the Text telephone access ("TTY") "Exclusions,Limitations,Coordination of Benefits, If you use a text telephone device("TTY,"also known as and Reductions"section) "TDD")to communicate by phone,you can use the • In some situations,you or another party may be California Relay Service by calling 711. responsible for reimbursing us for covered Services (refer to"Reductions"in the"Exclusions, Interpreter services Limitations,Coordination of Benefits,and If you need interpreter services when you call us or when Reductions"section) you get covered Services,please let us know.Interpreter . You must pay the full price for noncovered Services services,including sign language,are available during all business hours at no cost to you.For more information on the interpreter services we offer,please call Member Services. Payment Responsibility This"Payment Responsibility"section briefly explains who is responsible for payments related to the health care coverage described in this EOC.Payment responsibility is more fully described in other sections of the EOC as described below: • Your Group is responsible for paying Premiums, except that you are responsible for paying Premiums if you have COBRA or Cal-COBRA(refer to "Premiums"in the"Premiums,Eligibility,and Enrollment"section and"COBRA"and "Cal-COBRA"under"Continuation of Group Coverage"in the"Continuation of Membership" section) • Your Group may require you to contribute to Premiums(your Group will tell you the amount and how to pay) • You are responsible for paying your Cost Share for covered Services(refer to the"Cost Share Summary" section) • If you receive Emergency Services,Post-Stabilization Care,Out-of-Area Urgent Care,or COVID-19 Services from a Non—Plan Provider,or if you receive emergency ambulance Services,you must pay the provider and file a claim for reimbursement unless the provider agrees to bill us(refer to"Payment and Reimbursement"in the"Emergency Services and Urgent Care"section) Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#1 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 91 Important Notices Language Assistance Services English: Language assistance is available at no cost to you, 24 hours a day, 7 days a week. You can request interpreter services, or materials translated into your language or alternative formats. You can also request auxiliary aids and devices at our facilities. Call our Member Service Contact Center for help, 24 hours a day, 7 days a week (closed holidays). • Medi-Cal: 1-855-839-7613 (TTY 711) • All others: 1-800-464-4000 (TTY 711) jl a,��sll a�y,11 a oy J�LSAL, j��I�L,I aetS aLL"JI �I i a L�. liter JI o,9 j w a,,jell a.4-%.jilI c,LQ. :Arabic aA I � J.a,l ,L,s�lyo cal j apL.ol c=,IscL. 15t;< ".s yl -9 1,x11 li j a,�y, t�T Lgi et,i 7 9�j4Il 24 J� 4Lv4 sl .;=cT (TTY 711) 1-855-839-7613 :Medi-Cal • (TTY 711) 1-800-464-4000 :w Y''► �7.— • Armenian: Qhg 4wpnrl t wbg6wp lhgquz4wh u pw4gnLlajnLh ulpuidwilp4til opp 24 dLud, 2urpwlap 7 op: `1nLp llurpnrl hp ujurhw[t2hl pwhwgnp raurpgiiwli}h burnurjnLla Ithhp, till lhgtjnq lauzpgdLu5quub 4wd uzjlphuipuzhpuzjhh &tLui�Lu4inq 4wulpwuurquzb hjnLlahp: `1nLp hurlL llurpnrl lap luhrlphl odurhrlurll oghnLlajnLhhhp tL uurpphp r£lap huruulurulnLlajnLhhhpnLr£: OghnLlajuzh hLudwp guzhguzhwphp dtip Uhrjwdhhph uujuzuuzp4dLU5 4wu&llhhtnpnh opp 24 dLud, 2uzpuzlap 7 op (uinh ophphh giurll t): • Medi-Cal' 1-855-839-7613 (TTY 711) • UjI 1-800-464-4000 (TTY 711) Chinese: R fOX NN 7 )�, X)� 24 T,HI, #19PAi V#J o 18"7�R-*1914t Q 4-ry". --.14V4 UNW% ' 'uPTmiA R A0 Z'LT7L AAW ]�Ji��'r�ZftMim W11sAfpi�%Zro i* T i �Af17�'J ��R � ' ',��, �R�5 H 1��7 p 7 24 �1�� C i 4 „%h) • Pff4 7n,: 1-800-757-7585 (TTY 711) `:LiA -qj 7 9 .3j'6tiL,:—LW 24 :Farsi �cLDcio)s a � j&U�j a��S j a o-%.�, 3�)` �j j 7 9 -gjA� L. 24 9-� jc y ,luLi,c�.ly,�La ySlyo ,� I, jS��vc1�`SroS (TTY 711) 1-855-839-7613 :Medi-Cal • (TTY 711) 1-800-464-4000 :AL- • Hindi: fir f�7* RTTcT 4i gm Trgzrffr, f�F i�F 24 Et, TFaT t �B7t f�F _j qM st.T f I 3TTLf S Tftf;� zRf #dT3it t f�4v, zrr fir fir* RTjTiT t Tfi z�r 3m-�ft aTmT # 3T dTz� chiciiA zt f Av, ;ff c STY zhT 3 Jzh7 Tw�r t 13Trq NuzrcT fiAT3cAchiuf t f� a# 3mttTq�T TrEFfttm- Ttf�4vTgt �r #dT3iI ;t � Z�r, f�7t24-dt, TirFt �T fiit�T ( 4 m-4 ftfzii�r T6-icf T-W z rt I • Medi-Cal: 1-855-839-7613 (TTY 711) • Wctt �"`: 1-800-464-4000 (TTY 711) Hmong: Muaj kev pab txhais lus pub dawb rau koj, 24 teev tuaj ib hnub twg, 7 hnub tuaj ib lim tiam twg. Koj thov tau cov kev pab txhais lus, muab cov ntaub ntawv txhais ua koj hom lus, los yog ua lwm hom. Koj kuj thov tau lwm yam kev pab thiab khoom siv hauv peb tej tsev hauj lwm. Hu rau peb Qhov Chaw Pab Cov Tswv Cuab 24 teev tuaj ib hnub twg, 7 hnub tuaj ib lim tiam twg (cov hnub caiv kaw). • Medi-Cal: 1-855-839-7613 (TTY 711) • Dua lwm cov: 1-800-464-4000 (TTY 711) Japanese: g F=l PF BAR AfA< 24HiralMPN7H ) o • Medi-Cal: 1-855-839-7613 (TTY 711) • -�:OTAO�) ANq-,Ac: 1-800-464-4000 (TTY 711) Khmer (Cambodian): �� w�5� �� 24 � �� 41 7C=t�ScE3[S�S�iJLfl`1 c=t cz � iUi��U LJ'�1i�S1S�wGlStli �Ui��U �'fl�1i �L51�2µb � c� r��i� sU�,l�cis �ws� �sc��s�� .ju anri �S''IItSSIfiutO-31inftiSU€bI J''ItOtll=l)UlcSUJ 24 VL3n''IF'lL-UJIt; 7 1IL i tlUUit1iC1i Ul (� CLISU�5��31i5��)`i • Medi-Cal: 1-855-839-7613 (TTY 711) • ttat�� s� s3€,t: 1-800-464-4000 (TTY 711) K{,�lorean: °� �y�1l�l 7L� �l ��1�11��l^/l�^Jlal�l}}� ��l�l�� T_��'�'1{ °1l o�l�� t l Ll . ' 1 tt L O 01 A] ~I Zi 1E L ' I t�9 L I 1 L /fit� 1- ��I d �� _�d l- T �� 7, � A1�i:l N-�71� 7171 z ° �o o}t °� �rl. �� } �} A] A I Z 4 FI Ol 7 - o}7 24 Al 7L�(oT) �1 }o}Al A] �� • Medi-Cal: 1-855-839-7613 (TTY 711) • 71 q E-L o-°T: 1-800-464-4000 (TTY 711) Laotian: ain�ua��cuieci�u��uc��i�2rnccriui�u, 24 a�Fu�c��u, 7 61)C'M- o. ui-uAgz°) .U-)Ok65n°)uqcct3w.)z.) IB can L—()cctscisuw.)z')2equi°)u In 2uquccuueuZ6 putnauaC)ecsa) cc;:)t c�ie�u�s��uu�n�u�e��nc��Zc% Ftntn� uc�cic�u�n�u��u�an 2Bowonc6.)ct iak6)0.)aU�oe)cuna, 24 gJ'Augc�6u, 7 6x)c�a-)Coo (iA)6u6n). • Medi-Cal: 1-855-839-7613 (TTY 711) • au9tn96)o: 1-800-464-4000 (TTY 711) Mien: Mbenc nzoih houh wangv-henh tengx nzie faan waac bun muangx meih maiv cingv, yietc hnoi mbenc maaih 24 norm ziangh hoc, yiete norm leiz baaix mbenc maaih 7 hnoi. Meih se haih tov heuc tengx faan benx meih nyei waac bun muangx, a'fai zoux benx nyungc horngh jaa-sic zoux benx meih nyei waac. Meih corc haih tov tengx nyungc horngh jaa-dorngx aengx caux jaa-sic nzie bun yiem njiec zorc goux baengc zingh gorn zangc. Beiv hnangv qiemx zuqc longc mienh nzie weih nor done waac lorx taux yie mbuo ziux goux baengc mienh nyei gorn zangc, yietc hnoi tengx duqv 24 norm ziangh hoc, yietc norm leiz baaix tengx duqv 7 hnoi (simv cuotv gingc nyei hnoi se guon oc). • Medi-Cal: 1-855-839-7613 (TTY 711) • Yietc zungv da'nyeic deix: 1-800-464-4000 (TTY 711) Navajo: Dii h6zh6 nizhoni bee hane' d66 jiik'ah j66ni doonilwo'. Ndik'e yadi naaltsoos bee haz'aanii bee hane' doo yadi nihookaa doo nadaahagii yadi nihookaa. Shi ei bee haidinii bibee' haz'aanii doo bee fah kodi bizikinii wo'da'gi dooly6. Ah6hee' bik'ehgo noh6lggn'igii, 24 t'aadawolii, 7 t'aadawohigo (t'aadoo t'aalwo'). • Medi-Cal: 1-855-839-7613 (TTY 711) • Yadilzingo bilk'ehgo bee: 1-800-464-4000 (TTY 711) Punjabi: t t f--I*BTUFT tt, t�5 tt 24 W�, UU:E�tt 7 ftli5, SAT 3cT-.:t FE�@14 8EI14 cal -3A A�ifto T FS�ft, TT 7i� 2S WIft 3FIT Ae f u T4a qd<5 FSift Eu5c t d3 7F-T}cal 3AA ATT Affr�T f�t A-7-fu,� ATL46* wt T FS ft El 3 7d 7risi }u l wrI - FS ft 7ITt)�f 7�T t TkFdd�d t fiE z5 t�24 4�, U3tt7frz5( T-,;=-Tftfe?5EfFE3f-eT9)qitail • Medi-Cal: 1-855-839-7613 (TTY 711) • ;�U 7iri�: 1-800-464-4000 (TTY 711) Russian:A3biKOBaA TIOMoiAb AOCTyIIHa AJIA Bac 6ecrinaTHo KpyrrlocyToHHo, eWeAHeBHO. Bbi MO)KeTe 3aHpOCHTb yCJIyr 4 nepeBOq H3Ka HJIH MaTepHaTIbI,nepeseAexxble Ha BaHI A3bHC HJIH B anbTepxaTHBHble C opMaTbI. BbI TaIUKe MoweTe 3axa3aTb BcnoMoraTenbxble cpeACTBa H IIPHCH0006JieHHA.Aim iioa IeHI3A HOMOMH H03BOHHTe B Ham rjeHTp 06CJIy)MBaHM ygaCTHIHKOB eweAHeBHO,KpyrJIOCyTO'hIO(KpoMe Hpa3AHI3'IHbIX AHeil). • Medi-Cal: 1-855-839-7613 (JIHHHA TTY 711) • Bce OCTaJibHbie: 1-800-464-4000 (JIHHHA TTY 711) Spanish: Tenemos disponible asistencia en su idioma sin ningun costo para usted 24 horas al dia, 7 dias a la semana. Usted puede solicitar los servicios de un interprete, que los materiales se traduzcan a su idioma o formatos alternativos. Tambien puede solicitar recursos para discapacidades en nuestros centros de atenci6n. Llame a nuestra Central de Llamadas de Servicio a los Miembros para recibir ayuda 24 horas al dia, 7 dias a la semana(excepto los dias festivos). • Para todos los demas: 1-800-788-0616 (TTY 711) Tagalog: May magagamit na tulong sa wika nang wala kayong babayaran, 24 na oras sa isang araw, 7 araw sa isang linggo. Maaari kayong humiling ng mga serbisyo ng interpreter, o mga babasahin na isinalin sa inyong wika o sa mga alternatibong format. Maaari rin kayong humiling ng mga pantulong na gamit at device sa aming mga pasilidad. Tawagan ang aming Center sa Pakikipag-ugnayan ng Serbisyo sa Miyembro para sa tulong, 24 na oras sa isang araw, 7 araw sa isang linggo (sarado sa mga pista opisyal). • Medi-Cal: 1-855-839-7613 (TTY 711) • Lahat ng iba pa: 1-800-464-4000 (TTY 711) Thai: 24 q-vjuAAamaz)m 24 g3'-AmiAn�au (�1mvA-in-in -wau"Fjm) • Medi-Cal: 1-855-839-7613 (TTY 711) • W)ugiUiNP: 1-800-464-4000 (TTY 711) Ukrainian: 110CJIyrH nepeKJlagaga HagaIOTbcA 6e3KOIIiTOBHO, LjinoAo6OBO, 7 AHiB Ha TH)KAeHb. BH MO)KeTe 3po6HTH 3anHT Ha HOCJIYTH YCHOrO nepeimaAaga a6o oTpI3MaHHA MaTepiaiiiB y nepemaAi MOBOIO,AKOIO BOJIOAiCTe,iIH B anbTepxaTIIBHI3x()opMaTax. TaKOx(BI3 Mo)KeTe 3po6HTH 3aHHT Ha OTPHMaHHA AOHOMi)KHHX 3aco6iB i HPHCTpOIB y 3aKJIaAaX HamoY Mepe)Ki KOMnaHII3. TeJIe4)OHyf4Te B Ham KOHTaKTHHI3 ijeHTp AJIA o6CJIYTOBYBaHHA KJIICHTIB IjIJIOAo6OBO, 7 AHiB Ha TH)KAeHb(KpIM CBATKOBHX AHiB). • Medi-Cal: 1-855-839-7613 (TTY 711) • YCi iHIHi: 1-800-464-4000 (TTY 711) Vietnamese: Dich vu ho trg ng6n nix dugc cung cap mien phi cho quy vi 24 gia moi ngay, 7 ngay trong tuan. Quy vi co the yeu cau dich vu thong dich,hoar tai lieu dugc dich ra ngon ngir cua quy vi hoac nhieu hinh th*c khac. Quy vi tong co the yeu cau cac phuong tien trg gifip va thiet bi bo trg tai cac co so cfia chung t6i. Goi cho Trung Tam Lien Lac ban Dich Vu 1-16i Vien cua thong toi de dugc trg giup, 24 gi&moi ngay, 7 ngay trong tuan(trix cac ngay le). • Medi-Cal: 1-855-839-7613 (TTY 711) • Moi chuong trinh khac: 1-800-464-4000 (TTY 711) Nondiscrimination Notice Discrimination is against the law. Kaiser PermanenteI follows State and Federal civil rights laws. Kaiser Permanente does not unlawfully discriminate, exclude people, or treat them differently because of age, race, ethnic group identification, color, national origin, cultural background, ancestry, religion, sex, gender, gender identity, gender expression, sexual orientation, marital status, physical or mental disability, medical condition, source of payment, genetic information, citizenship, primary language, or immigration status. Kaiser Permanente provides the following services: • No-cost aids and services to people with disabilities to help them communicate better with us, such as: ♦ Qualified sign language interpreters ♦ Written information in other formats (braille, large print, audio, accessible electronic formats, and other formats) • No-cost language services to people whose primary language is not English, such as: ♦ Qualified interpreters ♦ Information written in other languages If you need these services, call our Member Service Contact Center, 24 hours a day, 7 days a week (closed holidays). The call is free: • Medi-Cal: 1-855-839-7613 (TTY 711) • All others: 1-800-464-4000 (TTY 711) Upon request, this document can be made available to you in braille, large print, audiocassette, or electronic form. To obtain a copy in one of these alternative formats, or another format, call our Member Service Contact Center and ask for the format you need. How to file a grievance with Kaiser Permanente You can file a discrimination grievance with Kaiser Permanente if you believe we have failed to provide these services or unlawfully discriminated in another way. You can file a grievance by phone, by mail, in person, or online. Please refer to your Evidence of Coverage or Certificate of Insurance for details. You can call Member Services for more information on the options that apply to you, or for help filing a grievance. You may file a discrimination grievance in the following ways: • By phone: Medi-Cal members may call 1-855-839-7613 (TTY 711). All other members may call 1-800-464-4000 (TTY 711). Help is available 24 hours a day, 7 days a week (closed holidays) • By mail: Download a form at kp.org or call Member Services and ask them to send you a form that you can send back. Kaiser Pennanente is inclusive of Kaiser Foundation Health Plan,Inc,Kaiser Foundation Hospitals,The Pennanente Medical Group,and the Southern California Medical Group • In person: Fill out a Complaint or Benefit Claim/Request form at a member services office located at a Plan Facility (go to your provider directory at kp.org/facilities for addresses) • Online: Use the online form on our website at kp.org You may also contact the Kaiser Permanente Civil Rights Coordinator directly at the addresses below: Attn: Kaiser Permanente Civil Rights Coordinator Member Relations Grievance Operations P.O. Box 939001 San Diego CA 92193 How to file a grievance with the California Department of Health Care Services Office of Civil Rights (For Medi-Cal Beneficiaries Only) You can also file a civil rights complaint with the California Department of Health Care Services Office of Civil Rights in writing, by phone or by email: • By phone: Call DHCS Office of Civil Rights at 916-440-7370 (TTY 711) • By mail: Fill out a complaint form or send a letter to: Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 Complaint forms are available at: http://www.dhcs.ca.gov[Pages/Language_Access.aspx • Online: Send an email to CivilRights@dhcs.ca.gov How to file a grievance with the U.S. Department of Health and Human Services Office of Civil Rights You can file a discrimination complaint with the U.S. Department of Health and Human Services Office for Civil Rights. You can file your complaint in writing, by phone, or online: • By phone: Call 1-800-368-1019 (TTY 711 or 1-800-537-7697) • By mail: Fill out a complaint form or send a letter to: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Complaint forms are available at: https://www.hhs.gov/ocr/complaints/index.html • Online: Visit the Office of Civil Rights Complaint Portal at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsL KAISER PERMANEWE® Kaiser Foundation Health Plan, Inc. Northern California Region A nonprofit corporation and a Medicare Advantage Organization EOC #2 - Kaiser Permanente Senior Advantage (HMO) with Part D Evidence of Coverage for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 36 EOC Number: 2 Issue Date: October 30, 2024 January 1,2025,through December 31, 2025 Member Services Seven days a week, 8 a.m.-8 p.m. 1-800-443-0815(TTY users call 711) kp.org This document is available for free in Spanish. Please contact our Member Services number at 1-800-443-0815 for additional information. (TTY users should call 711.) Hours are 8 a.m. to 8 p.m., 7 days a week. Este documento estd disponible de manera gratuita en espanol. Si desea informacion adicional, llame al ntimero de nuestro Servicio a los Miembros al 1-800-443-0815. (Los usuarios de TTYdeben llamar al 711). El horario de atencion es de 8 a. m. a 8 p. m., los 7 dias de la semana. This document explains your benefits and rights. Use this document to understand about: • Your cost sharing • Your medical and prescription drug benefits • How to file a complaint if you are not satisfied with a service or treatment • How to contact us if you need further assistance • Other protections required by Medicare law TABLE OF CONTENTS FOR EOC #2 BenefitHighlights..................................................................................................................................................................1 Introduction............................................................................................................................................................................3 AboutKaiser Permanente...................................................................................................................................................3 Termof this EOC...............................................................................................................................................................3 Definitions..............................................................................................................................................................................4 Premiums,Eligibility,and Enrollment.................................................................................................................................10 Premiums..........................................................................................................................................................................10 MedicarePremiums..........................................................................................................................................................10 WhoIs Eligible.................................................................................................................................................................11 Howto Enroll and When Coverage Begins.....................................................................................................................13 Howto Obtain Services........................................................................................................................................................15 RoutineCare.....................................................................................................................................................................16 UrgentCare......................................................................................................................................................................16 OurAdvice Nurses...........................................................................................................................................................16 YourPersonal Plan Physician..........................................................................................................................................16 Gettinga Referral.............................................................................................................................................................17 Travel and Lodging for Certain Services.........................................................................................................................18 SecondOpinions...............................................................................................................................................................18 Contractswith Plan Providers..........................................................................................................................................19 Receiving Care Outside of Your Home Region Service Area.........................................................................................19 YourID Card....................................................................................................................................................................19 GettingAssistance............................................................................................................................................................20 PlanFacilities.......................................................................................................................................................................20 ProviderDirectory............................................................................................................................................................20 PharmacyDirectory..........................................................................................................................................................20 Emergency Services and Urgent Care..................................................................................................................................21 EmergencyServices.........................................................................................................................................................21 UrgentCare......................................................................................................................................................................21 Paymentand Reimbursement...........................................................................................................................................22 Benefitsand Your Cost Share..............................................................................................................................................22 YourCost Share...............................................................................................................................................................23 OutpatientCare.................................................................................................................................................................25 HospitalInpatient Services...............................................................................................................................................27 AmbulanceServices.........................................................................................................................................................28 BariatricSurgery..............................................................................................................................................................28 DentalServices.................................................................................................................................................................29 DialysisCare....................................................................................................................................................................29 Durable Medical Equipment("DME")for Home Use.....................................................................................................30 FertilityServices...............................................................................................................................................................32 Fitnessbenefit(One PassTM)............................................................................................................................................33 HealthEducation..............................................................................................................................................................33 HearingServices...............................................................................................................................................................33 Home-Delivered Meals....................................................................................................................................................34 HomeHealth Care............................................................................................................................................................34 Home Medical Care Not Covered by Medicare for Members Who Live in Certain Counties(Advanced Care at Home).............................................................................................................................................................................3 5 HospiceCare....................................................................................................................................................................35 MentalHealth Services....................................................................................................................................................37 OpioidTreatment Program Services................................................................................................................................38 Ostomy,Urological,and Specialized Wound Care Supplies...........................................................................................38 Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services............................................................38 Outpatient Prescription Drugs,Supplies,and Supplements.............................................................................................39 Over-the-Counter(OTC)Health and Wellness................................................................................................................49 PreventiveServices..........................................................................................................................................................49 Prostheticand Orthotic Devices.......................................................................................................................................49 ReconstructiveSurgery....................................................................................................................................................51 Religious Nonmedical Health Care Institution Services..................................................................................................51 Services Associated with Clinical Trials..........................................................................................................................52 SkilledNursing Facility Care...........................................................................................................................................52 Substance Use Disorder Treatment..................................................................................................................................53 TelehealthVisits...............................................................................................................................................................54 TransplantServices..........................................................................................................................................................54 TransportationServices....................................................................................................................................................55 VisionServices.................................................................................................................................................................55 Exclusions,Limitations,Coordination of Benefits,and Reductions...................................................................................57 Exclusions........................................................................................................................................................................57 Limitations........................................................................................................................................................................59 Coordinationof Benefits..................................................................................................................................................59 Reductions........................................................................................................................................................................60 Requestsfor Payment...........................................................................................................................................................62 Requests for Payment of Covered Services or Part D drugs............................................................................................62 How to Ask Us to Pay You Back or to Pay a Bill You Have Received...........................................................................63 We Will Consider Your Request for Payment and Say Yes or No...................................................................................64 Other Situations in Which You Should Save Your Receipts and Send Copies to Us......................................................64 YourRights and Responsibilities.........................................................................................................................................64 We must honor your rights and cultural sensitivities as a Member of our plan...............................................................64 You have some responsibilities as a Member of our plan................................................................................................68 Coverage Decisions,Appeals,and Complaints....................................................................................................................69 What to Do if You Have a Problem or Concern..............................................................................................................69 Where To Get More Information and Personalized Assistance.......................................................................................69 To Deal with Your Problem,Which Process Should You Use?......................................................................................70 A Guide to the Basics of Coverage Decisions and Appeals.............................................................................................70 Your Medical Care:How to Ask for a Coverage Decision or Make an Appeal of a Coverage Decision.......................72 Your Part D Prescription Drugs:How to Ask for a Coverage Decision or Make an Appeal..........................................76 How to Ask Us to Cover a Longer Inpatient Hospital Stay if You Think You Are Being Discharged Too Soon..........81 How to Ask Us to Keep Covering Certain Medical Services if You Think Your Coverage Is Ending Too Soon..........83 Taking Your Appeal to Level 3 and Beyond...................................................................................................................85 How to Make a Complaint About Quality of Care,Waiting Times,Customer Service,or Other Concerns..................87 You can also tell Medicare about your complaint............................................................................................................88 AdditionalReview............................................................................................................................................................88 BindingArbitration..........................................................................................................................................................88 Terminationof Membership.................................................................................................................................................90 Termination Due to Loss of Eligibility............................................................................................................................91 Terminationof Agreement................................................................................................................................................91 Disenrolling from Senior Advantage...............................................................................................................................91 Termination of Contract with the Centers for Medicare&Medicaid Services...............................................................92 Terminationfor Cause......................................................................................................................................................92 Termination for Nonpayment of Premiums.....................................................................................................................92 Termination of a Product or all Products.........................................................................................................................92 Paymentsafter Termination.............................................................................................................................................92 Reviewof Membership Termination...............................................................................................................................93 Continuationof Membership................................................................................................................................................93 Continuation of Group Coverage.....................................................................................................................................93 Conversion from Group Membership to an Individual Plan............................................................................................93 MiscellaneousProvisions.....................................................................................................................................................94 Administrationof Agreement...........................................................................................................................................94 Amendmentof Agreement................................................................................................................................................94 Applicationsand Statements............................................................................................................................................94 Assignment.......................................................................................................................................................................94 Attorney and Advocate Fees and Expenses.....................................................................................................................94 ClaimsReview Authority.................................................................................................................................................94 EOCBinding on Members...............................................................................................................................................94 ERISANotices.................................................................................................................................................................94 GoverningLaw.................................................................................................................................................................95 Groupand Members Not Our Agents..............................................................................................................................95 NoWaiver........................................................................................................................................................................95 NoticesRegarding Your Coverage...................................................................................................................................95 Notice about Medicare Secondary Payer Subrogation Rights.........................................................................................95 OverpaymentRecovery....................................................................................................................................................95 PublicPolicy Participation...............................................................................................................................................95 TelephoneAccess(TTY).................................................................................................................................................96 Important Phone Numbers and Resources...........................................................................................................................96 Kaiser Permanente Senior Advantage..............................................................................................................................96 Medicare...........................................................................................................................................................................98 State Health Insurance Assistance Program.....................................................................................................................99 QualityImprovement Organization..................................................................................................................................99 SocialSecurity................................................................................................................................................................100 Medicaid.........................................................................................................................................................................100 RailroadRetirement Board.............................................................................................................................................100 Group Insurance or Other Health Insurance from an Employer....................................................................................101 Benefit Highlights Accumulation Period The Accumulation Period for this plan is l/l/25 through 12/31/25 (calendar year). Plan Out-of-Pocket Maximum For Services subject to the maximum,you will not pay any more Cost Share for the rest of the calendar year if the Copayments and Coinsurance you pay for those Services add up to the following amount: For any one Member.................................................................................$1,000 per calendar year Plan Deductible None Plan Provider Office Visits You Pay Most Primary Care Visits and most Non-Physician Specialist Visits.......... $15 per visit Most Physician Specialist Visits................................................................... $15 per visit Annual Wellness visit and the"Welcome to Medicare"preventive visit.... No charge Routine physical exams................................................................................ No charge Routine eye exams with a Plan Optometrist................................................. $15 per visit Urgent care consultations,evaluations,and treatment................................. $15 per visit Physical,occupational,and speech therapy.................................................. $15 per visit Telehealth Visits A You Pay Primary Care Visits and Non-Physician Specialist Visits by interactive video........................................................................................................... No charge Physician Specialist Visits by interactive video........................................... No charge Primary Care Visits and Non-Physician Specialist Visits by telephone...... No charge Physician Specialist Visits by telephone...................................................... No charge Outpatient Services You Pay Outpatient surgery and certain other outpatient procedures......................... $50 per procedure Allergy injections(including allergy serum)................................................ $3 per visit Most immunizations(including the vaccine)............................................... No charge Most X-rays and laboratory tests.................................................................. No charge Manual manipulation of the spine................................................................ $15 per visit Hospitalization Services You Pay Room and board,surgery,anesthesia,X-rays,laboratory tests,and drugs.. No charge Emergency Health Coverage You Pay Emergency Department visits....................................................................... $50 per visit Note:If you are admitted directly to the hospital as an inpatient for covered Services,you will pay the inpatient Cost Share instead of the Emergency Department Cost Share(see"Hospitalization Services"for inpatient Cost Share). Ambulance and Transportation Services You Pay Ambulance Services..................................................................................... $100 per trip Other transportation Services when provided by our designated No charge for up to 24 one-way trips(50 miles per transportation provider as described in this EOC....................................... trip)per calendar year Prescription Drug Coverage You Pay This plan covers Medicare Part D prescription drugs in accord with our Part D formulary. Initial coverage stage—until you have spent$2,000 in 2025. (If you spend$2,000,you move on to the catastrophic coverage stage): Generic drugs..................................................................................... $5 for up to a 100-day supply Brand-name drugs.............................................................................. $20 for up to a 100-day supply Catastrophic coverage stage................................................................... No charge Group ID:604334 Kaiser Pennanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOCW 2 Effective:1/1/25-12/31/25 Issue Date:October 30,2024 Page 1 Durable Medical Equipment(DME) You Pay Covered durable medical equipment for home use as described in this EOC............................................................................................................. 20 percent Coinsurance Mental Health Services You Pay Inpatient psychiatric hospitalization............................................................. No charge Individual outpatient mental health evaluation and treatment...................... $15 per visit Group outpatient mental health treatment.................................................... $7 per visit Substance Use Disorder Treatment You Pay Inpatient detoxification................................................................................. No charge Individual outpatient substance use disorder evaluation and treatment....... $15 per visit Group outpatient substance use disorder treatment...................................... $5 per visit Home Health Services You Pay Home health care(part-time,intermittent)................................................... No charge Other You Pay Eyeglasses or contact lenses every 24 months............................................. Amount in excess of$175 Allowance Hearing aid(s)every 36 months.................................................................... Amount in excess of$1,000 Allowance for each ear Skilled Nursing Facility care(up to 100 days per benefit period)................ No charge External prosthetic and orthotic devices as described in this EOC.............. 20 percent Coinsurance Ostomy,urological,and specialized wound care supplies........................... 20 percent Coinsurance Meals delivered to your home immediately following discharge from a No charge up to three meals per day in a Plan Hospital or Skilled Nursing Facility as an inpatient........................... consecutive four-week period,once per calendar year Over-the-Counter(OTC)Health and Wellness items obtained through our catalog......................................................................................................... No charge up to a quarterly benefit of$70 Fitness benefit—One PassTM(includes access to in-network gyms and one home fitness kit per calendar year)............................................................. No charge This is a summary of the most frequently asked-about benefits. This chart does not explain benefits,Cost Share,out-of- pocket maximums,exclusions,or limitations,nor does it list all benefits and Cost Share amounts.For a complete explanation,refer to the"Benefits and Your Cost Share"and"Exclusions,Limitations,Coordination of Benefits,and Reductions"sections. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOCW 2 Effective:1/1/25-12/31/25 Issue Date:October 30,2024 Page 2 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Introduction ERE" FROM WHOM OR WHAT GROUP OF PROVIDERS YOU MAY GET HEALTH CARE. Kaiser Foundation Health Plan,Inc. (Health Plan)has a contract with the Centers for Medicare&Medicaid Kaiser Permanente provides Services directly to our Services as a Medicare Advantage Organization. Members through an integrated medical care program. Health Plan,Plan Hospitals,and the Medical Group This contract provides Medicare Services(including work together to provide our Members with quality care. Medicare Part D prescription drug coverage)through Our medical care program gives you access to all of the "Kaiser Permanente Senior Advantage covered Services you may need,such as routine care (HMO)with Part D"(Senior Advantage),except for with your own personal Plan Physician,hospital hospice care for Members with Medicare Part A,which Services,laboratory and pharmacy Services,Emergency is covered under Original Medicare.Enrollment in this Services,Urgent Care,and other benefits described in Senior Advantage plan means that you are automatically this EOC.Plus,our health education programs offer you enrolled in Medicare Part D.Kaiser Permanente is an great ways to protect and improve your health. HMO plan with a Medicare contract.Enrollment in Kaiser Permanente depends on contract renewal. We provide covered Services to Members using Plan Providers located in our Service Area,which is described This Evidence of Coverage("EOC")describes our in the"Definitions"section.You must receive all Senior Advantage health care coverage provided under covered care from Plan Providers inside our Service the Group Agreement(Agreement)between Health Plan Area,except as described in the sections listed below for (Kaiser Foundation Health Plan,Inc.("Health Plan")and the following Services: your Group(the entity with which Health Plan has • Authorized referrals as described under"Getting a entered into the Agreement). Referral"in the"How to Obtain Services"section • Covered Services received outside of your Home This EOC is part of the Agreement between Health Plan Region Service Area as described under"Receiving and your Group.The Agreement contains additional Care Outside of Your Home Region Service Area"in terms such as Premiums,when coverage can change,the the"How to Obtain Services"section effective date of coverage,and the effective date of • Emergency ambulance Services as described under termination.The Agreement must be consulted to determine the exact terms of coverage.A copy of the "Ambulance Services"in the"Benefits and Your Cost Agreement is available from your Group. Share"section • Emergency Services,Post-Stabilization Care,and For benefits provided under any other program,refer to Out-of-Area Urgent Care as described in the that other plan's evidence of coverage.For benefits "Emergency Services and Urgent Care"section provided under any other program offered by your Group o Out-of-area dialysis care as described under"Dialysis (for example,workers compensation benefits),refer to Care"in the"Benefits and Your Cost Share"section your Group's materials. e Prescription drugs from Non—Plan Pharmacies as In this EOC,Health Plan is sometimes referred to as described under"Outpatient Prescription Drugs, "we"or"us."Members are sometimes referred to as Supplies,and Supplements"in the"Benefits and "you."Some capitalized terms have special meaning in Your Cost Share"section this EOC;please see the"Definitions"section for terms • Routine Services associated with Medicare-approved you should know. clinical trials as described under"Services Associated with Clinical Trials"in the"Benefits and Your Cost It is important to familiarize yourself with your coverage Share"section by reading this EOC completely,so that you can take full advantage of your Health Plan benefits.Also,if you have special health care needs,please carefully read the Term of this EOC sections that apply to you. This EOC is for the period January 1,2025,through December 31,2025,unless amended.Benefits, About Kaiser Permanente Copayments,and Coinsurance may change on January 1 of each year and at other times in accord with your PLEASE READ THE FOLLOWING Group's Agreement with us.Your Group can tell you INFORMATION SO THAT YOU WILL KNOW Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 3 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. whether this EOC is still in effect and give you a current dispensing drugs,the direct and indirect costs of one if this EOC has been amended. providing Kaiser Permanente pharmacy Services to Members,and the pharmacy program's contribution to the net revenue requirements of Health Plan) Definitions • For all other Services,the payments that Kaiser Some terms have special meaning in this EOC.When we Permanente makes for the Services or,if Kaiser use a term with special meaning in only one section of Permanente subtracts your Cost Share from its this EOC,we define it in that section.The terms in this payment,the amount Kaiser Permanente would have "Definitions"section have special meaning when paid if it did not subtract your Cost Share capitalized and used in any section of this EOC. Coinsurance:A percentage of Charges that you must Accumulation Period:A period of time no greater than pay when you receive a covered Service under this EOC. 12 consecutive months for purposes of accumulating Complaint:The formal name for"making a complaint" amounts toward any deductibles(if applicable)and out- is"filing a grievance."The complaint process is used of-pocket maximums. The Accumulation Period for this only for certain types of problems.This includes EOC is from 1/l/25 through 12/31/25. problems related to quality of care,waiting times,and Allowance:A specified credit amount that you can use the customer service you receive.It also includes toward the cost of an item.If the cost of the item(s)or complaints if your plan does not follow the time periods Service(s)you select exceeds the Allowance,you will in the appeal process. pay the amount in excess of the Allowance,which does Comprehensive Formulary(Formulary or Drug not apply to the maximum out-of-pocket amount. List):A list of Medicare Part D prescription drugs Catastrophic Coverage Stage: The stage in the Part D covered by our plan. The drugs on this list are selected drug benefit that begins when you(or other qualified by us with the help of doctors and pharmacists.The list parties on your behalf)have spent$2,000 for Part D includes both brand-name and generic drugs. covered drugs during the covered year.During this Comprehensive Outpatient Rehabilitation Facility payment stage,you pay nothing for your covered Part D (CORF):A facility that mainly provides rehabilitation drugs. Services after an illness or injury,including physician's Centers for Medicare&Medicaid Services(CMS): Services,physical therapy,social or psychological The federal agency that administers the Medicare Services,and outpatient rehabilitation. program. Copayment:A specific dollar amount that you must pay Ancillary Coverage: Optional benefits such as when you receive a covered Service under this EOC. acupuncture,chiropractic,or dental coverage that may be Note:The dollar amount of the Copayment can be$0(no available to Members enrolled under this EOC. If your charge). plan includes Ancillary Coverage,this coverage will be Cost Share: The amount you are required to pay for described in an amendment to this EOC or a separate covered Services.For example,your Cost Share may be agreement from the issuer of the coverage. a Copayment or Coinsurance.Cost Share also means any Charges: "Charges"means the following: Charges you are required to pay for covered Medicare Part D drugs.If your coverage includes a Plan • For Services provided by the Medical Group or Deductible and you receive Services that are subject to Kaiser Foundation Hospitals,the charges in Health the Plan Deductible,your Cost Share for those Services Plan's schedule of Medical Group and Kaiser will be Charges until you reach the Plan Deductible. Foundation Hospitals charges for Services provided to Members Coverage Determination:An initial determination we make about whether a Part D drug prescribed for you is • For Services for which a provider(other than the covered under Part D and the amount,if any,you are Medical Group or Kaiser Foundation Hospitals)is required to pay for the prescription.In general,if you compensated on a capitation basis,the charges in the bring your prescription for a Part D drug to a Plan schedule of charges that Kaiser Permanente Pharmacy and the pharmacy tells you the prescription negotiates with the capitated provider isn't covered by us,that isn't a Coverage Determination. • For items obtained at a pharmacy owned and operated You need to call or write us to ask for a formal decision by Kaiser Permanente,the amount the pharmacy about the coverage.Coverage Determinations are called would charge a Member for the item if a Member's "coverage decisions"in this EOC. benefit plan did not cover the item(this amount is an Dependent:A Member who meets the eligibility estimate of:the cost of acquiring,storing,and requirements as a Dependent(for Dependent eligibility Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 4 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. requirements,see"Who Is Eligible"in the"Premiums, (HMO)with Part D"under Health Plan's Agreement Eligibility,and Enrollment"section). with your Group. Durable Medical Equipment(DME): Certain medical "Extra Help":A Medicare program to help people with equipment that is ordered by your doctor for medical limited income and resources pay Medicare prescription reasons.Examples include walkers,wheelchairs, drug program costs,such as premiums,deductibles,and crutches,powered mattress systems,diabetic supplies,IV coinsurance. infusion pumps,speech-generating devices,oxygen Family:A Subscriber and all of their Dependents. equipment,nebulizers,or hospital beds ordered by a provider for use in the home. Grievance:A type of complaint you make about our Emergency Medical Condition:A medical or mental plan,providers,or pharmacies,including a complaint health condition manifesting itself by acute symptoms of concerning the quality of your care. This does not sufficient severity(including severe pain)such that a involve coverage or payment disputes. prudent layperson,with an average knowledge of health Group: The entity with which Health Plan has entered and medicine,could reasonably expect the absence of into the Agreement that includes this EOC. immediate medical attention to result in any of the Health Plan:Kaiser Foundation Health Plan,Inc.,a following: California nonprofit corporation.This EOC sometimes • Serious jeopardy to the health of the individual or,in refers to Health Plan as"we"or"us." the case of a pregnant woman,the health of the woman or her unborn child Home Region:The Region where you enrolled(either the Northern California Region or the Southern • Serious impairment to bodily functions California Region). • Serious dysfunction of any bodily organ or part Income Related Monthly Adjustment Amount A mental health condition is an emergency medical (IRMAA):If your modified adjusted gross income as condition when it meets the requirements of the reported on your IRS tax return from two years ago is paragraph above,or when the condition manifests itself above a certain amount,you'll pay the standard premium by acute symptoms of sufficient severity such that either amount and an Income Related Monthly Adjustment of the following is true: Amount,also known as IRMAA.IRMAA is an extra • The person is an immediate danger to themselves or charge added to your premium.Less than 5%of people to others with Medicare are affected, so most people will not pay a higher premium. • The person is immediately unable to provide for,or use,food,shelter,or clothing,due to the mental Initial Coverage Stage:This is the stage before your disorder out-of-pocket costs for 2025 have reached$2,000. Emergency Services: Covered Services that are(1) Initial Enrollment Period:When you are first eligible rendered by a provider qualified to furnish Emergency for Medicare,the period of time when you can sign up Services;and(2)needed to treat,evaluate,or Stabilize an for Medicare Part B.If you're eligible for Medicare Emergency Medical Condition such as: when you turn 65,your Initial Enrollment Period is the 7-month period that begins 3 months before the month • A medical screening exam that is within the you turn 65,includes the month you turn 65,and ends 3 capability of the Emergency Department of a hospital, months after the month you turn 65. including ancillary services(such as imaging and laboratory Services)routinely available to the Kaiser Permanente:Kaiser Foundation Hospitals(a Emergency Department to evaluate the Emergency California nonprofit corporation),Health Plan,and the Medical Condition Medical Group. • Within the capabilities of the staff and facilities Manufacturer Discount Program—A program under available at the hospital,Medically Necessary which drug manufacturers pay a portion of the plan's full examination and treatment required to Stabilize the cost for covered Part D brand-name drugs and biologics. patient(once your condition is Stabilized, Services Discounts are based on agreements between the federal you receive are Post Stabilization Care and not government and drug manufacturers. Emergency Services) Medical Group: The Permanente Medical Group,Inc.,a EOC: This Evidence of Coverage document,including for-profit professional corporation. any amendments,which describes the health care Medically Necessary: A Service is Medically Necessary coverage of"Kaiser Pennanente Senior Advantage if it is medically appropriate and required to prevent, Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 5 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. diagnose,or treat your condition or clinical symptoms in (such as nurse practitioners,physician assistants, accord with generally accepted professional standards of optometrists,podiatrists,and audiologists). practice that are consistent with a standard of care in the Non—Plan Hospital:A hospital other than a Plan medical community. Hospital. Medicare:The federal health insurance program for Non—Plan Pharmacy:A pharmacy other than a Plan people 65 years of age or older,some people under age Pharmacy.These pharmacies are also called"out-of- 65 with certain disabilities,and people with End-Stage network pharmacies." Renal Disease(generally those with permanent kidney failure who need dialysis or a kidney transplant). Non—Plan Physician: A physician other than a Plan Medicare Advantage Organization:A public or private Physician. entity organized and licensed by a state as a risk-bearing Non—Plan Provider:A provider other than a Plan entity that has a contract with the Centers for Medicare Provider. &Medicaid Services to provide Services covered by Medicare,except for hospice care covered by Original Non Psychiatrist:A psychiatrist who is not a Plan Medicare.Kaiser Foundation Health Plan,Inc.,is a Physician. cian. Medicare Advantage Organization. Non—Plan Skilled Nursing Facility:A Skilled Nursing Medicare Advantage Plan: Sometimes called Medicare Facility other than a Plan Skilled Nursing Facility. Part C.A plan offered by a private company that Organization Determination:A decision our plan contracts with Medicare to provide you with all your makes about whether items or services are covered or Medicare Part A and Part B benefits.A Medicare how much you have to pay for covered items or Services. Advantage Plan can be(i)an HMO,(ii)a PPO,(iii)a Organization determinations are called coverage Private Fee-for-Service(PFFS)plan,or(iv)a Medicare decisions in this EOC. Medical Savings Account(MSA)plan.Besides choosing from these types of plans,a Medicare Advantage HMO Original Medicare("Traditional Medicare"or"Fee- or PPO plan can also be a Special Needs Plan(SNP).In for-Service Medicare"): Original Medicare is offered most cases,Medicare Advantage Plans also offer by the government,and not a private health plan like Medicare Part D(prescription drug coverage). These Medicare Advantage Plans and prescription drug plans. Under Original Medicare,Medicare services are covered plans are called Medicare Advantage Plans with P by paying doctors,hospitals,and other health care Prescription Drug Coverage.A person enrolled in a Medicare Part D plan has Medicare Part D by virtue of providers payment amounts established by Congress. his or her enrollment in the Part D plan. This EOC is for You can see any doctor,hospital,or other health care a Medicare Part D plan. provider that accepts Medicare.You must pay the deductible.Medicare pays its share of the Medicare- Medicare Health Plan:A Medicare Health Plan is approved amount,and you pay your share. Original offered by a private company that contracts with Medicare has two parts:Part A(Hospital Insurance)and Medicare to provide Part A and Part B benefits to people Part B(Medical Insurance)and is available everywhere with Medicare who enroll in the plan.This term includes in the United States. all Medicare Advantage plans,Medicare Cost plans, Out-of-Area Urgent Care:Medically Necessary Demonstration/Pilot Programs,and Programs of All- Services to prevent serious deterioration of your health inclusive Care for the Elderly(PACE). resulting from an unforeseen illness or an unforeseen Medigap(Medicare Supplement Insurance)Policy: injury if all of the following are true: Medicare supplement insurance sold by private insurance . You are temporarily outside our Service Area companies to fill gaps in the Original Medicare plan coverage.Medigap policies only work with the Original • A reasonable person would have believed that your Medicare plan. (A Medicare Advantage Plan is not a health would seriously deteriorate if you delayed Medigap policy.) treatment until you returned to our Service Area Member:A person who is eligible and enrolled under Physician Specialist Visits: Consultations,evaluations, this EOC,and for whom we have received applicable and treatment by physician specialists,including Premiums. This EOC sometimes refers to a Member as personal Plan Physicians who are not Primary Care "YOU." Physicians. Non-Physician Specialist Visits: Consultations, Plan Deductible: The amount you must pay under this evaluations,and treatment by non-physician specialists EOC in the calendar year for certain Services before we will cover those Services at the applicable Copayment or Coinsurance in that calendar year.Refer to the"Benefits Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 6 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. and Your Cost Share"section to learn whether your physician who contracts to provide Services to Members coverage includes a Plan Deductible,the Services that (but not including physicians who contract only to are subject to the Plan Deductible,and the Plan provide referral Services). Deductible amount. Plan Provider:A Plan Hospital,a Plan Physician,the Plan Facility:Any facility listed in the Provider Medical Group,a Plan Pharmacy,or any other health Directory on our website at ko.org/facilities.Plan care provider that Health Plan designates as a Plan Facilities include Plan Hospitals,Plan Medical Offices, Provider. and other facilities that we designate in the directory. Plan Skilled Nursing Facility:A Skilled Nursing The directory is updated periodically.The availability of Facility approved by Health Plan. Plan Facilities may change.If you have questions,please call Member Services. Post-Stabilization Care:Medically Necessary Services Plan Hospital:Any hospital listed in the Provider related to your Emergency Medical Condition that you Directory on our website at ko.org/facilities.In the receive in a hospital(including the Emergency directory,some Plan Hospitals are listed as Kaiser Department)after your treating physician determines that Permanente Medical Centers.The directory is updated this condition is clinically stable.You are considered periodically. The availability of Plan Hospitals may clinically stable when your treating physician believes, change.If you have questions,please call Member within a reasonable medical probability and in Services. accordance with recognized medical standards that you are safe for discharge or transfer and that your condition Plan Medical Office:Any medical office listed in the is not expected to get materially worse during or as a Provider Directory on our website at ko.org/facilities. In result of the discharge or transfer. the directory,Kaiser Permanente Medical Centers may Premiums:The periodic amounts for your membership include Plan Medical Offices. The directory is updated under this EOC. periodically. The availability of Plan Medical Offices may change. If you have questions,please call Member Preventive Services: Covered Services that prevent or Services. detect illness and do one or more of the following: Plan Optical Sales Office:An optical sales office • Protect against disease and disability or further owned and operated by Kaiser Permanente or another progression of a disease optical sales office that we designate.Refer to the . Detect disease in its earliest stages before noticeable Provider Directory on our website at ko.org/facilities for symptoms develop locations of Plan Optical Sales Offices.In the directory, Plan Optical Sales Offices may be called"Vision Primary Care Physicians: Generalists in internal Essentials."The directory is updated periodically. The medicine,pediatrics,and family practice,and specialists availability of Plan Optical Sales Offices may change.If in obstetrics/gynecology whom the Medical Group you have questions,please call Member Services. designates as Primary Care Physicians.Refer to the Provider Directory on our website at ko.org for a list of Plan Optometrist:An optometrist who is a Plan physicians that are available as Primary Care Physicians. Provider. The directory is updated periodically.The availability of Plan Out-of-Pocket Maximum: The total amount of Primary Care Physicians may change.If you have Cost Share you must pay under this EOC in the calendar questions,please call Member Services. year for certain covered Services that you receive in the Primary Care Visits:Evaluations and treatment same calendar year.Refer to the`Benefits and Your Cost provided by Primary Care Physicians and primary care Share"section to find your Plan Out-of-Pocket Plan Providers who are not physicians(such as nurse Maximum amount and to learn which Services apply to practitioners). the Plan Out-of-Pocket Maximum. Provider Directory:A directory of Plan Physicians and Plan Pharmacy:A pharmacy owned and operated by Plan Facilities in your Home Region.This directory is Kaiser Permanente or another pharmacy that we available on our website at ko.org/directory. To obtain designate.Refer to the Provider Directory on our website a printed copy,call Member Services.The directory is at ko.org/facilities for locations of Plan Pharmacies.The updated periodically.The availability of Plan Physicians directory is updated periodically. The availability of Plan and Plan Facilities may change.If you have questions, Pharmacies may change.If you have questions,please please call Member Services. call Member Services. Real-Time Benefit Tool:A portal or computer Plan Physician:Any licensed physician who is an application in which enrollees can look up complete, employee of the Medical Group,or any licensed accurate,timely,clinically appropriate,enrollee-specific Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 7 Member Service:toll free 1-800-443-081 S(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. formulary and benefit information.This includes cost- • The following ZIP codes in Amador County are sharing amounts,alternative formulary medications that inside our Northern California Service Area: 95640, may be used for the same health condition as a given 95669 drug,and coverage restrictions(prior authorization,step • All ZIP codes in Contra Costa County are inside our therapy,quantity limits)that apply to alternative Northern California Service Area: 94505-07,94509, medications. 94511,94513-14,94516-31,94547-49,94551, Region:A Kaiser Foundation Health Plan organization 94553,94556,94561,94563-65,94569-70,94572, or allied plan that conducts a direct-service health care 94575,94582-83,94595-98,94706-08,94801-08, program.Regions may change on January 1 of each year 94820,94850 and are currently the District of Columbia and parts of . The following ZIP codes in El Dorado County are Northern California, Southern California,Colorado, inside our Northern California Service Area: 95613- Georgia,Hawaii,Maryland,Oregon,Virginia,and 14,95619,95623,95633-35,95651,95664,95667, Washington.For the current list of Region locations, 95672,95682,95762 please visit our website at ky.org or call Member Services. • The following ZIP codes in Fresno County are inside our Northern California Service Area: 93242,93602, Serious Emotional Disturbance of a Child Under Age 93606-07,93609,93611-13,93616,93618-19, 18:A condition identified as a"mental disorder"in the 93624-27,93630-31,93646,93648-52,93654, most recent edition of the Diagnostic and Statistical 93656-57,93660,93662,93667-68,93675,93701- Manual of Mental Disorders,other than a primary 12,93714-18,93720-30,93737,93740-41,93744- substance use disorder or developmental disorder,that 45,93747,93750,93755,93760-61,93764-65, results in behavior inappropriate to the child's age 93771-79,93786,93790-94,93844,93888 according to expected developmental norms,if the child also meets at least one of the following three criteria: • The following ZIP codes in Kings County are inside our Northern California Service Area: 93230,93232, • As a result of the mental disorder,(1)the child has 93242,93631,93656 substantial impairment in at least two of the following areas: self-care,school functioning,family • The following ZIP codes in Madera County are inside relationships,or ability to function in the community; our Northern California Service Area: 93601-02, and(2)either(a)the child is at risk of removal from 93654,93614,93623,93626,93636-39,93643-45, the home or has already been removed from the 93653,93669,93720 home,or(b)the mental disorder and impairments • All ZIP codes in Marin County are inside our have been present for more than six months or are Northern California Service Area: 94901,94903-04, likely to continue for more than one year without 94912-15,94920,94924-25,94929-30,94933, treatment 94937-42,94945-50,94952,94956-57,94960, • The child displays psychotic features,or risk of 94963-66,94970-71,94973-74,94976-79 suicide or violence due to a mental disorder • The following ZIP codes in Mariposa County are • The child meets special education eligibility inside our Northern California Service Area: 93 60 1, requirements under Section 5600.3(a)(2)(C)of the 93623,93653 Welfare and Institutions Code • All ZIP codes in Napa County are inside our Northern Service Area: The geographic area approved by the California Service Area: 94503,94508,94515, Centers for Medicare&Medicaid Services within which 94558-59,94562,94567,94573-74,94576,94581, an eligible person may enroll in Senior Advantage.Note: 94599,95476 Subject to approval by the Centers for Medicare& • The following ZIP codes in Placer County are inside Medicaid Services,we may reduce or expand our Service our Northern California Service Area: 95602-04, Area effective any January 1.ZIP codes are subject to 95610,95626,95648,95650,95658,95661,95663, change by the U.S.Postal Service.The ZIP codes below 95668,95677-78,95681,95703,95722,95736, for each county are in our Service Area: 95746-47,95765 • All ZIP codes in Alameda County are inside our • All ZIP codes in Sacramento County are inside our Northern California Service Area: 94501-02,94505, Northern California Service Area: 94203-09,94211, 94514,94536-46,94550-52,94555,94557,94560, 94229-30,94232,94234-37,94239-40,94244-45, 94566,94568,94577-80,94586-88,94601-15, 94247-50,94252,94254,94256-59,94261-63, 94617-21,94622-24,94649,94659-62,94666, 94267-69,94271,94273-74,94277-80,94282-85, 94701-10,94712,94720,95377,95391 94287-91,94293-98,94571,95608-11,95615, 95621,95624,95626,95628,95630,95632,95638- Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 8 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. 39,95641,95652,95655,95660,95662,95670-71, • The following ZIP codes in Tulare County are inside 95673,95678,95680,95683,95690,95693,95741- our Northern California Service Area: 93238,93261, 42,95757-59,95763,95811-38,95840-43,95851- 93618,93631,93646,93654,93666,93673 53,95860,95864-67,95894,95899 • The following ZIP codes in Yolo County are inside • All ZIP codes in San Francisco County are inside our our Northern California Service Area: 95605,95607, Northern California Service Area: 94102-05,94107- 95612,95615-18,95620,95645,95691,95694-95, 12,94114-34,94137,94139-47,94151,94158-61, 95697-98,95776, 95798-99 94163-64,94172,94177,94188 • The following ZIP codes in Yuba County are inside • All ZIP codes in San Joaquin County are inside our our Northern California Service Area: 95692,95903, Northern California Service Area: 94514,95201-15, 95961 95219-20,95227, 95230-31,95234,95236-37, 95240�2,95253,95258,95267,95269,95296-97, For each ZIP code listed for a county,our Service Area 95304,95320,95330,95336-37,95361,95366, includes only the part of that ZIP code that is in that 95376-78,95385,95391,95632,95686,95690 county.When a ZIP code spans more than one county, the part of that ZIP code that is in another county is not • All ZIP codes in San Mateo County are inside our inside our Service Area unless that other county is listed Northern California Service Area: 94002,94005, above and that ZIP code is also listed for that other 94010-11,94014-21,94025-28,94030,94037-38, county.If you have a question about whether a ZIP code 94044,94060-66,94070,94074,94080,94083, is in our Service Area,please call Member Services. 94128,94303,94401-04,94497 Also,the ZIP codes listed above may include ZIP codes • The following ZIP codes in Santa Clara County are for Post Office boxes and commercial rental mailboxes. inside our Northern California Service Area: 94022- A Post Office box or rental mailbox cannot be used to 24,94035,94039-43,94085-89,94301-06,94309, determine whether you meet the residence eligibility 94550,95002,95008-09,95011,95013-15,95020- requirements for Senior Advantage.Your permanent 21,95026,95030-33,95035-38,95042,95044, residence address must be used to determine your Senior 95046,95050-56,95070-71,95076,95101,95103, Advantage eligibility. 95106,95108-13,95115-36,95138-41,95148, Services:Health care services or items("health care" 95150-61,95164, 95170,95172-73,95190-94, includes both physical health care and mental health 95196 care)and services to treat Serious Emotional Disturbance • All ZIP codes in Santa Cruz County are inside our of a Child Under Age 18 or Severe Mental Illness. Northern California Service Area: 95001,95003, Severe Mental Illness: The following mental disorders: 95005-07,95010, 95017-19,95033,95041,95060- schizophrenia,schizoaffective disorder,bipolar disorder 67,95073,95076-77 (manic-depressive illness),major depressive disorders, • All ZIP codes in Solano County are inside our panic disorder,obsessive-compulsive disorder,pervasive Northern California Service Area: 94503,94510, developmental disorder or autism,anorexia nervosa,or 94512,94533-35,94571,94585,94589-92,95616, bulimia nervosa. 95618,95620,95625,95687-88,95690,95694, Skilled Nursing Facility:A facility that provides 95696 inpatient skilled nursing care,rehabilitation services,or • The following ZIP codes in Sonoma County are other related health services and is licensed by the state inside our Northern California Service Area: 94515, of California.The facility's primary business must be the 94922-23,94926-28,94931,94951-55,94972, provision of 24-hour-a-day licensed skilled nursing care. 94975,94999,95401-07,95409,95416,95419, The term"Skilled Nursing Facility"does not include 95421,95425,95430-31,95433,95436,95439, convalescent nursing homes,rest facilities,or facilities 95441-42,95444, 95446,95448,95450,95452, for the aged,if those facilities furnish primarily custodial 95462,95465,95471-73,95476,95486-87,95492 care,including training in routines of daily living.A • All ZIP codes in Stanislaus County are inside our "Skilled Nursing Facility"may also be a unit or section Northern California Service Area: 95230,95304, within another facility(for example,a hospital)as long 95307,95313,95316,95319,95322-23,95326, as it continues to meet this definition. 95328-29,95350-58,95360-61,95363,95367-68, Spouse: The person to whom the Subscriber is legally 95380-82, 95385-87,95397 married under applicable law.For the purposes of this • The following ZIP codes in Sutter County are inside EOC,the term"Spouse"includes the Subscriber's our Northern California Service Area: 95626,95645, domestic partner."Domestic partners"are two people 95659,95668,95674,95676,95692,95836-37 who are registered and legally recognized as domestic partners by California(if your Group allows enrollment Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 9 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. of domestic partners not legally recognized as domestic be expected to pay to your Group,please check with partners by California,"Spouse"also includes the your Group's benefits administrator. Subscriber's domestic partner who meets your Group's eligibility requirements for domestic partners). Medicare Premiums Stabilize: To provide the medical treatment of the Emergency Medical Condition that is necessary to Medicare Part D premium due to income assure,within reasonable medical probability,that no Some members may be required to pay an extra charge, material deterioration of the condition is likely to result known as the Part D Income Related Monthly from or occur during the transfer of the person from the Adjustment Amount,also known as IRMAA.The extra facility.With respect to a pregnant person who is having charge is figured out using your modified adjusted gross contractions,when there is inadequate time to safely income as reported on your IRS tax return from two transfer them to another hospital before delivery(or the years ago.If this amount is above a certain amount, transfer may pose a threat to the health or safety of the you'll pay the standard premium amount and the pregnant person or unborn child),"Stabilize"means to additional IRMAA.For more information on the extra deliver(including the placenta). amount you may have to pay based on your income,visit Subscriber:A Member who is eligible for membership hti)s://www.medicare.2ov. on their own behalf and not by virtue of Dependent If you have to pay an extra amount, Social Security,not status and who meets the eligibility requirements as a your Medicare plan,will send you a letter telling you Subscriber(for Subscriber eligibility requirements,see what that extra amount will be. The extra amount will be "Who Is Eligible"in the"Premiums,Eligibility,and withheld from your Social Security,Railroad Retirement Enrollment"section). Board,or Office of Personnel Management benefit Surrogacy Arrangement:An arrangement in which an check,no matter how you usually pay your plan individual agrees to become pregnant and to surrender premium,unless your monthly benefit isn't enough to the baby(or babies)to another person or persons who cover the extra amount owed.If your benefit check isn't intend to raise the child(or children).The person may be enough to cover the extra amount,you will get a bill impregnated in any manner including,but not limited to, from Medicare.You must pay the extra amount to the artificial insemination,intrauterine insemination,in vitro government.If you do not pay the extra amount,you fertilization,or through the surgical implantation of a will be disenrolled from the plan and lose fertilized egg of another person.For the purposes of this prescription drug coverage. EOC,"Surrogacy Arrangements"includes all types of surrogacy arrangements,including traditional surrogacy If you disagree about paying an extra amount,you can arrangements and gestational surrogacy arrangements. ask Social Security to review the decision.To find out more about how to do this,contact Social Security at Telehealth Visits:Interactive video visits and scheduled 1-800-772-1213(TTY users call 1-800-325-0778). telephone visits between you and your provider. Urgent Care:Medically Necessary Services for a Medicare Part D late enrollment penalty condition that requires prompt medical attention but is Some members are required to pay a Part D late not an Emergency Medical Condition. enrollment penalty. The Part D late enrollment penalty is an additional premium that must be paid for Part D coverage if at any time after your initial enrollment Premiums, Eligibility, and period is over,there is a period of 63 days or more in a row when you did not have Part D or other creditable Enrollment prescription drug coverage."Creditable prescription drug coverage"is coverage that meets Medicare's minimum standards since it is expected to pay,on average,at least Premiums as much as Medicare's standard prescription drug coverage.The cost of the late enrollment penalty Please contact your Group for information about your depends on how long you went without Part D or other plan Premiums.You must also continue to pay Medicare creditable prescription drug coverage.You will have to your monthly Medicare premium. pay this penalty for as long as you have Part D coverage. The Part D late enrollment penalty is added to your plan If you do not have Medicare Part A,you may be eligible premium.Your Group or Health Plan will inform you if to purchase Medicare Part A from Social Security.Please the penalty applies to you. contact Social Security for more information.If you get Medicare Part A,this may reduce the amount you would Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 10 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. You will not have to pay it if: Copayments.This"Extra Help"also counts toward your out-of-pocket costs. • You receive"Extra Help"from Medicare to pay for your prescription drugs People with limited income and resources may qualify • You have gone less than 63 days in a row without for"Extra Help."If you automatically qualify for"Extra creditable coverage Help,"Medicare will mail you a letter.You will not have to apply.If you do not automatically qualify,you may be • You have had creditable drug coverage through able to get"Extra Help"to pay for your prescription drug another source such as a former employer,union, premiums and costs.To see if you qualify for getting TRICARE,or Veterans Health Administration(VA). "Extra Help,"call: Your insurer or your human resources department will tell you each year if your drug coverage is • 1-800-MEDICARE(1-800-633-4227)(TTY users creditable coverage. This information may be sent to call 1-877-486-2048),24 hours a day,seven days a you in a letter or included in a newsletter from the week; plan.Keep this information because you may need it • The Social Security Office at 1-800-772-1213(TTY if you join a Medicare drug plan later users call 1-800-325-0778),8 a.m.to 7 p.m.,Monday ♦ any notice must state that you had"creditable" through Friday;or prescription drug coverage that is expected to pay . Your state Medicaid office(see the"Important Phone as much as Medicare's standard prescription drug Numbers and Resources"section for contact plan pays information) ♦ the following are not creditable prescription drug coverage:prescription drug discount cards,free If you qualify for"Extra Help,"we will send you an clinics,and drug discount websites Evidence of Coverage Rider for People Who Get Extra Medicare determines the amount of the penalty.There Help Paying for Prescription Drugs(also known as the are three important things to note about this monthly Part Low Income Subsidy Rider or the LIS Rider),that D late enrollment penalty: explains your costs as a Member of our plan.If the amount of your"Extra Help"changes during the year, • First,the penalty may change each year because the we will also mail you an updated Evidence of Coverage average monthly premium can change each year Rider for People Who Get Extra Help Paying for • Second,you will continue to pay a penalty every Prescription Drugs. month for as long as you are enrolled in a plan that has Medicare Part D drug benefits,even if you Who Is Eligible change plans • Third,if you are under 65 and currently receiving To enroll and to continue enrollment,you must meet all of the eligibility requirements described in this Who Is Medicare benefits,the Part D late enrollment penalty Eligible"section,including your Group's eligibility will reset when you turn 65.After age 65,your Part D requirements and your Home Region Service Area late enrollment penalty will be based only on the months that you don't have coverage after your initial eligibility requirements. enrollment period for aging into Medicare Group eligibility requirements If you disagree about your Part D late enrollment You must meet your Group's eligibility requirements. penalty,you or your representative can ask for a Your Group is required to inform Subscribers of its review. Generally,you must request this review within eligibility requirements. 60 days from the date on the first letter you receive stating you have to pay a late enrollment penalty. Senior Advantage eligibility requirements However,if you were paying a penalty before joining our plan,you may not have another chance to request a • You must have Medicare Part B review of that late enrollment penalty. • You must be a United States citizen or lawfully present in the United States Medicare's "Extra Help" Program • Your Medicare coverage must be primary and your Medicare provides"Extra Help"to pay prescription drug Group's health care plan must be secondary costs for people who have limited income and resources. • You may not be enrolled in another Medicare Health Resources include your savings and stocks,but not your Plan or Medicare prescription drug plan home or car.If you qualify,you get help paying for any Medicare drug plan's monthly premium and prescription Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 11 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Note:If you are enrolled in a Medicare plan and lose • Prescription drugs from Non—Plan Pharmacies as Medicare eligibility,you may be able to enroll under described under"Outpatient Prescription Drugs, your Group's non-Medicare plan if that is permitted by Supplies,and Supplements"in the"Benefits and your Group(please ask your Group for details). Your Cost Share"section • Routine Services associated with Medicare-approved Service Area eligibility requirements clinical trials as described under"Services Associated with Clinical Trials"in the"Benefits and Your Cost You must live in our Service Area,unless you have been Share"section continuously enrolled in Senior Advantage since December 31, 1998,and lived outside our Service Area If you are not eligible to continue enrollment because during that entire time.In which case,you may continue you move to the service area of another Region,please your membership unless you move and are still outside contact your Group to learn about your Group health care your Home Region Service Area.The"Definitions" options.You may be able to enroll in the service area of section describes our Service Area and how it may another Region if there is an agreement between your change. Group and that Region,but the plan,including coverage, premiums,and eligibility requirements,might not be the Moving outside your Home Region Service Area. same as under this EOC. If you permanently move outside your Home Region Service Area,or you are temporarily absent from your For more information about the service areas of the other Home Region Service Area for a period of more than six Regions,please call Member Services. months in a row,you must notify us and you cannot continue your Senior Advantage membership under this Eligibility as a Subscriber EOC. You may be eligible to enroll and continue enrollment as Send your notice to: a Subscriber if you are: • An employee of your Group Kaiser Foundation Health Plan,Inc. . A proprietor or partner of your Group California Service Center P.O.Box 232400 • Otherwise entitled to coverage under a trust San Diego,CA 92193-2400 agreement,retirement benefit program,or employment contract(unless the Internal Revenue It is in your best interest to notify us as soon as possible Service considers you self-employed) because until your Senior Advantage coverage is officially terminated by the Centers for Medicare& Eligibility as a Dependent Medicaid Services,you will not be covered by us or Enrolling as a Dependent Original Medicare for any care you receive from Non— Dependent eligibility is subject to your Group's Plan Providers,except as described in the sections listed eligibility requirements,which are not described in this below for the following Services: EOC.You can obtain your Group's eligibility • Authorized referrals as described under"Getting a requirements directly from your Group.If you are a Referral"in the"How to Obtain Services"section Subscriber under this EOC: • Covered Services received outside of your Home • Your Spouse Region Service Area as described under"Receiving • Your or your Spouse's Dependent children,who meet Care Outside of Your Home Region Service Area"in the requirements described under"Age limit of the"How to Obtain Services"section Dependent children,"if they are any of the following: • Emergency ambulance Services as described under ♦ biological children "Ambulance Services"in the"Benefits and Your Cost ♦ stepchildren Share"section • Emergency Services,Post-Stabilization Care,and ♦ adopted children Out-of-Area Urgent Care as described in the ♦ children placed with you for adoption "Emergency Services and Urgent Care"section ♦ foster children if you or your Spouse have the • Out-of--area dialysis care as described under"Dialysis legal authority to direct their care Care"in the"Benefits and Your Cost Share"section ♦ children for whom you or your Spouse is the court-appointed guardian(or was when the child reached age 18) Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 12 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Children whose parent is a Dependent child under date coverage will end due to reaching the age limit. your family coverage(including adopted children and The Dependent's membership will terminate as children placed with your Dependent child for described in our notice unless the Subscriber provides adoption or foster care)if they meet all of the us documentation of the Dependent's incapacity and following requirements: dependency within 60 days of receipt of our notice ♦ they are not married and do not have a domestic and we determine that the Dependent is eligible as a partner(for the purposes of this requirement only, disabled dependent.If the Subscriber provides us this "domestic partner"means someone who is documentation in the specified time period and we do registered and legally recognized as a domestic not make a determination about eligibility before the partner by California) termination date,coverage will continue until we make a determination.If we determine that the ♦ they meet the requirements described under"Age Dependent does not meet the eligibility requirements limit of Dependent children" as a disabled dependent,we will notify the Subscriber ♦ they receive all of their support and maintenance that the Dependent is not eligible and let the from you or your Spouse Subscriber know the membership termination date. ♦ they permanently reside with you or your Spouse If we determine that the Dependent is eligible as a disabled dependent,there will be no lapse in Age limit of Dependent children coverage.Also,starting two years after the date that Children must be under age 26 as of the effective date of the Dependent reached the age limit,the Subscriber this EOC to enroll as a Dependent under your plan. must provide us documentation of the Dependent's incapacity and dependency annually within 60 days Dependent children are eligible to remain on the plan after we request it so that we can determine if the through the end of the month in which they reach the age Dependent continues to be eligible as a disabled limit. dependent • If the child is not a Member because you are changing Dependent children of the Subscriber or Spouse coverage,you must give us proof,within 60 days (including adopted children and children placed with you after we request it,of the child's incapacity and for adoption,but not including children placed with you dependency as well as proof of the child's coverage for foster care)who reach the age limit may continue under your prior coverage.In the future,you must coverage under this EOC if all of the following provide proof of the child's continued incapacity and conditions are met: dependency within 60 days after you receive our • They meet all requirements to be a Dependent except request,but not more frequently than annually for the age limit Dependents not eligible to enroll under a Senior • Your Group permits enrollment of Dependents Advantage plan.If you have dependents who do not • They are incapable of self-sustaining employment have Medicare Part B coverage or for some other reason because of a physically-or mentally-disabling injury, are not eligible to enroll under this EOC,you may be illness,or condition that occurred before they reached able to enroll them as your dependents under a non- the age limit for Dependents Medicare plan offered by your Group.Please contact • They receive 50 percent or more of their support and your Group for details,including eligibility and benefit maintenance from you or your Spouse information,and to request a copy of the non-Medicare plan document. • If requested,you give us proof of their incapacity and dependency within 60 days after receiving our request (see"Disabled Dependent certification"below in this How to Enroll and When Coverage "Eligibility as a Dependent"section) Begins Disabled Dependent certification Your Group is required to inform you when you are Proof may be required for a Dependent to be eligible to eligible to enroll and what your effective date of continue coverage as a disabled Dependent.If we request coverage is.If you are eligible to enroll as described it,the Subscriber must provide us documentation of the under"Who Is Eligible"in this"Premiums,Eligibility, dependent's incapacity and dependency as follows: and Enrollment"section,enrollment is permitted as described below and membership begins at the beginning • If the child is a Member,we will send the Subscriber (12:00 a.m.)of the effective date of coverage indicated a notice of the Dependent's membership termination below,except that: due to loss of eligibility at least 90 days before the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 13 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Your Group may have additional requirements,which Group open enrollment allow enrollment in other situations You may enroll as a Subscriber(along with any eligible • The effective date of your Senior Advantage coverage Dependents),and existing Subscribers may add eligible under this EOC must be confirmed by the Centers for Dependents,by submitting a Health Plan—approved Medicare&Medicaid Services,as described under enrollment application,and a Senior Advantage Election "Effective date of Senior Advantage coverage"in this Form for each person to your Group during your Group's "How to Enroll and When Coverage Begins"section open enrollment period.Your Group will let you know when the open enrollment period begins and ends and the If you are a Subscriber under this EOC and you have effective date of coverage,which is subject to dependents who do not have Medicare Part B coverage or confirmation by the Centers for Medicare&Medicaid for some other reason are not eligible to enroll under this Services. EOC,you may be able to enroll them as your dependents under a non-Medicare plan offered by your Group.Please Special enrollment contact your Group for details,including eligibility and If you do not enroll when you are first eligible and later benefit information,and to request a copy of the non- want to enroll,you can enroll only during open Medicare plan document. enrollment unless one of the following is true: • You become eligible because you experience a If you are eligible to be a Dependent under this EOC but the qualifying event(sometimes called a"triggering subscriber in your family is enrolled under a non-Medicare event")as described in this"Special enrollment" plan offered by your Group,the subscriber must follow the section rules applicable to Subscribers who are enrolling • You did not enroll in any coverage offered by your Dependents in this"How to Enroll and When Coverage Group when you were first eligible and your Group Begins"section. does not give us a written statement that verifies you Effective date of Senior Advantage coverage signed a document that explained restrictions about enrolling in the future. Subject to confirmation by the After we receive your completed Senior Advantage Centers for Medicare&Medicaid Services,the Election Form,we will submit your enrollment request to effective date of an enrollment resulting from this the Centers for Medicare&Medicaid Services for provision is no later than the first day of the month confirmation and send you a notice indicating the following the date your Group receives a Health proposed effective date of your Senior Advantage Plan—approved enrollment or change of enrollment coverage under this EOC. application,and a Senior Advantage Election Form for each person,from the Subscriber If the Centers for Medicare&Medicaid Services confirms your Senior Advantage enrollment and Special enrollment due to new Dependents effective date,we will send you a notice that confirms You may enroll as a Subscriber(along with eligible your enrollment and effective date.If the Centers for Dependents),and existing Subscribers may add eligible Medicare&Medicaid Services tells us that you do not Dependents,within 30 days after marriage,establishment have Medicare Part B coverage,we will notify you that of domestic partnership,birth,adoption,placement for you will be disenrolled from Senior Advantage. adoption,or placement for foster care by submitting to New employees your Group a Health Plan—approved enrollment application,and a Senior Advantage Election Form for When your Group informs you that you are eligible to each person. enroll as a Subscriber,you may enroll yourself and any eligible Dependents by submitting a Health Plan— Subject to confirmation by the Centers for Medicare& approved enrollment application,and a Senior Medicaid Services,the effective date of an enrollment Advantage Election Form for each person,to your Group resulting from marriage or establishment of domestic within 31 days. partnership is no later than the first day of the month following the date your Group receives an enrollment Effective date of Senior Advantage coverage.The application,and a Senior Advantage Election Form for effective date of Senior Advantage coverage for new each person,from the Subscriber. Subject to employees and their eligible family Dependents or newly confirmation by the Centers for Medicare&Medicaid acquired Dependents,is determined by your Group, Services,enrollments of newly acquired Dependent subject to confirmation by the Centers for Medicare& children are effective as follows: Medicaid Services. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 14 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Enrollments due to birth are effective on the date of change of enrollment application,and Senior Advantage birth Election Form for each person,from the Subscriber. • Enrollments due to adoption are effective on the date of adoption Special enrollment due to court or administrative order.Within 31 days after the date of a court or • Enrollments due to placement for adoption or foster administrative order requiring a Subscriber to provide care are effective on the date you or your Spouse have health care coverage for a Spouse or child who meets the newly assumed a legal right to control health care eligibility requirements as a Dependent,the Subscriber may add the Spouse or child as a Dependent by Special enrollment due to loss of other coverage.You submitting to your Group a Health Plan—approved may enroll as a Subscriber(along with any eligible enrollment or change of enrollment application,and a Dependents),and existing Subscribers may add eligible Senior Advantage Election Form for each person. Dependents,if all of the following are true: • The Subscriber or at least one of the Dependents had Subject to confirmation by the Centers for Medicare& other coverage when they previously declined all Medicaid Services,the effective date of coverage coverage through your Group resulting from a court or administrative order is the first of the month following the date we receive the • The loss of the other coverage is due to one of the enrollment request,unless your Group specifies a following: different effective date(if your Group specifies a ♦ exhaustion of COBRA coverage different effective date,the effective date cannot be ♦ termination of employer contributions for non- earlier than the date of the order). COBRA coverage ♦ loss of eligibility for non-COBRA coverage,but Special enrollment due to eligibility for premium not termination for cause or termination from an assistance.You may enroll as a Subscriber(along with individual(nongroup)plan for nonpayment.For eligible Dependents),and existing Subscribers may add example,this loss of eligibility may be due to legal eligible Dependents,if you or a dependent become separation or divorce,moving out of the plan's eligible for premium assistance through the Medi-Cal service area,reaching the age limit for dependent program.Premium assistance is when the Medi-Cal children,or the subscriber's death,termination of program pays all or part of premiums for employer group employment,or reduction in hours of employment coverage for a Medi-Cal beneficiary. To request ♦ loss of eligibility(but not termination for cause) enrollment in your Group's health care coverage,the for coverage through Covered California, Subscriber must submit a Health Plan—approved Medicaid coverage(known as Medi-Cal in enrollment or change of enrollment application,and a California),Children's Health Insurance Program Senior Advantage Election Form for each person,to your coverage,or Medi-Cal Access Program coverage Group within 60 days after you or a dependent become eligible for premium assistance.Please contact the ♦ reaching a lifetime maximum on all benefits California Department of Health Care Services to find out if premium assistance is available and the eligibility Note:If you are enrolling yourself as a Subscriber along requirements. with at least one eligible Dependent,only one of you must meet the requirements stated above. Special enrollment due to reemployment after military service.If you terminated your health care To request enrollment,the Subscriber must submit a coverage because you were called to active duty in the Health Plan—approved enrollment or change of military service,you may be able to reenroll in your enrollment application,and a Senior Advantage Election Group's health plan if required by state or federal law. Form for each person,to your Group within 30 days after Please ask your Group for more information. loss of other coverage,except that the timeframe for submitting the application is 60 days if you are requesting enrollment due to loss of eligibility for coverage through Covered California,Medicaid, How to Obtain Services Children's Health Insurance Program,or Medi-Cal Access Program coverage. Subject to confirmation by As a Member,you are selecting our medical care the Centers for Medicare&Medicaid Services,the program to provide your health care.You must receive effective date of an enrollment resulting from loss of all covered care from Plan Providers inside our Service other coverage is no later than the first day of the month following the date your Group receives an enrollment or Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 15 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Area,except as described in the sections listed below for Our Advice Nurses the following Services: • Authorized referrals as described under"Getting a We know that sometimes it's difficult to know what type Referral"in this"How to Obtain Services"section of care you need.That's why we have telephone advice nurses available to assist you.Our advice nurses are • Covered Services received outside of your Home registered nurses specially trained to help assess medical Region Service Area as described under"Receiving symptoms and provide advice over the phone,when Care Outside of Your Home Region Service Area"in medically appropriate.Whether you are calling for this"How to Obtain Services"section advice or to make an appointment,you can speak to an • Emergency ambulance Services as described under advice nurse.They can often answer questions about a "Ambulance Services"in the"Benefits and Your Cost minor concern,tell you what to do if a Plan Medical Share"section Office is closed,or advise you about what to do next, including making a same-day Urgent Care appointment • Emergency Services,Post-Stabilization Care,and for you if it's medically appropriate.To reach an advice Out-of--Area Urgent Care as described in the nurse,refer to our Provider Directory or call Member "Emergency Services and Urgent Care"section Services. • Out-of-area dialysis care as described under"Dialysis Care"in the"Benefits and Your Cost Share"section • Prescription drugs from Non—Plan Pharmacies as Your Personal Plan Physician described under"Outpatient Prescription Drugs, Personal Plan Physicians provide primary care and play Supplies,and Supplements"in the"Benefits and an important role in coordinating care,including hospital Your Cost Share"section stays and referrals to specialists. • Routine Services associated with Medicare-approved clinical trials as described under"Services Associated We encourage you to choose a personal Plan Physician. with Clinical Trials"in the"Benefits and Your Cost You may choose any available personal Plan Physician. Share"section Parents may choose a pediatrician as the personal Plan Physician for their child. Most personal Plan Physicians Our medical care program gives you access to all of the are Primary Care Physicians(generalists in internal covered Services you may need,such as routine care medicine,pediatrics,or family practice,or specialists in with your own personal Plan Physician,hospital obstetrics/gynecology whom the Medical Group Services,laboratory and pharmacy Services,Emergency designates as Primary Care Physicians). Some specialists Services,Urgent Care,and other benefits described in who are not designated as Primary Care Physicians but this EOC. who also provide primary care may be available as personal Plan Physicians.For example,some specialists in internal medicine and obstetrics/gynecology who are Routine Care not designated as Primary Care Physicians may be available as personal Plan Physicians.However,if you To request a non-urgent appointment,you can call your choose a specialist who is not designated as a Primary local Plan Facility or request the appointment online.For Care Physician as your personal Plan Physician,the Cost appointment phone numbers,refer to our Provider Share for a Physician Specialist Visit will apply to all Directory or call Member Services.To request an visits with the specialist except for Preventive Services appointment online,go to our website at kp•org. listed in the"Benefits and Your Cost Share"section. Urgent Care To learn how to select or change to a different personal Plan Physician,visit our website at kp•org,or call An Urgent Care need is one that requires prompt medical Member Services.Refer to our Provider Directory for a attention but is not an Emergency Medical Condition. list of physicians that are available as Primary Care If you think you may need Urgent Care,call the Physicians.The directory is updated periodically.The appropriate appointment or advice phone number at a availability of Primary Care Physicians may change.If Plan Facility.For phone numbers,refer to our Provider you have questions,please call Member Services.You Directory or call Member Services. can change your personal Plan Physician at any time for any reason. For information about Out-of-Area Urgent Care,refer to "Urgent Care"in the"Emergency Services and Urgent Care"section. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 16 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Getting a Referral Utilization Management("UM")is a process that determines whether a Service recommended by your Referrals to Plan Providers treating provider is Medically Necessary for you.Prior A Plan Physician must refer you before you can receive authorization is a UM process that determines whether care from specialists,such as specialists in surgery, the requested services are Medically Necessary before orthopedics,cardiology,oncology,dermatology,and care is provided. If it is Medically Necessary,then you physical,occupational,and speech therapies.However, will receive authorization to obtain that care in a you do not need a referral or prior authorization to clinically appropriate place consistent with the terms of receive most care from any of the following Plan your health coverage.Decisions regarding requests for Providers: authorization will be made only by licensed physicians • Your personal Plan Physician or other appropriately licensed medical professionals. • Generalists in internal medicine,pediatrics,and For the complete list of Services that require prior family practice authorization,and the criteria that are used to make • Specialists in optometry,mental health Services, authorization decisions,please visit our website at substance use disorder treatment,and ky.orE/UM or call Member Services to request a printed obstetrics/gynecology copy.Refer to"Post-Stabilization Care"under "Emergency Services"in the"Emergency Services and A Plan Physician must refer you before you can get care Urgent Care"section for authorization requirements that from a specialist in urology except that you do not need a apply to Post-Stabilization Care from Non—Plan referral to receive Services related to sexual or Providers. reproductive health,such as a vasectomy. Additional information about prior authorization for Although a referral or prior authorization is not required durable medical equipment,ostomy,urological,and to receive most care from these providers,a referral may specialized wound care supplies.The prior be required in the following situations: authorization process for durable medical equipment, ostomy,urological,and specialized wound care supplies • The provider may have to get prior authorization for includes the use of formulary guidelines. These certain Services in accord with"Medical Group guidelines were developed by a multidisciplinary clinical authorization procedure for certain referrals"in this and operational work group with review and input from "Getting a Referral"section Plan Physicians and medical professionals with clinical • The provider may have to refer you to a specialist expertise.The formulary guidelines are periodically who has a clinical background related to your illness updated to keep pace with changes in medical or condition technology,Medicare guidelines,and clinical practice. Standing referrals If your Plan Physician prescribes one of these items,they If a Plan Physician refers you to a specialist,the referral will submit a written referral in accord with the UM will be for a specific treatment plan.Your treatment plan process described in this"Medical Group authorization may include a standing referral if ongoing care from the procedure for certain referrals"section. If the formulary specialist is prescribed.For example,if you have a life- guidelines do not specify that the prescribed item is threatening,degenerative,or disabling condition,you can appropriate for your medical condition,the referral will get a standing referral to a specialist if ongoing care from be submitted to the Medical Group's designee Plan the specialist is required. Physician,who will make an authorization decision as described under"Medical Group's decision time frames" Medical Group authorization procedure for in this"Medical Group authorization procedure for certain referrals certain referrals"section. The following are examples of Services that require prior authorization by the Medical Group for the Services to Medical Group's decision time frames.The applicable be covered("prior authorization"means that the Medical Medical Group designee will make the authorization Group must approve the Services in advance): decision within the time frame appropriate for your • Durable medical equipment condition,but no later than five business days after receiving all of the information(including additional • Ostomy and urological supplies examination and test results)reasonably necessary to • Services not available from Plan Providers make the decision,except that decisions about urgent Services will be made no later than 72 hours after receipt • Transplants of the information reasonably necessary to make the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 17 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. decision.If the Medical Group needs more time to make reimbursement,refer to the Travel and Lodging Program the decision because it doesn't have information Description.The Travel and Lodging Program reasonably necessary to make the decision,or because it Description is available online at ku.org/suecialty- has requested consultation by a particular specialist,you care/travel-reimbursements or by calling Member and your treating physician will be informed about the Services. additional information,testing,or specialist that is needed,and the date that the Medical Group expects to make a decision. Second Opinions Your treating physician will be informed of the decision If you want a second opinion,you can ask Member within 24 hours after the decision is made.If the Services Services to help you arrange one with a Plan Physician are authorized,your physician will be informed of the who is an appropriately qualified medical professional scope of the authorized Services.If the Medical Group for your condition. If there isn't a Plan Physician who is does not authorize all of the Services,Health Plan will an appropriately qualified medical professional for your send you a written decision and explanation within two condition,Member Services will help you arrange a business days after the decision is made.Any written consultation with a Non—Plan Physician for a second criteria that the Medical Group uses to make the decision opinion.For purposes of this"Second Opinions" to authorize,modify,delay,or deny the request for provision,an"appropriately qualified medical authorization will be made available to you upon request. professional"is a physician who is acting within their scope of practice and who possesses a clinical If the Medical Group does not authorize all of the background,including training and expertise,related to Services requested and you want to appeal the decision, the illness or condition associated with the request for a you can file a grievance as described in the"Coverage second medical opinion. Decisions,Appeals,and Complaints"section. Here are some examples of when a second opinion may For these referral Services,you pay the Cost Share be provided or authorized: required for Services provided by a Plan Provider as • Your Plan Physician has recommended a procedure described in this EOC. and you are unsure about whether the procedure is reasonable or necessary • You question a diagnosis or plan of care for a Travel and Lodging for Certain Services condition that threatens substantial impairment or loss of life,limb,or bodily functions The following are examples of when we will arrange or . The clinical indications are not clear or are complex provide reimbursement for certain travel and lodging expenses in accord with our Travel and Lodging and confusing Program Description: • A diagnosis is in doubt due to conflicting test results • If Medical Group refers you to a provider that is more • The Plan Physician is unable to diagnose the than 50 miles from where you live for certain condition specialty Services such as bariatric surgery,complex . The treatment plan in progress is not improving your thoracic surgery,transplant nephrectomy,or inpatient medical condition within an appropriate period of chemotherapy for leukemia and lymphoma time,given the diagnosis and plan of care • If Medical Group refers you to a provider that is • You have concerns about the diagnosis or plan of care outside your Home Region Service Area for certain specialty Services such as a transplant or transgender An authorization or denial of your request for a second surgery opinion will be provided in an expeditious manner,as • If you are outside of California and you need an appropriate for your condition.If your request for a abortion on an emergency or urgent basis,and the second opinion is denied,you will be notified in writing abortion can't be obtained in a timely manner due to a of the reasons for the denial and of your right to file a near total or total ban on health care providers' ability grievance as described in the"Coverage Decisions, to provide such Services Appeals,and Complaints"section. For the complete list of specialty Services for which we For these referral Services,you pay the Cost Share will arrange or provide reimbursement for travel and required for Services provided by a Plan Provider as lodging expenses,the amount of reimbursement, described in this EOC. limitations and exclusions,and how to request Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 18 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Contracts with Plan Providers For the Services of a terminated provider,you pay the Cost Share required for Services provided by a Plan How Plan Providers are paid Provider as described in this EOC. Health Plan and Plan Providers are independent contractors.Plan Providers are paid in a number of ways, More information.For more information about this such as salary,capitation,per diem rates,case rates,fee provision,or to request the Services,please call Member for service,and incentive payments. To learn more about Services. how Plan Physicians are paid to provide or arrange medical and hospital Services for Members,please visit our website at kp.org or call Member Services. Receiving Care Outside of Your Home Region Service Area Financial liability Our contracts with Plan Providers provide that you are For information about your coverage when you are away not liable for any amounts we owe.However,you may from home,visit our website at kp.org/travel.You can have to pay the full price of noncovered Services you also call the Away from Home Travel Line at obtain from Plan Providers or Non—Plan Providers. 1-951-268-3900,24 hours a day,seven days a week (closed holidays). When you are referred to a Plan Provider for covered Services,you pay the Cost Share required for Services Receiving care in another Kaiser Permanente from that provider as described in this EOC. service area If you are visiting in another Kaiser Permanente service Termination of a Plan Provider's contract and area,you may receive certain covered Services from completion of Services designated providers in that other Kaiser Permanente If our contract with any Plan Provider terminates while service area,subject to exclusions,limitations,prior you are under the care of that provider,we will retain authorization or approval requirements,and reductions. financial responsibility for the covered Services you For more information about receiving covered Services receive from that provider until we make arrangements in another Kaiser Permanente service area,including for the Services to be provided by another Plan Provider provider and facility locations,please visit ky.org/travel and notify you of the arrangements. or call our Away from Home Travel Line at 1-951-268- 3900,24 hours a day,seven days a week(closed Completion of Services.If you are undergoing holidays). treatment for specific conditions from a Plan Physician (or certain other providers)when the contract with him Receiving care outside of any Kaiser or her ends(for reasons other than medical disciplinary Permanente service area cause,criminal activity,or the provider's voluntary If you are traveling outside of any Kaiser Permanente termination),you may be eligible to continue receiving service area,we cover Services as described in the covered care from the terminated provider for your "Emergency Services and Urgent Care"section about condition. The conditions that are subject to this Emergency Services,Post-Stabilization Care,and Out- continuation of care provision are: of-Area Urgent Care and the"Benefits and Your Cost Share"section about out-of-area dialysis care. • Certain conditions that are either acute,or serious and chronic.We may cover these Services for up to 90 days,or longer,if necessary for a safe transfer of care Your ID Card to a Plan Physician or other contracting provider as determined by the Medical Group Each Member's Kaiser Permanente ID card has a • A high-risk pregnancy or a pregnancy in its second or medical record number on it,which you will need when third trimester.We may cover these Services through you call for advice,make an appointment,or go to a postpartum care related to the delivery,or longer provider for covered care.When you get care,please if Medically Necessary for a safe transfer of care to a bring your Kaiser Permanente ID card and a photo ID. Plan Physician as determined by the Medical Group Your medical record number is used to identify your medical records and membership information.Your medical record number should never change.Please call The Services must be otherwise covered under this EOC. Member Services if we ever inadvertently issue you Also,the terminated provider must agree in writing to more than one medical record number or if you need to our contractual terms and conditions and comply with replace your Kaiser Permanente ID card. them for Services to be covered by us. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 19 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Your ID card is for identification only.To receive Plan Facilities covered Services,you must be a current Member. Anyone who is not a Member will be billed as a non- Plan Medical Offices and Plan Hospitals are listed in the Member for any Services they receive.If you let Provider Directory for your Home Region.The directory someone else use your ID card,we may keep your ID describes the types of covered Services that are available card and terminate your membership as described under from each Plan Facility,because some facilities provide "Termination for Cause"in the"Termination of only specific types of covered Services.This directory is Membership"section. available on our website at kp.or2/facilities.To obtain a Your Medicare card printed copy,call Member Services.The directory is updated periodically.The availability of Plan Facilities Do NOT use your red,white,and blue Medicare card for may change.If you have questions,please call Member covered medical Services while you are a Member of this Services. plan.If you use your Medicare card instead of your Senior Advantage membership card,you may have to At most of our Plan Facilities,you can usually receive all pay the full cost of medical services yourself.Keep your of the covered Services you need,including specialty Medicare card in a safe place.You may be asked to show care,pharmacy,and lab work.You are not restricted to a it if you need hospice services or participate in routine particular Plan Facility,and we encourage you to use the research studies. facility that will be most convenient for you: • All Plan Hospitals provide inpatient Services and are Getting Assistance open 24 hours a day, seven days a week We want you to be satisfied with the health care you • Emergency Services are available from Plan Hospital receive from Kaiser Permanente.If you have any Emergency Departments(for Emergency Department questions or concerns,please discuss them with your locations,refer to our Provider Directory or call personal Plan Physician or with other Plan Providers Member Services) who are treating you.They are committed to your • Same-day Urgent Care appointments are available at satisfaction and want to help you with your questions. many locations(for Urgent Care locations,refer to our Provider Directory or call Member Services) Member Services • Many Plan Medical Offices have evening and Member Services representatives can answer any weekend appointments questions you have about your benefits,available Services,and the facilities where you can receive care. • Many Plan Facilities have a Member Services office For example,they can explain the following: (for locations,refer to our Provider Directory or call Member Services) • Your Health Plan benefits • Plan Pharmacies are located at most Plan Medical • How to make your first medical appointment Offices(refer to our Kaiser Permanente Pharmacy • What to do if you move Directory for pharmacy locations) • How to replace your Kaiser Permanente ID card Provider Directory Many Plan Facilities have an office staffed with representatives who can provide assistance if you need The Provider Directory lists our Plan Providers.It is help obtaining Services.At different locations,these subject to change and periodically updated. If you don't offices may be called Member Services,Patient have our Provider Directory,you can get a copy by Assistance,or Customer Service.In addition,Member calling Member Services or by visiting our website at Services representatives are available to assist you seven kp.ore/directory. days a week from 8 a.m.to 8 p.m.toll free at 1-800-443- 0815 or 711 (TTY for the deaf,hard of hearing,or speech impaired).For your convenience,you can also Pharmacy Directory contact us through our website at kp.ora. The Kaiser Permanente Pharmacy Directory lists the Cost Share estimates locations of Plan Pharmacies,which are also called "network pharmacies."The pharmacy directory provides For information about estimates,see"Getting an additional information about obtaining prescription estimate of your Cost Share"under"Your Cost Share"in drugs.It is subject to change and periodically updated. the"Benefits and Your Cost Share"section. If you don't have the Kaiser Permanente Pharmacy Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 20 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Directory,you can get a copy by calling Member Your Cost Share Services or by visiting our website at kp.org/directory. Your Cost Share for covered Emergency Services and Post-Stabilization Care is described in the`Benefits and Your Cost Share"section.Your Cost Share is the same Emergency Services and Urgent whether you receive the Services from a Plan Provider or a Non—Plan Provider.For example: Care • If you receive Emergency Services in the Emergency Department of a Non—Plan Hospital,you pay the Cost Emer lency Services Share for an Emergency Department visit as described under"Outpatient Care" If you have an Emergency Medical Condition,call 911 • If we gave prior authorization for inpatient Post- (where available)or go to the nearest Emergency Stabilization Care in a Non—Plan Hospital,you pay Department.You do not need prior authorization for the Cost Share for hospital inpatient care as described Emergency Services.When you have an Emergency under"Hospital Inpatient Care" Medical Condition,we cover Emergency Services you receive from Plan Providers or Non—Plan Providers anywhere in the world. Urgent Care Emergency Services are available from Plan Hospital Inside your Home Region Service Area Emergency Departments 24 hours a day, seven days a An Urgent Care need is one that requires prompt medical week. attention but is not an Emergency Medical Condition. If you think you may need Urgent Care,call the Post-Stabilization Care appropriate appointment or advice phone number at a Post-Stabilization Care is Medically Necessary Services Plan Facility.For appointment and advice phone related to your Emergency Medical Condition that you numbers,refer to our Provider Directory or call Member receive in a hospital(including the Emergency Services. Department)after your treating physician determines that your condition is Stabilized. In the event of unusual circumstances that delay or render impractical the provision of Services under this To request prior authorization,the Non—Plan Provider EOC(such as a major disaster,epidemic,war,riot,and must call 1-800-225-8883 or the notification phone civil insurrection),we cover Urgent Care inside our number on your Kaiser Permanente ID card before you Service Area from a Non—Plan Provider. receive the care.We will discuss your condition with the Non—Plan Provider.If we determine that you require Out-of-Area Urgent Care Post-Stabilization Care and that this care is part of your If you need Urgent Care due to an unforeseen illness or covered benefits,we will authorize your care from the unforeseen injury,we cover Medically Necessary Non—Plan Provider or arrange to have a Plan Provider(or Services to prevent serious deterioration of your health other designated provider)provide the care with the from a Non—Plan Provider if all of the following are true: treating physician's concurrence.If we decide to have a . You receive the Services from Non—Plan Providers Plan Hospital,Plan Skilled Nursing Facility,or while you are temporarily outside our Service Area designated Non—Plan Provider provide your care,we may authorize special transportation services that are • A reasonable person would have believed that your medically required to get you to the provider.This may health would seriously deteriorate if you delayed include transportation that is otherwise not covered. treatment until you returned to our Service Area Be sure to ask the Non—Plan Provider to tell you what You do not need prior authorization for Out-of-Area care(including any transportation)we have authorized Urgent Care.We cover Out-of-Area Urgent Care you because we will not cover unauthorized Post- receive from Non—Plan Providers if the Services would Stabilization Care or related transportation provided by have been covered under this EOC if you had received Non—Plan Providers.If you receive care from a Non— them from Plan Providers. Plan Provider that we have not authorized,you may have to pay the full cost of that care if you are notified by the We do not cover follow-up care from Non—Plan Non—Plan Provider or us about your potential liability. Providers after you no longer need Urgent Care.To obtain follow-up care from a Plan Provider,call the appointment or advice phone number at a Plan Facility. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 21 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. For phone numbers,refer to our Provider Directory or Benefits and Your Cost Share call Member Services. This section describes the Services that are covered Your Cost Share under this EOC. Your Cost Share for covered Urgent Care is the Cost Services are covered under this EOC as specifically Share required for Services provided by Plan Providers described in this EOC. Services that are not specifically as described in this EOC.For example: described in this EOC are not covered,except as required • If you receive an Urgent Care evaluation as part of by federal law. Services are subject to exclusions and covered Out-of-Area Urgent Care from a Non—Plan limitations described in the"Exclusions,Limitations, Provider,you pay the Cost Share for Urgent Care Coordination of Benefits,and Reductions"section. consultations,evaluations,and treatment as described Except as otherwise described in this EOC,all of the under"Outpatient Care" following conditions must be satisfied: • If the Out-of-Area Urgent Care you receive includes • You are a Member on the date that you receive the an X-ray,you pay the Cost Share for an X-ray as Services described under"Outpatient Imaging,Laboratory,and • The Services are Medically Necessary Other Diagnostic and Treatment Services"in addition to the Cost Share for the Urgent Care evaluation • The Services are one of the following: ♦ Preventive Services Note:If you receive Urgent Care in an Emergency ♦ health care items and services for diagnosis, Department,you pay the Cost Share for an Emergency assessment,or treatment Department visit as described under"Outpatient Care." ♦ health education covered under"Health Education"in this`Benefits and Your Cost Share" Payment and Reimbursement section ♦ other health care items and services If you receive Emergency Services,Post-Stabilization ♦ other services to treat Serious Emotional Care,or Urgent Care from a Non—Plan Provider as Disturbance of a Child Under Age 18 or Severe described in this"Emergency Services and Urgent Care" Mental Illness section,or emergency ambulance Services described under"Ambulance Services"in the`Benefits and Your • The Services are provided,prescribed,authorized,or Cost Share"section,ask the Non—Plan Provider to directed by a Plan Physician except for: submit a claim to us within 60 days or as soon as ♦ covered Services received outside of your Home possible,but no later than 15 months after receiving the Region Service Area,as described under care(or up to 27 months according to Medicare rules,in "Receiving Care Outside of Your Home Region some cases). If the provider refuses to bill us,send us the Service Area"in the"How to Obtain Services" unpaid bill with a claim form.Also,if you receive section Services from a Plan Provider that are prescribed by a ♦ drugs prescribed by dentists,as described under Non—Plan Provider as part of covered Emergency "Outpatient Prescription Drugs, Supplies,and Services,Post-Stabilization Care,and Urgent Care(for Supplements"in this"Benefits and Your Cost example,drugs),you may be required to pay for the Share"section Services and file a claim.To request payment or ♦ emergency ambulance Services,as described reimbursement,you must file a claim as described in the under"Ambulance Services"in this"Benefits and "Requests for Payment"section. Your Cost Share"section We will reduce any payment we make to you or the ♦ Emergency Services,Post-Stabilization Care,and Non—Plan Provider by the applicable Cost Share.Also, Out-of-Area Urgent Care,as described in the in accord with applicable law,we will reduce our "Emergency Services and Urgent Care"section payment by any amounts paid or payable(or that in the ♦ eyeglasses and contact lenses prescribed by Non— absence of this plan would have been payable)for the Plan Providers,as described under"Vision Services under any insurance policy,or any other Services"in this`Benefits and Your Cost Share" contract or coverage,or any government program except section Medicaid. ♦ out-of-area dialysis care,as described under "Dialysis Care"in this"Benefits and Your Cost Share"section Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 22 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. ♦ routine Services associated with Medicare- Services that are subject to the Plan Deductible,your approved clinical trials,as described under Cost Share for those Services will be Charges until you "Services Associated with Clinical Trials"in this reach the Plan Deductible. "Benefits and Your Cost Share"section • You receive the Services from Plan Providers inside General rules, examples, and exceptions our Service Area,except for: Your Cost Share for covered Services will be the Cost ♦ authorized referrals,as described under"Getting a Share in effect on the date you receive the Services, Referral"in the"How to Obtain Services"section except as follows: ♦ covered Services received outside of your Home • If you are receiving covered hospital inpatient Region Service Area,as described under Services on the effective date of this EOC,you pay "Receiving Care Outside of Your Home Region the Cost Share in effect on your admission date until Service Area"in the"How to Obtain Services" you are discharged if the Services were covered under section your prior Health Plan evidence of coverage and there ♦ emergency ambulance Services,as described has been no break in coverage.However,if the Services were not covered under your prior Health under"Ambulance Services"in this"Benefits and Plan evidence of coverage,or if there has been a Your Cost Share"section break in coverage,you pay the Cost Share in effect on ♦ Emergency Services,Post-Stabilization Care,and the date you receive the Services Out-of-Area Urgent Care,as described in the • For items ordered in advance "Emergency Services and Urgent Care"section ,you pay the Cost Share in effect on the order date(although we will not cover ♦ out-of-area dialysis care,as described under the item unless you still have coverage for it on the "Dialysis Care"in this"Benefits and Your Cost date you receive it)and you may be required to pay Share"section the Cost Share when the item is ordered.For ♦ prescription drugs from Non—Plan Pharmacies,as outpatient prescription drugs,the order date is the described under"Outpatient Prescription Drugs, date that the pharmacy processes the order after Supplies,and Supplements"in this"Benefits and receiving all of the information they need to fill the Your Cost Share"section prescription ♦ routine Services associated with Medicare- approved clinical trials,as described under Payment toward your Cost Share(and when you may "Services Associated with Clinical Trials"in this be billed) "Benefits and Your Cost Share"section In most cases,your provider will ask you to make a • The Medical Group has given prior authorization for payment toward your Cost Share at the time you receive the Services,if required,as described under"Medical Services.If you receive more than one type of Services Group authorization procedure for certain referrals" (such as primary care treatment and laboratory tests),you in the"How to Obtain Services"section may be required to pay separate Cost Share for each of those Services.Keep in mind that your payment toward Please also refer to: your Cost Share may cover only a portion of your total Cost Share for the Services you receive,and you will be • The"Emergency Services and Urgent Care"section billed for any additional amounts that are due.The for information about how to obtain covered following are examples of when you may be asked to Emergency Services,Post-Stabilization Care,and pay(or you may be billed for)Cost Share amounts in Out-of-Area Urgent Care addition to the amount you pay at check-in: • Our Provider Directory for the types of covered • You receive non-preventive Services during a Services that are available from each Plan Facility, preventive visit.For example,you go in for a routine because some facilities provide only specific types of physical exam,and at check-in you pay your Cost covered Services Share for the preventive exam(your Cost Share may be"no charge").However,during your preventive Your Cost Share exam your provider finds a problem with your health and orders non-preventive Services to diagnose your Your Cost Share is the amount you are required to pay problem(such as laboratory tests).You may be asked for covered Services.The Cost Share for covered to pay(or you will be billed for)your Cost Share for Services is listed in this EOC.For example,your Cost these additional non-preventive diagnostic Services Share may be a Copayment or Coinsurance.If your • You receive diagnostic Services during a treatment coverage includes a Plan Deductible and you receive visit.For example,you go in for treatment of an Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 23 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. existing health condition,and at check-in you pay receive care.You are not responsible for any amounts your Cost Share for a treatment visit.However, beyond your Cost Share for the covered Services you during the visit your provider finds a new problem receive at Plan Facilities or at contracted facilities where with your health and performs or orders diagnostic we have authorized you to receive care.However,if the Services(such as laboratory tests).You may be asked provider does not agree to bill us,you may have to pay to pay(or you will be billed for)your Cost Share for for the Services and file a claim for reimbursement.For these additional diagnostic Services information on how to file a claim,please see the • You receive treatment Services during a diagnostic "Requests for Payment"section. visit.For example,you go in for a diagnostic exam, and at check-in you pay your Cost Share fora Primary Care Visits,Non-Physician Specialist Visits, diagnostic exam.However,during the diagnostic and Physician Specialist Visits.The Cost Share for a exam your provider confirms a problem with your Primary Care Visit applies to evaluations and treatment health and performs treatment Services(such as an provided by generalists in internal medicine,pediatrics, outpatient procedure).You may be asked to pay(or or family practice,and by specialists in you will be billed for)your Cost Share for these obstetrics/gynecology whom the Medical Group additional treatment Services designates as Primary Care Physicians. Some physician specialists provide primary care in addition to specialty • You receive Services from a second provider during care but are not designated as Primary Care Physicians. your visit.For example,you go in for a diagnostic If you receive Services from one of these specialists,the exam,and at check-in you pay your Cost Share for a Cost Share for a Physician Specialist Visit will apply to diagnostic exam.However,during the diagnostic all consultations,evaluations,and treatment provided by exam your provider requests a consultation with a the specialist except for routine preventive counseling specialist.You may be asked to pay(or you will be and exams listed under"Preventive Services"in this billed for)your Cost Share for the consultation with "Benefits and Your Cost Share"section.For example, the specialist if your personal Plan Physician is a specialist in internal medicine or obstetrics/gynecology who is not a Primary In some cases,your provider will not ask you to make a Care Physician,you will pay the Cost Share for a payment at the time you receive Services,and you will Physician Specialist Visit for all consultations, be billed for your Cost Share(for example,some evaluations,and treatment by the specialist except Laboratory Departments are not able to collect Cost routine preventive counseling and exams listed under Shares). "Preventive Services"in this"Benefits and Your Cost Share"section.The Non-Physician Specialist Visit Cost When we send you a bill,it will list Charges for the Share applies to consultations,evaluations,and treatment Services you received,payments and credits applied to provided by non-physician specialists(such as nurse your account,and any amounts you still owe.Your practitioners,physician assistants,optometrists, current bill may not always reflect your most recent podiatrists,and audiologists). Charges and payments.Any Charges and payments that are not on the current bill will appear on a future bill. Noncovered Services.If you receive Services that are Sometimes,you may see a payment but not the related not covered under this EOC,you may have to pay the Charges for Services. That could be because your full price of those Services.Payments you make for payment was recorded before the Charges for the noncovered Services do not apply to any deductible or Services were processed.If so,the Charges will appear out-of-pocket maximum. on a future bill.Also,you may receive more than one bill for a single outpatient visit or inpatient stay.For Getting an estimate of your Cost Share example,you may receive a bill for physician services If you have questions about the Cost Share for specific and a separate bill for hospital services.If you don't see Services that you expect to receive or that your provider all the Charges for Services on one bill,they will appear orders during a visit or procedure,please visit our on a future bill.If we determine that you overpaid and website at ky.org to use our cost estimate tool or call are due a refund,then we will send a refund to you Member Services. within four weeks after we make that determination. If you have questions about a bill,please call the phone • If you have a Plan Deductible and would like an number on the bill. estimate for Services that are subject to the Plan Deductible,please call 1-800-390-3507(TTY users In some cases,a Non—Plan Provider may be involved in call 711)Monday through Friday,6 a.m.to 5 p.m. the provision of covered Services at a Plan Facility or a contracted facility where we have authorized you to Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 24 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • For all other Cost Share estimates,please call 1-800- Copayments or Coinsurance even if you have already 443-0815,8 a.m.to 8 p.m.,seven days a week(TTY reached the out-of-pocket maximum.In addition: users should call 711) • If your plan includes supplemental chiropractic or acupuncture Services described in an amendment to Cost Share estimates are based on your benefits and the this EOC,those Services do not apply toward the Services you expect to receive.They are a prediction of maximum cost and not a guarantee of the final cost of Services. Your final cost may be higher or lower than the estimate • If your plan includes an Allowance for specific since not everything about your care can be known in Services(such as eyeglasses,contact lenses,or hearing aids),any amounts you pay that exceed the advance. Allowance do not apply toward the maximum Copayments and Coinsurance The Copayment or Coinsurance you must pay for each Outpatient Care covered Service,after you meet any applicable deductible,is described in this EOC. We cover the following outpatient care subject to the Cost Share indicated: Note:If Charges for Services are less than the Copayment or Coinsurance described in this EOC,you Office visits will pay the lesser amount. • Primary Care Visits and Non-Physician Specialist Plan Out-of-Pocket Maximum Visits that are not described elsewhere in this EOC: a $15 Copayment per visit There is a limit to the total amount of Cost Share you • Physician Specialist Visits that are not described must pay under this EOC in the calendar year for y p covered Services that you receive in the same calendar elsewhere in this EOC: a$15 Copayment per visit year.The Services that apply to the Plan Out-of-Pocket • Outpatient visits that are available as group Maximum are described under the"Payments that count appointments that are not described elsewhere in this toward the Plan Out-of-Pocket Maximum"section EOC: a$7 Copayment per visit below.The limit is: • House calls by a Plan Physician(or a Plan Provider • $1,000 per calendar year for any one Member who is a registered nurse)inside our Service Area when care can best be provided in your home as For Services subject to the Plan Out-of-Pocket determined by a Plan Physician: Maximum,you will not pay any more Cost Share during ♦ Primary Care Visits and Non-Physician Specialist the remainder of the calendar year,but every other Visits: a$15 Copayment per visit Member in your Family must continue to pay Cost Share during the remainder of the calendar year until either he ♦ physician Specialist Visits: a$15 Copayment per visit or she reaches the$1,000 maximum for any one Member. • Routine physical exams that are medically appropriate preventive care in accord with generally Payments that count toward the Plan Out-of-Pocket accepted professional standards of practice: Maximum.Any amounts you pay for the following ac charge Services apply toward the out-of-pocket maximum: • Family planning counseling,or internally implanted • Covered in-network Medicare Part A and Part B time-release contraceptives or intrauterine devices Services (IUDs)and office visits related to their administration • Medicare Part B drugs(all other drugs do not apply) and management: a$15 Copayment per visit • Residential treatment program Services covered in the • After confirmation of pregnancy,the normal series of "Substance Use Disorder Treatment"and"Mental regularly scheduled preventive prenatal care exams Health Services"sections and the first postpartum follow-up consultation and Copayments and Coinsurance you pay for Services that exam: a$15 Copayment per visit are not described above,do not apply to the out-of- • Voluntary termination of pregnancy and related pocket maximum.For these Services,you must pay Services: no charge • Physical,occupational,and speech therapy in accord with Medicare guidelines: a$15 Copayment per visit Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 25 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Group and individual physical therapy prescribed by a are admitted for observation but are not admitted as an Plan Provider to prevent falls: no charge inpatient. • Physical,occupational,and speech therapy provided in an organized,multidisciplinary rehabilitation day- Outpatient surgeries and procedures treatment program in accord with Medicare • Outpatient surgery and outpatient procedures when guidelines: a$15 Copayment per day provided in an outpatient or ambulatory surgery • Manual manipulation of the spine to correct center or in a hospital operating room,or if it is subluxation,in accord with Medicare guidelines,is provided in any setting and a licensed staff member covered when provided by a Plan Provider or a monitors your vital signs as you regain sensation after chiropractor when referred by a Plan Provider: a receiving drugs to reduce sensation or to minimize $15 Copayment per visit. (For the list of discomfort: a$50 Copayment per procedure participating ASH Plans providers,please refer to • Any other outpatient surgery that does not require a your Provider Directory) licensed staff member to monitor your vital signs as described above: a$15 Copayment per procedure Acupuncture Services • Any other outpatient procedures that do not require a • Acupuncture for chronic low back pain up to 12 visits licensed staff member to monitor your vital signs as in 90 days,in accord with Medicare guidelines: a described above: the Cost Share that would $15 Copayment per visit. Chronic low back pain is otherwise apply for the procedure in this"Benefits defined as follows: and Your Cost Share"section(for example,radiology ♦ lasting 12 weeks or longer procedures that do not require a licensed staff member to monitor your vital signs as described ♦ non-specific,in that it has no identifiable systemic above are covered under"Outpatient Imaging, cause(i.e.not associated with metastatic, Laboratory,and Other Diagnostic and Treatment inflammatory,infectious,disease,etc) Services") ♦ not associated with surgery or pregnancy • Pre-and post-operative visits: • An additional eight sessions will be covered for those ♦ Primary Care Visits and Non-Physician Specialist patients demonstrating an improvement.No more Visits: a$15 Copayment per visit than 20 acupuncture treatments may be administered annually.Treatment must be discontinued if the ♦ Physician Specialist Visits: a$15 Copayment per patient is not improving or is regressing visit • Acupuncture not covered by Medicare(typically Administered drugs and products provided only for the treatment of nausea or as part of Administered drugs and products are medications and a comprehensive pain management program for the products that require administration or observation by treatment of chronic pain): a$15 Copayment per medical personnel.We cover these items when visit prescribed by a Plan Provider,in accord with our drug Emergency Services and Urgent Care formulary guidelines,and they are administered to you in a Plan Facility or during home visits. • Urgent Care consultations,evaluations,and treatment: a$15 Copayment per visit We cover the following Services and their administration • Emergency Department visits: a$50 Copayment per in a Plan Facility at the Cost Share indicated: visit • Whole blood,red blood cells,plasma,and platelets: no charge If you are admitted from the Emergency Department. • Allergy antigens(including administration): a If you are admitted to the hospital as an inpatient for $3 Copayment per visit covered Services(either within 24 hours for the same condition or after an observation stay),then the Services • Cancer chemotherapy drugs and adjuncts:no charge you received in the Emergency Department and • Drugs and products that are administered via observation stay,if applicable,will be considered part of intravenous therapy or injection that are not for your inpatient hospital stay. For the Cost Share for cancer chemotherapy,including blood factor products inpatient care,refer to"Hospital Inpatient Services"in and biological products("biologics")derived from this"Benefits and Your Cost Share"section.However, tissue,cells,or blood: no charge the Emergency Department Cost Share does apply if you . Tuberculosis skin tests: no charge Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 26 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • All other administered drugs and products: no charge Hospital Inpatient Services We cover drugs and products administered to you during We cover the following inpatient Services in a Plan a home visit at no charge. Hospital,when the Services are generally and customarily provided by acute care general hospitals Certain administered drugs are Preventive Services. inside our Service Area: Refer to"Preventive Services"for information on • Room and board,including a private room immunizations. if Medically Necessary Note:Vaccines covered by Medicare Part D are not • Specialized care and critical care units covered under this"Outpatient Care"section(instead, • General and special nursing care refer to"Outpatient Prescription Drugs, Supplies,and . Operating and recovery rooms Supplements"in this"Benefits and Your Cost Share" section). • Services of Plan Physicians,including consultation and treatment by specialists For the following Services, refer to these • Anesthesia sections o Drugs prescribed in accord with our drug formulary • Bariatric Surgery guidelines(for discharge drugs prescribed when you are released from the hospital,refer to"Outpatient • Dental Services Prescription Drugs, Supplies,and Supplements"in • Dialysis Care this"Benefits and Your Cost Share"section) • Durable Medical Equipment("DME")for Home Use • Radioactive materials used for therapeutic purposes • Fertility Services • Durable medical equipment and medical supplies • Health Education • Imaging,laboratory,and other diagnostic and • Hearing Services treatment Services,including MRI,CT,and PET scans • Home-Delivered Meals • Whole blood,red blood cells,plasma,platelets,and • Home Health Care their administration • Hospice Care o Obstetrical care and delivery(including cesarean • Mental Health Services section).Note:If you are discharged within 48 hours • Ostomy,Urological,and Specialized Wound Care after delivery(or within 96 hours if delivery is by Supplies cesarean section),your Plan Physician may order a follow-up visit for you and your newborn to take • Outpatient Imaging,Laboratory,and Other place within 48 hours after discharge(for visits after Diagnostic and Treatment Services you are released from the hospital,please refer to • Outpatient Prescription Drugs,Supplies,and "Outpatient Care"in this`Benefits and Your Cost Supplements Share"section) • Preventive Services • Physical,occupational,and speech therapy(including treatment in an organized,multidisciplinary • Prosthetic and Orthotic Devices rehabilitation program)in accord with Medicare • Reconstructive Surgery guidelines • Services Associated with Clinical Trials • Respiratory therapy • Substance Use Disorder Treatment • Medical social services and discharge planning • Transplant Services Your Cost Share.We cover hospital inpatient Services • Transportation Services at no charge. • Vision Services For the following Services, refer to these sections • Bariatric surgical procedures(refer to"Bariatric Surgery") Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 27 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Dental procedures(refer to"Dental Services") Nonemergency • Dialysis care(refer to"Dialysis Care") Inside our Service Area,we cover nonemergency ambulance Services in accord with Medicare guidelines • Fertility Services related to diagnosis and treatment of if a Plan Physician determines that your condition infertility,artificial insemination,or assisted requires the use of Services that only a licensed reproductive technology(refer to"Fertility Services") ambulance can provide and that the use of other means • Hospice care(refer to"Hospice Care") of transportation would endanger your health. These • Mental health Services(refer to"Mental Health Services are covered only when the vehicle transports Services") you to and from qualifying locations as defined by Medicare guidelines. • Prosthetics and orthotics(refer to"Prosthetic and Orthotic Devices") Your Cost Share • Reconstructive surgery Services(refer to You pay the following for covered ambulance Services: "Reconstructive Surgery") . Emergency ambulance Services: a$100 Copayment • Religious Nonmedical Health Care Institution per trip Services(refer to"Religious Nonmedical Health Care . Nonemergency Services: a$100 Copayment per Institution") trip • Services in connection with a clinical trial(refer to "Services in Connection with a Clinical Trial") Ambulance Services exclusions • Skilled inpatient Services in a Plan Skilled Nursing • Transportation by car,taxi,bus,gurney van, Facility(refer to"Skilled Nursing Facility Care") wheelchair van,and any other type of transportation • Substance use disorder treatment Services(refer to (other than a licensed ambulance),even if it is the "Substance Use Disorder Treatment") only way to travel to a Plan Provider,except as otherwise covered under"Transportation Services"in • Transplant Services(refer to"Transplant Services") this section Ambulance Services Bariatric Surgery Emergency We cover hospital inpatient Services related to bariatric We cover Services of a licensed ambulance anywhere in surgical procedures(including room and board,imaging, the world without prior authorization(including laboratory,other diagnostic and treatment Services,and transportation through the 911 emergency response Plan Physician Services)when performed to treat obesity system where available)in the following situations: by modification of the gastrointestinal tract to reduce • You reasonably believed that the medical condition nutrient intake and absorption,if all of the following was an Emergency Medical Condition which required requirements are met: ambulance Services • You complete the Medical Group—approved pre- • Your treating physician determines that you must be surgical educational preparatory program regarding transported to another facility because your lifestyle changes necessary for long term bariatric Emergency Medical Condition is not Stabilized and surgery success the care you need is not available at the treating • A Plan Physician who is a specialist in bariatric care facility determines that the surgery is Medically Necessary If you receive emergency ambulance Services that are Your Cost Share.For covered Services related to not ordered by a Plan Provider,you are not responsible bariatric surgical procedures that you receive,you will for any amounts beyond your Cost Share for covered pay the Cost Share you would pay if the Services were emergency ambulance Services.However,if the provider not related to a bariatric surgical procedure.For does not agree to bill us,you may have to pay for the example,see"Hospital Inpatient Services"in this Services and file a claim for reimbursement.For "Benefits and Your Cost Share"section for the Cost information on how to file a claim,please see the Share that applies for hospital inpatient Services. "Requests for Payment"section. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 28 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. For the following Services, refer to these Your Cost Share sections You pay the following for dental Services covered under • Outpatient prescription drugs(refer to"Outpatient this"Dental Services"section: Prescription Drugs, Supplies,and Supplements") • Non-Physician Specialist Visits with dentists for • Outpatient administered drugs(refer to"Outpatient Services covered under this"Dental Services" Care") section: a$15 Copayment per visit • Physician Specialist Visits for Services covered under this"Dental Services"section: a$15 Copayment per Dental Services visit Dental Services for radiation treatment • Outpatient surgery and outpatient procedures when We cover services in accord with Medicare guidelines, provided in an outpatient or ambulatory surgery including dental evaluation,X-rays,fluoride treatment, center or in a hospital operating room,or if it is and extractions necessary to prepare your jaw for provided in any setting and a licensed staff member radiation therapy of cancer in your head or neck if a Plan monitors your vital signs as you regain sensation after Physician provides the Services or if the Medical Group receiving drugs to reduce sensation or to minimize authorizes a referral to a dentist for those Services(as discomfort: a$50 Copayment per procedure described in"Medical Group authorization procedure for • Any other outpatient surgery that does not require a certain referrals"under"Getting a Referral"in the"How licensed staff member to monitor your vital signs as to Obtain Services"section). described above: a$15 Copayment per procedure Dental Services for transplants • Any other outpatient procedures that do not require a licensed staff member to monitor your vital signs as We cover dental services that are Medically Necessary to described above: the Cost Share that would free the mouth from infection in order to prepare fora otherwise apply for the procedure in this"Benefits transplant covered under"Transplant Services"in this and Your Cost Share"section(for example,radiology "Benefits and Your Cost Share"section,if a Plan procedures that do not require a licensed staff Physician provides the Services or if the Medical Group member to monitor your vital signs as described authorizes a referral to a dentist for those Services(as above are covered under"Outpatient Imaging, described in"Medical Group authorization procedure for Laboratory,and Other Diagnostic and Treatment certain referrals"under"Getting a Referral"in the"How Services") to Obtain Services"section). • Hospital inpatient Services(including room and Dental anesthesia board,drugs,imaging,laboratory,other diagnostic For dental procedures at a Plan Facility,we provide and treatment Services,and Plan Physician Services): general anesthesia and the facility's Services associated no charge with the anesthesia if all of the following are true: For the following Services, refer to these • You are under age 7,or you are developmentally sections disabled,or your health is compromised • Office visits not described in this"Dental Services" • Your clinical status or underlying medical condition section(refer to"Outpatient Care") requires that the dental procedure be provided in a hospital or outpatient surgery center • Outpatient imaging,laboratory,and other diagnostic and treatment Services(refer to"Outpatient Imaging, • The dental procedure would not ordinarily require Laboratory,and Other Diagnostic and Treatment general anesthesia Services") We do not cover any other Services related to the dental • Outpatient prescription drugs(refer to"Outpatient procedure,such as the dentist's Services,unless the Prescription Drugs, Supplies,and Supplements") Service is covered in accord with Medicare guidelines or for transplant services. Dialysis Care We cover acute and chronic dialysis Services if all of the following requirements are met: • You satisfy all medical criteria developed by the Medical Group Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 29 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • The facility is certified by Medicare • Outpatient laboratory(refer to"Outpatient Imaging, • A Plan Physician provides a written referral for your Laboratory,and Other Diagnostic and Treatment dialysis treatment except for out-of-area dialysis care Services") • Outpatient prescription drugs(refer to"Outpatient We also cover hemodialysis and peritoneal home dialysis Prescription Drugs, Supplies,and Supplements") (including equipment,training,and medical supplies). • Outpatient administered drugs(refer to"Outpatient Coverage is limited to the standard item of equipment or Care") supplies that adequately meets your medical needs.We . Telehealth Visits(refer to"Telehealth Visits") decide whether to rent or purchase the equipment and supplies,and we select the vendor.You must return the equipment and any unused supplies to us or pay us the Dialysis care exclusions fair market price of the equipment and any unused • Comfort,convenience,or luxury equipment,supplies supply when we are no longer covering them. and features Out-of-area dialysis care • Nonmedical items,such as generators or accessories We cover dialysis(kidney) Services that you get at a to make home dialysis equipment portable for travel Medicare-certified dialysis facility when you are temporarily outside our Service Area.If possible,before Durable Medical Equipment ("DME") for you leave the Service Area,please let us know where Home Use you are going so we can help arrange for you to have maintenance dialysis while outside our Service Area. DME coverage rules DME for home use is an item that meets the following The procedure for obtaining reimbursement for out-of- criteria: area dialysis care is described in the"Requests for • The item is intended for repeated use Payment"section. • The item is primarily and customarily used to serve a Your Cost Share.You pay the following for these medical purpose covered Services related to dialysis: o The item is generally useful only to an individual • Equipment and supplies for home hemodialysis and with an illness or injury home peritoneal dialysis: no charge . The item is appropriate for use in the home(or • One routine outpatient visit per month with the another location used as your home as defined by multidisciplinary nephrology team for a consultation, Medicare) evaluation,or treatment: no charge • The item is expected to last at least 3 years • Hemodialysis and peritoneal dialysis treatment: no charge For a DME item to be covered,all of the following • Hospital inpatient Services(including room and requirements must be met: board,drugs,imaging,laboratory,and other • Your EOC includes coverage for the requested DME diagnostic and treatment Services,and Plan Physician item Services): no charge • A Plan Physician has prescribed the DME item for For the following Services, refer to these your medical condition sections • The item has been approved for you through the Plan's prior authorization process,as described in • Durable medical equipment for home use(refer to "Medical Group authorization procedure for certain "Durable Medical Equipment("DME")for Home referrals"under"Getting a Referral"in the"How to Use") Obtain Services"section • Hospital inpatient Services(refer to"Hospital • The Services are provided inside our Service Area Inpatient Services") • Office visits not described in this"Dialysis Care" Coverage is limited to the standard item of equipment section(refer to"Outpatient Care") that adequately meets your medical needs.We decide • Kidney disease education(refer to"Health whether to rent or purchase the equipment,and we select Education") the vendor. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 30 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. DME for diabetes ("DME")for Home Use"section are met,we cover the We cover the following diabetes testing supplies and following other DME items(including repair or equipment and insulin-administration devices if all of the replacement of covered equipment): requirements described under"DME coverage rules"in • Bed accessories for a hospital bed when bed this"Durable Medical Equipment("DME")for Home extension is required Use"section are met: • Heel or elbow protectors to prevent or minimize • Glucose monitors for diabetes testing and their advanced pressure relief equipment use supplies(such as glucose monitor test strips,lancets, • Iontophoresis device to treat hyperhidrosis when and lancet devices) antiperspirants are contraindicated and the • Insulin pumps and supplies to operate the pump hyperhidrosis has created medical complications(for example,skin infection)or preventing daily living Your Cost Share.You pay the following for covered activities DME for diabetes(including repair or replacement of • Nontherapeutic continuous glucose monitoring covered equipment): devices and related supplies • Glucose monitors for diabetes testing and their • Peak flow meters supplies(such as glucose monitor test strips,lancets, and lancet devices): no charge • Resuscitation bag if tracheostomy patient has • Insulin pumps and supplies to operate the pump: significant secretion management problems,needing 20 percent Coinsurance lavage and suction technique aided by deep breathing via resuscitation bag Base DME Items Your Cost Share.You pay the following for other We cover Base DME Items(including repair or covered DME items: 20 percent Coinsurance,except replacement of covered equipment)if all of the peak flow meters are covered at: no charge. requirements described under"DME coverage rules"in this"Durable Medical Equipment("DME")for Home Outside our Service Area Use"section are met. "Base DME Items"means the following items: We do not cover most DME for home use outside our Service Area.However,if you live outside our Service • Glucose monitors for diabetes blood testing and their Area,we cover the following DME(subject to the Cost supplies(such as blood glucose monitor test strips, Share and all other coverage requirements that apply to lancets,and lancet devices) DME for home use inside our Service Area)when the • Bone stimulator item is dispensed at a Plan Facility: • Canes(standard curved handle or quad)and • Blood glucose monitors for diabetes blood testing and replacement supplies their supplies(such as blood glucose monitor test Cervical traction(over door) strips,lancets,and lancet devices)from a Plan • Pharmacy • Crutches(standard or forearm)and replacement • Canes(standard curved handle) supplies • Dry pressure pad for a mattress • Crutches(standard) • Nebulizers and their supplies for the treatment of • Infusion pumps(such as insulin pumps)and supplies pediatric asthma to operate the pump IV pole • Peak flow meters from a Plan Pharmacy • • Nebulizer and supplies For the following Services, refer to these • Phototherapy blankets for treatment of jaundice in sections newborns • Dialysis equipment and supplies required for home hemodialysis and home peritoneal dialysis(refer to Your Cost Share.You pay the following for covered "Dialysis Care") Base DME Items: 20 percent Coinsurance. • Diabetes urine testing supplies and insulin- Other covered DME items administration devices other than insulin pumps(refer to"Outpatient Prescription Drugs, Supplies,and If all of the requirements described under"DME Supplements") coverage rules"in this"Durable Medical Equipment Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 31 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Durable medical equipment related to the terminal You pay the following for covered infertility Services: illness for Members who are receiving covered • Office visits: a$15 Copayment per visit hospice care(refer to"Hospice Care") • Most outpatient surgery and outpatient procedures • Insulin and any other drugs administered with an when provided in an outpatient or ambulatory surgery infusion pump(refer to"Outpatient Prescription center or in a hospital operating room,or provided in Drugs,Supplies,and Supplements") any setting where a licensed staff member monitors your vital signs as you regain sensation after DME for home use exclusions receiving drugs to reduce sensation or to minimize • Comfort,convenience,or luxury equipment or discomfort: a$15 Copayment per procedure features • Any other outpatient surgery that does not require a • Dental appliances licensed staff member to monitor your vital signs as • Items not intended for maintaining normal activities described above: a$15 Copayment per procedure of daily living,such as exercise equipment(including • Outpatient imaging: no charge devices intended to provide additional support for • Outpatient laboratory: no charge recreational or sports activities) • Outpatient administered drugs: no charge • Hygiene equipment • Hospital inpatient Services(including room and • Nonmedical items,such as sauna baths or elevators board,imaging,laboratory,and other diagnostic and • Modifications to your home or car,unless covered in treatment Services,and Plan Physician Services): accord with Medicare guidelines no charge • Devices for testing blood or other body substances (except diabetes glucose monitors and their supplies) Note:Administered drugs and products are medications and products that require administration or observation • Electronic monitors of the heart or lungs except infant by medical personnel.We cover these items when they apnea monitors are prescribed by a Plan Provider,in accord with our • Repair or replacement of equipment due to misuse drug formulary guidelines,and they are administered to you in a Plan Facility. Fertility Services For the following Services, refer to these sections "Fertility Services"means treatments and procedures to • Outpatient drugs,supplies,and supplements(refer to help you become pregnant. "Outpatient Prescription Drugs, Supplies,and Before starting or continuing a course of fertility Supplements") Services,you may be required to pay initial and • Diagnostic Services provided by Plan Providers who subsequent deposits toward your Cost Share for some or are not physicians,such as EKGs and EEGs(refer to all of the entire course of Services,along with any past- "Outpatient Imaging,Laboratory,and Other due fertility-related Cost Share.Any unused portion of Diagnostic and Treatment Services") your deposit will be returned to you.When a deposit is not required,you must pay the Cost Share for the Fertility Services exclusions procedure,along with any past-due fertility-related Cost • Reversal of surgical sterilization originally performed Share,before you can schedule a fertility procedure. for family planning purposes Diagnosis and treatment of infertility • Semen and eggs(and Services related to their For purposes of this"Diagnosis and treatment of procurement and storage) infertility"section,"infertility"means not being able to • Assisted reproductive technology Services,such as get pregnant or carry a pregnancy to a live birth after a ovum transplants,gamete intrafallopian transfer year or more of regular sexual relations without (GIFT),in vitro fertilization(IVF),and zygote contraception or having a medical or other demonstrated intrafallopian transfer(ZIFT) condition that is recognized by a Plan Physician as a cause of infertility.We cover the following: • Services for the diagnosis and treatment of infertility • Artificial insemination Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 32 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Fitness benefit (One Pass TM) Health Education A fitness benefit is provided through the One Pass We cover a variety of health education counseling, program to help members take control of their health and programs,and materials that your personal Plan feel their best.The One Pass program includes: Physician or other Plan Providers provide during a visit • Gyms and Fitness Locations:You receive a covered under another part of this EOC. membership with access to a wide variety of in- network gyms through the core and premium We also cover a variety of health education counseling, networks.Fitness locations include national,local, programs,and materials to help you take an active role in and community fitness centers and boutique studios. protecting and improving your health,including You can use any in-network location,and you may programs for tobacco cessation,stress management,and use multiple participating fitness locations during the chronic conditions(such as diabetes and asthma).Kaiser Permanente also offers health education counseling, same month programs,and materials that are not covered,and you • Online Fitness:You have access to live,digital fitness may be required to pay a fee. classes and on-demand workouts through the One Pass member website or mobile app For more information about our health education • Fitness and Social Activities:You also have access to counseling,programs,and materials,please contact a groups,clubs,and social events through the One Pass Health Education Department or Member Services or go member website to our website at ky.org. • Home Fitness Kits:If you prefer to work out at home, you can select a home fitness kit for Strength,Yoga, Note: Our Health Education Department offers a comprehensive self-management workshop to help or Dance members learn the best choices in exercise,diet, • Brain Health:Access to online brain health cognitive monitoring,and medications to manage and control training programs diabetes.Members may also choose to receive diabetes self-management training from a program outside our For more information about participating gyms and plan that is recognized by the American Diabetes fitness locations,the program's benefits,or to set up your Association(ADA)and approved by Medicare.Also,our online account,please visit www.YourOnePass.com or Health Education Department offers education to teach call 1-877-614-0618(TTY 711),Monday through kidney care and help members make informed decisions Friday,6 a.m.to 7 p.m. about their care. One Pass®is a registered trademark of Optum,Inc. in Your Cost Share.You pay the following for these the U.S. and other jurisdictions and is a voluntary covered Services: program.The One Pass program and amenities vary by plan,area,and location.The information provided under • Covered health education programs,which may this program is for general informational purposes only include programs provided online and counseling and is not intended to be nor should be construed as over the phone: no charge medical advice. One Pass is not responsible for the • Other covered individual counseling when the office services or information provided by third parties. visit is solely for health education: a$15 Copayment Individuals should consult an appropriate health care per visit professional before beginning any exercise program o Health education provided during an outpatient and/or to determine what may be right for them. consultation or evaluation covered in another part of this EOC: no additional Cost Share beyond the Your Cost Share:You pay the following: no charge. Cost Share required in that other part of this EOC Fitness benefit exclusions • Covered health education materials: no charge • Additional services(such as personal training,fee- based group fitness classes,expanded access hours,or Hearing Services additional classes outside of the standard membership offering) We cover the following: • Hearing exams with an audiologist to determine the need for hearing correction: a$15 Copayment per visit Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 33 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Physician Specialist Visits to diagnose and treat of discharge.You can contact Member Services if hearing problems: a$15 Copayment per visit you have any questions about your meals coverage • In addition to meals for general health,there are Hearing aids menus to support specific conditions and diets We cover the following Services related to hearing aids: • A$1,000 Allowance for each ear toward the purchase Your Cost Share.We cover home-delivered meals at price of a hearing aid(including fitting,counseling, no charge. adjustment,cleaning,and inspection during the 3-year warranty)every 36 months when prescribed by a Plan Home-delivered meals exclusions Physician or by a Plan Provider who is an audiologist. We will not cover meals if more than 30 days have We will cover hearing aids for both ears only if both passed since your discharge(except in limited aids are required to provide significant improvement circumstances)or if you are discharged as follows: that is not obtainable with only one hearing aid.We . To another facility that provides meals(for example, will not provide the Allowance if we have provided inpatient rehabilitation) an Allowance toward(or otherwise covered)a hearing aid within the previous 36 months.Also,the • From a Non-Plan Hospital or Skilled Nursing Allowance can only be used at the initial point of sale. Facility,Hospital Observation,Outpatient Surgery,or If you do not use all of your Allowance at the initial Emergency Department point of sale,you cannot use it later • To a home outside of California We select the provider or vendor that will furnish the covered hearing aids.Coverage is limited to the types Home Health Care and models of hearing aids furnished by the provider or "Home health care"means Services provided in the vendor. home by nurses,medical social workers,home health For the following Services, refer to these aides,and physical,occupational,and speech therapists. sections We cover part-time or intermittent home health care in accord with Medicare guidelines.Home health care • Services related to the ear or hearing other than those services are covered up to the number of visits and described in this section, such as outpatient care to length of time that are determined to be medically treat an ear infection or outpatient prescription drugs, necessary under the Member's home health treatment supplies,and supplements(refer to the applicable plan and no more than the limits established under heading in this"Benefits and Your Cost Share" Medicare guidelines,only if all of the following are true: section) o You are substantially confined to your home • Cochlear implants and osseointegrated hearing devices(refer to"Prosthetic and Orthotic Devices") • Your condition requires the Services of a nurse, physical therapist,or speech therapist or continued Hearing Services exclusions need for an occupational therapist(home health aide Services are not covered unless you are also getting • Internally implanted hearing aids covered home health care from a nurse,physical • Replacement parts and batteries,repair of hearing therapist,occupational therapist,or speech therapist aids,and replacement of lost or broken hearing aids that only a licensed provider can provide) (the manufacturer warranty may cover some of these) • A Plan Physician determines that it is feasible to maintain effective supervision and control of your care in your home and that the Services can be safely Home-Delivered Meals and effectively provided in your home Immediately following discharge from a Plan Hospital or • The Services are provided inside our Service Area Skilled Nursing Facility as an inpatient,we cover up to three meals per day in a consecutive four-week period, Your Cost Share.We cover home health care Services once per calendar year as follows: at no charge. • When you are discharged from a Plan Hospital or Skilled Nursing Facility,the meal delivery vendor For the following Services, refer to these will contact you to review your meal options and sections arrange meal delivery to your home in California.In • Dialysis care(refer to"Dialysis Care") most cases,the meals must be initiated within 30 days Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 34 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Durable medical equipment(refer to"Durable • The following equipment necessary to ensure that you Medical Equipment("DME")for Home Use") are monitored appropriately in your home:blood • Ostomy,urological,and specialized wound care pressure cuff/monitor,pulse oximeter,scale,and supplies(refer to"Ostomy,Urological,and thermometer Specialized Wound Care Supplies") • Mobile imaging and tests such as X-rays,labs,and • Outpatient drugs,supplies,and supplements(refer to EKGs "Outpatient Prescription Drugs, Supplies,and • The following safety items: shower stools,raised Supplements") toilet seats,grabbers,long handle shoehorn,and sock • Outpatient physical,occupational,and speech therapy aid visits(refer to"Outpatient Care") • Up to 21 meals per week while you are receiving • Prosthetic and orthotic devices(refer to"Prosthetic acute care in the home and Orthotic Devices") In addition,for Medicare-covered services and items Home health care exclusions listed below,the Cost-Sharing indicated elsewhere in this EOC does not apply when the Services and items are • Care in the home if the home is not a safe and prescribed as part of your home treatment plan: effective treatment setting • Durable medical equipment • Medical supplies Home Medical Care Not Covered by Non-emergent ambulance transportation to and from Medicare for Members Who Live in network facilities when scheduled ambulance Certain Counties (Advanced Care at transport is Medically Necessary Home) • Physician assistant and nurse practitioner house calls We cover inedical care in your home that is not or office visits otherwise covered by Medicare when found medically • The following Services at a Plan Facility if the appropriate by a physician based on your health status to Services are part of your home treatment plan: provide you with an alternative to receiving acute care in ♦ Network Emergency Department visits associated a hospital and post-acute care Services in the home to with this benefit support your recovery. Services in the home must be: ♦ Physical,speech,or occupational therapy office • Prescribed by a network hospitalist who has visits determined that based on your health status,treatment ♦ X-rays,labs,ultrasounds,and EKGs plan,and home setting that you can be treated safely and effectively in the home The cost-sharing indicated elsewhere in this EOC will • Elected by you because you prefer to receive the care apply to all other Services and items that are not part of described in your treatment plan in your home your home treatment plan(for example,DME unrelated to your home treatment plan)or are part of your home Our network provider will provide the following services treatment plan,but are not provided in your home except and items in your home in accord with your treatment as listed above.Note:For prescription drug Cost-Sharing plan for as long as they are prescribed by a network information,refer to the"Outpatient Prescription Drugs, hospitalist: Supplies,and Supplements"section. • Home visits by RNs,physical therapists,occupational therapists,speech therapists,respiratory therapists, Hospice Care nutritionist,home health aides,and other healthcare professionals in accord with the home care treatment Hospice care is a specialized form of interdisciplinary plan and the provider's scope of practice and license health care designed to provide palliative care and to • Communication devices to allow you to contact the alleviate the physical,emotional,and spiritual Advanced Care at Home command center 24 hours a discomforts of a Member experiencing the last phases of day,7 days a week.This includes needed life due to a terminal illness.It also provides support to communication technology to support reliable the primary caregiver and the Member's family.A communication,and an PERS alert device to contact Member who chooses hospice care is choosing to receive the command center if you are unable to get to a palliative care for pain and other symptoms associated phone with the terminal illness,but not to receive care to try to Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 35 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. cure the terminal illness.You may change your decision For drugs that may be covered by our plan's Part D to receive hospice care benefits at any time. benefit:If these drugs are unrelated to your terminal hospice condition,you pay cost-sharing.If they are If you have Medicare Part A,you are eligible for the related to your terminal hospice condition,then you pay hospice benefit when your doctor and the hospice Original Medicare cost-sharing.Drugs are never covered medical director have given you a terminal prognosis by both hospice and our plan at the same time.For more certifying that you're terminally ill and have six months information,please see"What if you're in a Medicare- or less to live if your illness runs its normal course.You certified hospice"in the"Outpatient Prescription Drugs, may receive care from any Medicare-certified hospice Supplies,and Supplements"section. program. Our plan is obligated to help you find Medicare-certified hospice programs in our plan's Note:If you need non-hospice care(care that is not Service Area,including those the MA organization owns, related to your terminal prognosis),you should contact controls,or has a financial interest in.Your hospice us to arrange the services. doctor can be a Plan Provider or a Non—Plan Provider. Covered Services include: For more information about Original Medicare hospice • Drugs for symptom control and pain relief coverage,visit https://www.medicare.2ov,and under "Search Tools,"choose"Find a Medicare Publication"to • Short-term respite care view or download the publication"Medicare Hospice • Home care Benefits."Or call 1-800-MEDICARE(1-800-633-4227) (TTY users call 1-877-486-2048),24 hours a day,seven When you are admitted to a hospice you have the right to days a week. remain in your plan;if you chose to remain in your plan, you must continue to pay plan premiums. Special note if you do not have Medicare Part A We cover the hospice Services listed below at no charge For hospice services and for services that are covered only if all of the following requirements are met: by Medicare Part A or B and are related to your o You are not entitled to Medicare Part A terminal prognosis: Original Medicare(rather than our plan)will a our hospice provider for our hospice • A Plan Physician has diagnosed you with a terminal p ) pay y p p y p expectancy life ext that our i t d determines a services and any Part A and Part B services related to illness an y p y is 12 your terminal condition.While you are in the hospice months or less program,your hospice provider will bill Original • The Services are provided inside our Service Area(or Medicare for the services that Original Medicare pays inside California but within 15 miles or 30 minutes for.You will be billed Original Medicare cost-sharing. from our Service Area if you live outside our Service Area,and you have been a Senior Advantage Member For services that are covered by Medicare Part A or continuously since before January 1, 1999,at the B and are not related to your terminal prognosis: same home address) If you need nonemergency,non—urgently needed o The Services are provided by a licensed hospice services that are covered under Medicare Part A or B and agency that is a Plan Provider that are not related to your terminal condition,your cost for these services depends on whether you use a Plan • A Plan Physician determines that the Services are Provider and follow plan rules(such as if there is a necessary for the palliation and management of your requirement to obtain prior authorization): terminal illness and related conditions • If you obtain the covered services from a Plan If all of the above requirements are met,we cover the Provider and follow plan rules for obtaining service, following hospice Services,if necessary for your hospice you only pay the Plan Cost Share amount care: • If you obtain the covered services from a Non—Plan o Plan Physician Services Provider,you pay the cost sharing under Fee-for- Service Medicare(Original Medicare) • Skilled nursing care,including assessment, evaluation,and case management of nursing needs, For services that are covered by our plan but are not treatment for pain and symptom control,provision of covered by Medicare Part A or B:We will continue to emotional support to you and your family,and cover Plan-covered Services that are not covered under instruction to caregivers Part A or B whether or not they are related to your terminal condition.You pay your Plan Cost Share amount for these Services. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 36 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Physical,occupational,and speech therapy for "Mental Disorders"include the following conditions: purposes of symptom control or to enable you to • Severe Mental Illness of a person of any age maintain activities of daily living • Serious Emotional Disturbance of a Child Under Age • Respiratory therapy 18 • Medical social services • Home health aide and homemaker services In addition to the Services described in this Mental Health Services section,we also cover other Services • Palliative drugs prescribed for pain control and that are Medically Necessary to treat Serious Emotional symptom management of the terminal illness for up to Disturbance of a Child Under Age 18 or Severe Mental a 100-day supply in accord with our drug formulary Illness,if the Medical Group authorizes a written referral guidelines.You must obtain these drugs from a Plan (as described in"Medical Group authorization procedure Pharmacy.Certain drugs are limited to a maximum for certain referrals"under"Getting a Referral"in the 30-day supply in any 30-day period(your Plan "How to Obtain Services"section). Pharmacy can tell you if a drug you take is one of these drugs) Outpatient mental health Services • Durable medical equipment We cover the following Services when provided by Plan • Respite care when necessary to relieve your Physicians or other Plan Providers who are licensed caregivers.Respite care is occasional short-term health care professionals acting within the scope of their inpatient Services limited to no more than five license: consecutive days at a time • Individual and group mental health evaluation and • Counseling and bereavement services treatment • Psychological testing when necessary to evaluate a • Dietary counseling Mental Disorder We also cover the following hospice Services only • Outpatient Services for the purpose of monitoring during periods of crisis when they are Medically drug therapy Necessary to achieve palliation or management of acute medical symptoms: Intensive psychiatric treatment programs • Nursing care on a continuous basis for as much as 24 We cover intensive psychiatric treatment programs at a hours a day as necessary to maintain you at home Plan Facility,such as: • Short-term inpatient Services required at a level that • Partial hospitalization cannot be provided at home • Multidisciplinary treatment in an intensive outpatient or day-treatment program Mental Health Services • Psychiatric observation for an acute psychiatric crisis We cover Services specified in this"Mental Health Your Cost Share.You pay the following for these Services"section only when the Services are for the covered Services: diagnosis or treatment of Mental Disorders.A"Mental • Individual mental health evaluation and treatment: a Disorder"is a mental health condition identified as a $15 Copayment per visit "mental disorder"in the Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition, Text • Group mental health treatment: a$7 Copayment per Revision,as amended in the most recently issued edition, visit (`DSM")that results in clinically significant distress or • Partial hospitalization: no charge impairment of mental,emotional,or behavioral functioning.We do not cover services for conditions that • Other intensive psychiatric treatment programs: the DSM identifies as something other than a"mental no charge disorder."For example,the DSM identifies relational Residential treatment problems as something other than a"mental disorder,"so we do not cover services(such as couples counseling or Inside our Service Area,we cover the following Services family counseling)for relational problems. when the Services are provided in a licensed residential treatment facility that provides 24-hour individualized mental health treatment,the Services are generally and customarily provided by a mental health residential treatment program in a licensed residential treatment Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 37 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. facility,and the Services are above the level of custodial • Toxicology testing care: . Intake activities • Individual and group mental health evaluation and . Periodic assessments treatment Medical services • Medicare Part B clinically administered drugs • • Medication monitoring Your Cost Share:You pay the following for these • Room and board covered Services: no charge. • Drugs prescribed by a Plan Provider as part of your plan of care in the residential treatment facility in Ostomy, Urological, and Specialized accord with our drug formulary guidelines if they are Wound Care Supplies administered to you in the facility by medical personnel(for discharge drugs prescribed when you We cover ostomy,urological,and specialized wound are released from the residential treatment facility, care supplies if the following requirements are met: refer to"Outpatient Prescription Drugs, Supplies,and . A Plan Physician has prescribed ostomy,urological, Supplements"in this"Benefits and Your Cost Share" section) and specialized wound care supplies for your medical condition • Discharge planning • The item has been approved for you through the Your Cost Share.We cover residential mental health Plan's prior authorization process,as described in "Medical Group authorization procedure for certain treatment Services at no charge. referrals"under"Getting a Referral"in the"How to Inpatient psychiatric hospitalization Obtain Services"section We cover care for acute psychiatric conditions in a • The Services are provided inside our Service Area Medicare-certified psychiatric hospital. Coverage is limited to the standard item of equipment Your Cost Share.We cover inpatient psychiatric that adequately meets your medical needs.We decide hospital Services at no charge. whether to rent or purchase the equipment,and we select the vendor. For the following Services, refer to these sections Your Cost Share:You pay the following for covered ostomy,urological,and specialized wound care supplies: • Outpatient drugs,supplies,and supplements(refer to 20 percent Coinsurance. "Outpatient Prescription Drugs, Supplies,and Supplements") Ostomy, urological, and specialized wound care • Outpatient laboratory and sleep studies(refer to supplies exclusions "Outpatient Imaging,Laboratory,and Other • Comfort,convenience,or luxury equipment or Diagnostic and Treatment Services") features • Telehealth Visits(refer to"Telehealth Visits") Outpatient Imaging, Laboratory, and Opioid Treatment Program Services Other Diagnostic and Treatment Members with opioid use disorder(OUD)can receive Services coverage of Services to treat OUD through an Opioid We cover the following Services at the Cost Share Treatment Program(OTP)which includes the following indicated only when part of care covered under other Services: headings in this"Benefits and Your Cost Share"section. • U.S.Food and Drug Administration(FDA)approved The Services must be prescribed by a Plan Provider: opioid agonist and antagonist medication-assisted . Complex imaging(other than preventive)such as CT treatment(MAT)medications and the dispensing and scans,MRIs,and PET scans: no charge administration of MAT medications(if applicable) • Basic imaging Services,such as diagnostic and • Substance use disorder counseling therapeutic X-rays,mammograms,and ultrasounds: • Individual and group therapy no charge Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 38 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Nuclear medicine: no charge Outpatient Imaging, Laboratory, and Other • Routine preventive retinal photography screenings: Diagnostic and Treatment Services exclusions no charge • Ultraviolet light therapy comfort,convenience,or • Routine laboratory tests to monitor the effectiveness luxury equipment or features of dialysis:no charge • Repair or replacement of ultraviolet light therapy • Hemoglobin(Alc)testing for diabetes,Low-Density equipment due to misuse Lipoprotein(LDL)testing for heart disease, International Normalized Ratio(INR)for persons Outpatient Prescription Drugs, Supplies, with liver disease or certain blood disorders,and glucose quantitative blood tests not covered at$0 and Supplements under Original Medicare: no charge We cover outpatient drugs,supplies,and supplements • All other laboratory tests(including tests for specific specified in this"Outpatient Prescription Drugs, genetic disorders for which genetic counseling is Supplies,and Supplements"section,in accord with our available): no charge drug formulary guidelines,subject to any applicable • Diagnostic Services provided by Plan Providers who exclusions or limitations under this EOC.We cover are not physicians(such as EKGs,EEGs,and sleep items described in this section when prescribed as studies): no charge follows: • Radiation therapy: no charge • Items prescribed by Plan Providers,within the scope of their licensure and practice • Ultraviolet light therapy treatments,including . Items prescribed by the following Non—Plan ultraviolet light therapy equipment for home use,if (1)the equipment has been approved for you through Providers unless a Plan Physician determines that the the Plan's prior authorization process,as described in item is not Medically Necessary or the drug is for a "Medical Group authorization procedure for certain sexual dysfunction disorder: referrals"under"Getting a Referral"in the"How to ♦ dentists if the drug is for dental care Obtain Services"section and(2)the equipment is ♦ Non—Plan Physicians if the Medical Group provided inside your Home Region Service Area. authorizes a written referral to the Non—Plan (Coverage for ultraviolet light therapy equipment is Physician(in accord with"Medical Group limited to the standard item of equipment that authorization procedure for certain referrals" adequately meets your medical needs.We decide under"Getting a Referral'in the"How to Obtain whether to rent or purchase the equipment,and we Services"section)and the drug, supply,or select the vendor.You must return the equipment to supplement is covered as part of that referral us or pay us the fair market price of the equipment ♦ Non—Plan Physicians if the prescription was when we are no longer covering it.): no charge obtained as part of covered Emergency Services, For the following Services, refer to these Post-Stabilization Care,or Out-of-Area Urgent sections Care described in the"Emergency Services and Urgent Care"section(if you fill the prescription at • Outpatient imaging and laboratory Services that are a Plan Pharmacy,you may have to pay Charges Preventive Services,such as routine mammograms, for the item and file a claim for reimbursement as bone density scans,and laboratory screening tests described in the"Requests for Payment"section) (refer to"Preventive Services") • The item meets the requirements of our applicable • Outpatient procedures that include imaging and drug formulary guidelines diagnostic Services(refer to "Outpatient surgeries and • You obtain the item at a Plan Pharmacy or through procedures") our mail-order service,except as otherwise described • Services related to diagnosis and treatment of under"Certain items from Non—Plan Pharmacies"in infertility,artificial insemination,or assisted this"Outpatient Prescription Drugs, Supplies,and reproductive technology("ART")Services(refer to Supplements"section.Refer to our Kaiser "Fertility Services") Permanente Pharmacy Directory for the locations of Plan Pharmacies in your area.Plan Pharmacies can change without notice and if a pharmacy is no longer a Plan Pharmacy,you must obtain covered items from another Plan Pharmacy,except as otherwise described under"Certain items from Non—Plan Pharmacies"in Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 39 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. this"Outpatient Prescription Drugs, Supplies,and covered Part D prescription drugs.We will cover Supplements"section prescriptions that are filled at a Non—Plan • Your prescriber must either accept Medicare or file Pharmacy according to our Medicare Part D documentation with the Centers for Medicare& formulary guidelines Medicaid Services showing that he or she is qualified ♦ if you are unable to obtain a covered drug in a to write prescriptions,or your Part D claim will be timely manner inside your Home Region Service denied.You should ask your prescribers the next time Area because there is no Plan Pharmacy within a you call or visit if they meet this condition.If not, reasonable driving distance that provides 24-hour please be aware it takes time for your prescriber to service.We may not cover your prescription if a submit the necessary paperwork to be processed reasonable person could have purchased the drug at a Plan Pharmacy during normal business hours In addition to our plan's Part D and medical benefits ♦ if you are trying to fill a prescription for a drug coverage,if you have Medicare Part A,your drugs may that is not regularly stocked at an accessible Plan be covered by Original Medicare if you are in Medicare Pharmacy or available through our mail-order hospice.For more information,please see"What pharmacy(including high-cost drugs) if you're in a Medicare-certified hospice"in this ♦ if you are not able to get your prescriptions from a "Outpatient Prescription Drugs, Supplies,and Plan Pharmacy during a disaster Supplements"section. In these situations,please check first with Member Obtaining refills by mail Services to see if there is a Plan Pharmacy nearby. Most refills are available through our mail-order service, You may be required to pay the difference between what but there are some restrictions.A Plan Pharmacy,our you pay for the drug at the Non—Plan Pharmacy and the Kaiser Permanente Pharmacy Directory,or our cost that we would cover at Plan Pharmacy. website at ky.org/refill can give you more information about obtaining refills through our mail-order service. Payment and reimbursement.If you go to a Non—Plan Please check with your local Plan Pharmacy if you have Pharmacy for the reasons listed,you may have to pay the a question about whether your prescription can be full cost(rather than paying just your Copayment or mailed.Items available through our mail-order service Coinsurance)when you fill your prescription.You may are subject to change at any time without notice. ask us to reimburse you for our share of the cost by submitting a request for reimbursement as described in Certain items from Non—Plan Pharmacies the"Requests for Payment"section.If we pay for the Generally,we cover drugs filled at a Non—Plan drugs you obtained from a Non—Plan Pharmacy,you may Pharmacy only when you are not able to use a Plan still pay more for your drugs than what you would have Pharmacy.If you cannot use a Plan Pharmacy,here are paid if you had gone to a Plan Pharmacy because you the circumstances when we would cover prescriptions may be responsible for paying the difference between filled at a Non—Plan Pharmacy. Plan Pharmacy Charges and the price that the Non—Plan • The drug is related to covered Emergency Services, Pharmacy charged you. Post-Stabilization Care,or Out-of-Area Urgent Care described in the"Emergency Services and Urgent What if you're in a Medicare-certified hospice Care"section.Note:Prescription drugs prescribed If you have Medicare Part A,drugs are never covered by and provided outside of the United States and its both hospice and our plan at the same time.If you are territories as part of covered Emergency Services or enrolled in Medicare hospice and require an anti-nausea, Urgent Care are covered up to a 30-day supply in a laxative,pain medication,or antianxiety drug that is not 30-day period.These drugs are covered under your covered by your hospice because it is unrelated to your medical benefits,and are not covered under Medicare terminal illness and related conditions,our plan must Part D.Therefore,payments for these drugs do not receive notification from either the prescriber or your count toward reaching the Part D Catastrophic hospice provider that the drug is unrelated before our Coverage Stage plan can cover the drug. To prevent delays in receiving • For Medicare Part D covered drugs,the following are any unrelated drugs that should be covered by our plan, additional situations when a Part D drug may be you can ask your hospice provider or prescriber to make covered: sure we have the notification that the drug is unrelated before you ask a pharmacy to fill your prescription. ♦ if you are traveling outside your Home Region Service Area,but in the United States and its In the event you either revoke your hospice election or territories,and you become ill or run out of your are discharged from hospice,our plan should cover all Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 40 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. your drugs.To prevent any delays at a pharmacy when thresholds that apply for the calendar year.We will your Medicare hospice benefit ends,you should bring notify you in advance of any change to your coverage. documentation to the pharmacy to verify your revocation or discharge.For more information about Medicare These payments are included in your out-of-pocket Part D coverage and what you pay,please see"Medicare costs.Your out-of-pocket costs include the payments Part D drugs"in this"Outpatient Prescription Drugs, listed below(as long as they are for Part D covered Supplies,and Supplements"section. drugs,and you followed the rules for drug coverage that are explained in this section): Medicare Part D drugs . The amount you pay for drugs when you are in the Medicare Part D covers most outpatient prescription Initial Coverage Stage drugs if they are sold in the United States and approved for sale by the federal Food and Drug Administration. • Any payments you made during this calendar year as Our Part D formulary includes drugs that can be covered a member of a different Medicare prescription drug under Medicare Part D according to Medicare plan before you joined our plan requirements and certain insulin administration devices (needles,syringes,alcohol swabs,and gauze).Refer to It matters who pays: our"Medicare Part D drug formulary(2025 . If you make these payments yourself,they are Comprehensive Formulary)"in this"Outpatient included in your out-of-pocket costs Prescription Drugs, Supplies,and Supplements"section • These payments are also included in your out-of- for more information about this formulary. pocket costs if they are made on your behalf by Initial Coverage Stage certain other individuals or organizations.This includes payments for your drugs made by a friend or During the Initial Coverage Stage,we pay our share of relative,by most charities,by AIDS drug assistance the cost of your covered prescription drugs,and you pay programs,employer or union health plans, your Cost Share.Your Cost Share will vary depending TRICARE,or by the Indian Health Service.Payments on the drug and where you fill your prescription. made by Medicare's"Extra Help"Program are also Sometimes the cost of the drug is lower than your Cost included Share.In these cases,you pay the lower price for the drug instead of your Cost Share. These payments are not included in your out-of- pocket costs.Your out-of-pocket costs do not include Cost Share for Medicare Part D drugs.You will pay any of these types of payments: the following Cost Share for covered Medicare Part D drugs in this stage: • The amount you contribute,if any,toward your • Generic drugs: a$5 Copayment for up to a 100-day group's Premium supply 1 • Drugs you buy outside the United States and its territories • Brand-name and specialty drugs: a$20 Copayment for up to a 100-day supply • Drugs that are not covered by our plan • Injectable Part D vaccines: no charge • Drugs you get at an out-of-network pharmacy that do not meet our plan's requirements for out-of-network • Emergency contraceptive pills: no charge coverage • The following insulin-administration devices at a o Non—Part D drugs,including prescription drugs $5 Copayment for up to a 100-day supply:needles, covered by Part A or Part B and other drugs excluded syringes,alcohol swabs,and gauze from coverage by Medicare Catastrophic Coverage Stage • Payments for your drugs that are made by the You enter the Catastrophic Coverage Stage when your Veterans Health Administration(VA) out-of-pocket costs have reached the$2,000 limit for the • Payments for your drugs made by a third-party with a calendar year. Once you are in the Catastrophic legal obligation to pay for prescription costs(for Coverage Stage,you will stay in this payment stage until example,Workers' Compensation) the end of the calendar year.During this payment stage, . Payments made by drug manufacturers under the you pay nothing for your covered Part D drugs. Manufacturer Discount Program Note:Each year,effective on January 1,the Centers for Reminder: If any other organization such as the ones Medicare&Medicaid Services may change coverage described above pays part or all of your out-of-pocket Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 41 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. costs for Part D drugs,you are required to tell our plan You or your appointed representative may need to by calling Member Services. provide the evidence to a Plan Pharmacy when obtaining covered Part D prescriptions so that we may charge you Keeping track of Medicare Part D drugs.The Part D the appropriate Cost Share amount until the Centers for Explanation of Benefits is a document you will get for Medicare&Medicaid Services(CMS)updates its each month you use your Part D prescription drug records to reflect your current status.Once CMS updates coverage.The Part D Explanation of Benefits will tell its records,you will no longer need to present the you the total amount you,or others on your behalf,have evidence to the Plan Pharmacy.Please provide your spent on your prescription drugs and the total amount we evidence in one of the following ways so we can forward have paid for your prescription drugs.A Part D it to CMS for updating: Explanation of Benefits is also available upon request • Write to Kaiser Permanente at: from Member Services. California Service Center Attn:Best Available Evidence Medicare's "Extra Help" Program P.O.Box 232400 Medicare provides"Extra Help"to pay prescription drug San Diego,CA 92193-2400 costs for people who have limited income and resources. • Fax it to 1-877-528-8579 Resources include your savings and stocks,but not your home or car.If you qualify,you get help paying for any • Take it to a Plan Pharmacy or your local Member Medicare drug plan's monthly premium and prescription Services office at a Plan Facility Copayments.This"Extra Help"also counts toward your out-of-pocket costs. When we receive the evidence showing your Cost Share level,we will update our system so that you can pay the If you automatically qualify for"Extra Help"Medicare correct Cost Share when you get your next prescription will mail you a letter.You will not have to apply.If you at our Plan Pharmacy.If you overpay your Cost Share, do not automatically qualify you may be able to get we will reimburse you.Either we will forward a check to "Extra Help"to pay for your prescription drug premiums you in the amount of your overpayment,or we will offset and costs. To see if you qualify for getting"Extra Help," future Cost Share.If our Plan Pharmacy hasn't collected call: a Cost Share from you and is carrying your Cost Share as • 1-800-MEDICARE(1-800-633-4227)(TTY users a debt owed by you,we may make the payment directly call 1-877-486-2048),24 hours a day,seven days a to our Plan Pharmacy.If a state paid on your behalf,we week; may make payment directly to the state.Please call Member Services if you have questions. • The Social Security Office at 1-800-772-1213(TTY users call 1-800-325-0778),between 8 a.m. and 7 If you qualify for"Extra Help,"we will send you an p.m.,Monday through Friday;or Evidence of Coverage Rider for People Who Get • Your state Medicaid office. See the"Important Phone "Extra Help"Paying for Prescription Drugs(also Numbers and Resources"section for contact known as the Low Income Subsidy Rider or the LIS information Rider),which tells you about your Part D drug coverage. If you don't have this insert,please call Member If you believe you have qualified for"Extra Help"and Services and ask for the LIS Rider. you believe that you are paying an incorrect Cost Share amount when you get your prescription at a Plan The AIDS Drug Assistance Program (ADAP) Pharmacy,our plan has a process for you to either The AIDS Drug Assistance Program(ADAP)helps request assistance in obtaining evidence of your proper ADAP-eligible individuals living with HIV/AIDS have Cost Share level,or,if you already have the evidence,to access to life-saving HIV medications.Medicare Part D provide this evidence to us. prescription drugs that are also on the ADAP formulary qualify for prescription cost-sharing assistance through If you aren't sure what evidence to provide us,please the California AIDS Drug Assistance Program. contact a Plan Pharmacy or Member Services.The evidence is often a letter from either your state Medicaid Note:To be eligible for the ADAP operating in your or Social Security office that confirms you are qualified state,individuals must meet certain criteria,including for"Extra Help."The evidence may also be state-issued proof of state residence and HIV status,low income as documentation with your eligibility information defined by the state,and uninsured/under-insured status. associated with Home and Community-Based Services. If you change plans,please notify your local ADAP enrollment worker so you can continue to receive Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 42 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. assistance.For information on eligibility criteria,covered in this section and the drug is used for a medically drugs,or how to enroll in the program,please call the accepted indication.A medically accepted indication is a ADAP call center at 1-844-421-7050 between 8 a.m. and use of the drug that is either: 5 p.m.(excluding holidays). • Approved by the Food and Drug Administration for the diagnosis or condition for which it is being Medicare Prescription Payment Plan prescribed,or The Medicare Prescription Payment Plan is a new payment option that works with your current drug • Supported by certain references, such as the coverage,and it can help you manage your drug costs by American Hospital Formulary Service Drug spreading them across monthly payments that vary Information and the Micromedex DRUGDEX throughout the year(January—December). This Information System payment option might help you manage your expenses,but it doesn't save you money or lower your Our Drug List includes brand-name drugs,generic drugs, drug costs. "Extra Help"from Medicare and help from and biological products(which may include biosimilars). your State Pharmaceutical Assistance Program(SPAP) A brand-name drug is a prescription drug that is sold and AIDS Drug Assistance Program(ADAP),for those under a trademarked name owned by the drug who qualify,is more advantageous than participation in manufacturer.Biological products are drugs that are the Medicare Prescription Payment Plan.All members more complex than typical drugs.On the Drug List, are eligible to participate in this payment option, when we refer to drugs,this could mean a drug or a regardless of income level,and all Medicare drug plans biological product. and Medicare health plans with drug coverage must offer this payment option. Contact us or visit Medicare.gov to A generic drug is a prescription drug that has the same find out if this payment option is right for you. active ingredients as the brand-name drug.Biological products have alternatives that are called biosimilars. If you're participating in the Medicare Prescription Generally,generics and biosimilars work just as well as Payment Plan,each month you'll pay your plan premium the brand-name drug or original biological product and (if you have one)and you'll get a bill from your health or usually cost less.There are generic drug substitutes drug plan for your prescription drugs(instead of paying available for many brand-name drugs and biosimilar the pharmacy).Your monthly bill is based on what you alternatives for some original biological products. Some owe for any prescriptions you get,plus your previous biosimilars are interchangeable biosimilars and, month's balance,divided by the number of months left in depending on state law,may be substituted for the the year. original biological product at the pharmacy without needing a new prescription,just like generic drugs can be The"Important Phone Numbers and Resources"section substituted for brand-name drugs. tells more about the Medicare Prescription Payment Plan.If you disagree with the amount billed as part of Preferred generic and generic drugs listed in the this payment option,you can follow the steps described formulary will be subject to the generic drug Copayment in the"Coverage Decisions.Appeals,and Complaints" or Coinsurance listed under"Cost Share for Medicare section to make a complaint or appeal. Part D drugs"in this"Outpatient Prescription Drugs, Supplies,and Supplements"section.Preferred and Medicare Part D drug formulary(2025 nonpreferred brand-name drugs and specialty tier drugs Comprehensive Formulary) listed in the formulary will be subject to the brand-name Our plan has a 2025 Comprehensive Formulary. In this Copayment or Coinsurance listed under"Cost Share for EOC,we call it the Drug List for short. Medicare Part D drugs"in this"Outpatient Prescription Drugs,Supplies,and Supplements"section.Please note The drugs on this list are selected by our plan with the that sometimes a drug may appear more than once on our help of a team of doctors and pharmacists.The list meets 2025 Comprehensive Formulary.This is because Medicare's requirements and has been approved by different restrictions or cost-sharing may apply based on Medicare. factors such as the strength,amount,or form of the drug prescribed by your health care provider(for instance, 10 The drugs on our Drug List are only those covered under mg versus 100 mg;one per day versus two per day; Medicare Part D. tablet versus liquid). We will generally cover a drug on our plan's Drug List You can get updated information about the drugs our as long as you follow the other coverage rules explained plan covers by visiting our website at kp.org/seniorrx. You may also call Member Services to find out if your Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 43 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. drug is on the formulary or to request an updated copy of cover or request a Part D formulary exception in order to our formulary. get coverage for the drug.Refer to our formulary or our website,ku.org/seniorrx,for more information about We may make certain changes to our formulary during our Part D transition coverage. the year. Changes in the formulary may affect which drugs are covered and how much you will pay when Medicare Part D exclusions(non—Part D drugs).If filling your prescription. The kinds of formulary changes you get drugs that are excluded,you must pay for them we may make include: yourself.If you appeal and the requested drug is found • Adding or removing drugs from the formulary not to be excluded under Part D,we will pay for or cover it.For information about appealing a decision,go to • Adding prior authorizations or other restrictions on a "Coverage Decisions,Appeals,and Complaints." If a drug drug is not covered by Medicare Part D,any amounts you pay for that drug will not count toward reaching the If we remove drugs from the formulary or add prior Catastrophic Coverage Stage. authorizations or restrictions on a drug,and you are taking the drug affected by the change,you will be Here are three general rules about drugs that Medicare permitted to continue receiving that drug at the same drug plans will not cover under Part D: level of Cost Share for the remainder of the calendar year.However,if a brand-name drug is replaced with a • Our plan's Part D drug coverage cannot cover a drug new generic drug,or our formulary is changed as a result that would be covered under Medicare Part A or of new information on a drug's safety or effectiveness, Part B you may be affected by this change.We will notify you • Our Plan cannot cover a drug purchased outside the of the change at least 30 days before the date that the United States or its territories change becomes effective or provide you with at least a • Our plan cannot cover off-label use of a drug when month's supply at the Plan Pharmacy.This will give you the use is not supported by certain references,such as an opportunity to work with your physician to switch to a the American Hospital Formulary Service Drug different drug that we cover or request an exception. (If a Information and the Micromedex DRUGDEX drug is removed from our formulary because the drug Information System. Off-label use is any use of the has been recalled,we will not give 30 days'notice before drug other than those indicated on a drug's label as removing the drug from the formulary.Instead,we will approved by the Food and Drug Administration remove the drug immediately and notify members taking the drug about the change as soon as possible.) In addition,by law,the following categories of drugs are If your drug isn't listed on your copy of our formulary, not covered by Medicare drug plans: you should first check the formulary on our website, • Nonprescription drugs(also called over-the-counter which we update when there is a change.In addition,you cgs) may call Member Services to be sure it isn't covered. . Drugs when used to promote fertility If Member Services confirms that we don't cover your . Drugs when used for the relief of cough or cold drug,you have two options: symptoms • You may ask your Plan Physician if you can switch to . Drugs when used for cosmetic purposes or to promote another drug that is covered by us hair growth • You or your Plan Physician may ask us to make an o Prescription vitamins and mineral products,except exception(a type of coverage determination)to cover your Medicare Part D drug. See the"Coverage prenatal vitamins and fluoride preparations Decisions,Complaints,and Appeals"section for • Drugs when used for the treatment of sexual or more information on how to request an exception erectile dysfunction • Drugs when used for treatment of anorexia,weight Transition policy.If you recently joined our plan,you loss,or weight gain may be able to get a temporary supply of a Medicare . Outpatient drugs for which the manufacturer seeks to Part D drug you were previously taking that may not be on our formulary or has other restrictions,during the first require that associated tests or monitoring services be 90 days of your membership.Current members may also purchased exclusively from the manufacturer as a be affected by changes in our formulary from one year to condition of sale the next.Members should talk to their Plan Physicians to decide if they should switch to a different drug that we Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 44 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Note:In addition to the coverage provided under this (an oral form of a drug that,when ingested,breaks Medicare Part D plan,you also have coverage for non— down into the same active ingredient found in the Part D drugs described under"Home infusion therapy," injectable drug)of the injectable drug.As new oral "Outpatient drugs covered by Medicare Part B,""Certain cancer drugs become available,Part B may cover intravenous drugs,supplies,and supplements,"and them.If Part B doesn't cover them,Part D does "Outpatient drugs,supplies,and supplements not . Intravenous Immune Globulin for the home treatment covered by Medicare"in this"Outpatient Prescription of primary immune deficiency diseases Drugs,Supplies,and Supplements"section.If a drug is not covered under Medicare Part D,refer to those • Drugs that usually aren't self-administered by the headings for information about your non—Part D drug patient and are injected or infused while you are coverage. getting physician,hospital outpatient,or ambulatory surgical center services Other prescription drug coverage.If you have • Insulin furnished through an item of durable medical additional health care or drug coverage from another equipment(such as a Medically Necessary insulin plan,you must provide that information to our plan. The pump) information you provide helps us calculate how much . Injectable osteoporosis drugs,if you are homebound, you and others have paid for your prescription drugs.In have a bone fracture that a doctor certifies was related addition,if you lose or gain additional health care or to post-menopausal osteoporosis,and cannot self- prescription drug coverage,please call Member Services administer the drug to update your membership records. • Some Antigens:Medicare covers antigens if a doctor Home infusion therapy prepares them and a properly instructed person(who We cover home infusion supplies and drugs at no charge could be you,the patient)gives them under if all of the following are true: appropriate supervision • Your prescription drug is on our Medicare Part D • Oral anti-nausea drugs:Medicare covers oral anti- formulary nausea drugs you use as part of an anti-cancer chemotherapeutic regimen if they're administered • We approved your prescription drug for home before,at,or within 48 hours of chemotherapy or are infusion therapy used as a full therapeutic replacement for an • Your prescription is written by a Plan Provider and intravenous anti-nausea drug filled at a Plan home-infusion pharmacy o Certain oral End-Stage Renal Disease(ESRD)drugs if the same drug is available in injectable form and Outpatient drugs covered by Medicare Part B the Part B ESRD benefit covers it In addition to Medicare Part D drugs,we also cover • Calcimimetic medications under the ESRD payment outpatient prescription drugs that are covered by Medicare Part B.The following are the types of drugs system,including the intravenous medication Parsabiv®,and the oral medication Sensipar® that Medicare Part B covers: • Drugs you take using durable medical equipment • Certain drugs for home dialysis,including heparin, (such as nebulizers)that were prescribed by a Plan the antidote for heparin,when Medically Necessary, Physician and topical anesthetics • Clotting factors you give yourself by injection if you • Erythropoiesis-stimulating agents:Medicare covers have hemophilia erythropoietin by injection if you have End-Stage Renal Disease(ESRD)or you need this drug to treat • Transplant/Immunosuppressive drugs,if Medicare anemia related to certain other conditions(such as paid for your organ transplant(or a group plan was Procrit®,Retacrit®,Epoetin Alfa,Aranesp®,or required to pay before Medicare paid for it).You Darbepoetin Alfa) must have Part A at the time of the covered . The Alzheimer's drug,Leqembi®(generic name transplant,and you must have Part B at the time you get immunosuppressive drugs.Keep in mind, lecanemab),which is administered intravenously.In Medicare drug coverage(Part D)covers addition to medication costs,you may need additional immunosuppressive drugs if Part B doesn't cover scans and tests before and/or during treatment that them could add to your overall costs.Talk to your doctor about what scans and tests you may need as part of • Certain oral anti-cancer drugs:Medicare covers some your treatment oral cancer drugs you take by mouth if the same drug is available in injectable form or the drug is a prodrug Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 45 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Parenteral and enteral nutrition(intravenous and tube • Generic drugs prescribed for the treatment of sexual feeding) dysfunction disorders:25 percent Coinsurance for up to a 100-day supply Your Cost Share for Medicare Part B drugs.You pay • Brand drugs prescribed for the treatment of sexual the following for Medicare Part B drugs: dysfunction disorders:25 percent Coinsurance for • Generic drugs: a$5 Copayment for up to a 100-day up to a 100-day supply supply o Generic drugs prescribed for the treatment of • Brand-name drugs,specialty drugs,and compounded infertility: a$5 Copayment for up to a 100-day products: a$20 Copayment for up to a 100-day supply supply • Brand drugs prescribed for the treatment of infertility: Certain intravenous drugs, supplies, and a$20 Copayment for up to a 100-day supply supplements • Amino acid—modified products used to treat We cover certain self-administered intravenous drugs, congenital errors of amino acid metabolism(such as fluids,additives,and nutrients that require specific types phenylketonuria): no charge for up to a 30-day of parenteral-infusion(such as an intravenous or supply intraspinal-infusion)at no charge for up to a 30-day • Elemental dietary enteral formula when used as a supply.In addition,we cover the supplies and equipment primary therapy for regional enteritis:no charge for required for the administration of these drugs at up to a 30-day supply no charge. • Ketone test strips and sugar or acetone test tablets or Outpatient drugs, supplies, and supplements tapes for diabetes urine testing: no charge for up to a 100-da supply not covered by Medicare y pp y If adrug,supply,or supplement is not covered by • Tobacco cessation drugs: no charge.For over-the- Medicare Part B or D,we cover the following additional counter medications,we cover up to two 100-day items in accord with our non—Part D drug formulary: supplies per calendar year • Drugs for which a prescription is required by law.We Note:If Charges for the drug,supply,or supplement are also cover certain drugs that do not require a less than the Copayment or Coinsurance,you will pay prescription by law if they are listed on our drug the lesser amount. formulary applicable to non—Part D items and prescribed by a Plan Physician Non—Part D drug formulary.The non—Part D drug • Diaphragms,cervical caps,contraceptive rings,and formulary includes a list of drugs that our Pharmacy and contraceptive patches Therapeutics Committee has approved for our Members. Our Pharmacy and Therapeutics Committee,which is • Disposable needles and syringes needed for injecting primarily composed of Plan Physicians and pharmacists, covered drugs and supplements selects drugs for the drug formulary based on several • Inhaler spacers needed to inhale covered drugs factors,including safety and effectiveness as determined • Ketone test strips and sugar or acetone test tablets or from a review of medical literature.The drug formulary tapes for diabetes urine testing is updated monthly based on new information or new drugs that become available.To find out which drugs are • FDA-approved medications for tobacco cessation, on the formulary for your plan,please refer to the including over-the-counter medications when California Commercial HMO formulary on our website prescribed by a Plan Physician at ku.orWformulary. The formulary also discloses requirements or limitations that apply to specific drugs, Your Cost Share for outpatient drugs,supplies,and such as whether there is a limit on the amount of the drug supplements not covered by Medicare.Your Cost that can be dispensed and whether the drug must be Share for these items is as follows: obtained at certain specialty pharmacies.If you would • Generic items(that are not described elsewhere in this like to request a copy of this drug formulary,please call EOC): a$5 Copayment for up to a 100-day supply Member Services.Note:The presence of a drug on the • Brand-name items,specialty drugs,and compounded drug formulary does not necessarily mean that it will be products(that are not described elsewhere in this prescribed for a particular medical condition. EOC): a$20 Copayment for up to a 100-day supply Drug formulary guidelines allow you to obtain anon- formulary prescription drug(those not listed on our drug Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 46 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. formulary for your condition)if it would otherwise be • Possible harmful interactions between drugs you are covered by your plan,as described above,and it is taking Medically Necessary.If you disagree with a Health Plan . Drug allergies determination that a non-formulary prescription drug is not covered,you may file a grievance as described in the • Drug dosage errors "Coverage Decisions,Appeals,and Complaints"section. e Unsafe amounts of opioid pain medications Continuity drugs.If this EOC is amended to exclude a If we identify a medication problem during our drug drug that we have been covering and providing to you utilization review,we will work with your doctor to under this EOC,we will continue to provide the drug if a correct the problem. prescription is required by law and a Plan Physician continues to prescribe the drug for the same condition Drug management program and for a use approved by the federal Food and Drug We have a program that that helps make sure members Administration. safely use prescription opioids and other frequently abused medications.This program is called a Drug About specialty drugs. Specialty drugs are high-cost Management Program(DMP).If you use opioid drugs that are on our specialty drug list.If your Plan medications that you get from several prescribers or Physician prescribes more than a 30-day supply for an pharmacies,or if you had a recent opioid overdoes,we outpatient drug,you may be able to obtain more than a may talk to your prescribers to make sure your use of 30-day supply at one time,up to the day supply limit for opioid medications is appropriate and Medically that drug.However,most specialty drugs are limited to a Necessary.Working with your prescribers,if we decide 30-day supply in any 30-day period.Your Plan your use of prescription opioid or benzodiazepine Pharmacy can tell you if a drug you take is one of these medications may not be safe,we may limit how you can drugs. get those medications.If we place you in our DMP,the limitations may be: Manufacturer coupon program.For outpatient • Requiring you to get all your prescriptions for opioid prescription drugs or items that are covered under the "Outpatient drugs,supplies,and supplements not or benzodiazepine medications from a certain pharmacy(ies) covered by Medicare"section above and obtained at a Plan Pharmacy,you may be able to use approved • Requiring you to get all your prescriptions for opioid manufacturer coupons as payment for the Cost Share that or benzodiazepine medications from a certain you owe,as allowed under Health Plan's coupon prescriber program.You will owe any additional amount if the • Limiting the amount of opioid or benzodiazepine coupon does not cover the entire amount of your Cost medications we will cover for you Share for your prescription. Certain health plan coverages are not eligible for coupons.You can get more If we plan on limiting how you may get these information regarding the Kaiser Permanente coupon medications or how much you can get,we will send you program rules and limitations at k%org/rxcoupons. a letter in advance. The letter will tell you if we will limit coverage of these drugs for you,or if you'll be required Drug utilization review to get the prescriptions for these drugs only from a We conduct drug utilization reviews to make sure that specific prescriber or pharmacy.You will have an you are getting safe and appropriate care.These reviews opportunity to tell us which prescribers or pharmacies are especially important if you have more than one you prefer to use,and about any other information you doctor who prescribes your medications.We conduct think is important for us to know.After you've had the drug utilization reviews each time you fill a prescription opportunity to respond,if we decide to limit your and on a regular basis by reviewing our records.During coverage for these medications,we will send you another these reviews,we look for medication problems such as: letter confirming the limitation.If you think we made a • Possible medication errors mistake or you disagree with our decision or with the limitation,you and your prescriber have the right to • Duplicate drugs that are unnecessary because you are appeal.If you appeal,we will review your case and give taking another similar drug to treat the same medical you a new decision.If we continue to deny any part of condition your request related to the limitations that apply to your • Drugs that are inappropriate because of your age or access to medications,we will automatically send your gender case to an independent reviewer outside of our plan. See Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 47 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. the"Coverage Decisions,Appeals,and Complaints" constitutes a Medically Necessary 30-or 100-day section for information about how to ask for an appeal. supply for you.Upon payment of the Cost Share specified in the"Outpatient prescription drugs, You will not be placed in our DMP if you have certain supplies,and supplements,"you will receive the medical conditions,such as cancer-related pain or sickle supply prescribed up to the day supply limit specified cell disease,you are receiving hospice,palliative,or end- in this section or in the drug formulary for your plan of-life care,or you live in a long-term care facility. (see"Non—Part D drug formulary"above).The maximum you may receive at one time of a covered Medication therapy management program item,is either one 30-day supply in a 30-day period or We offer a medication therapy management program at one 100-day supply in a 100-day period. If you wish no additional cost to Members who have multiple to receive more than the covered day supply limit, medical conditions,who are taking many prescription then you must pay Charges for any prescribed drugs,and who have high drug costs.This program was quantities that exceed the day supply limit developed for us by a team of pharmacists and doctors. • For sexual dysfunction drugs,the maximum you may We use this medication therapy management program to receive at one time of episodic drugs prescribed for help us provide better care for our members.For the treatment of sexual dysfunction disorders is eight example,this program helps us make sure that you are doses in any 30-day period or up to 27 doses in any using appropriate drugs to treat your medical conditions 100-day period and help us identify possible medication errors. • The pharmacy may reduce the day supply dispensed If you are selected to join a medication therapy at the Cost Share specified under"Outpatient prescription drugs,supplies,and supplements not management program,we will send you information covered by Medicare"for any drug to a 30-day supply about the specific program,including information about in any 30-day period if the pharmacy determines that how to access the program. the item is in limited supply�1 the market or for m For the following Services, refer to these specific drugs(your Plan Pharmacy can tell you if a sections drug you take is one of these drugs) • Diabetes blood-testing equipment and their supplies, Outpatient prescription drugs, supplies, and and insulin pumps and their supplies(refer to supplements not covered by Medicare "Durable Medical Equipment for Home Use") exclusions • Drugs covered during a covered stay in a Plan • Any requested packaging(such as dose packaging) Hospital or Skilled Nursing Facility(refer to other than the dispensing pharmacy's standard "Hospital Inpatient Care"and"Skilled Nursing packaging Facility Care") • Compounded products unless the drug is listed on one • Drugs prescribed for pain control and symptom of our drug formularies or one of the ingredients management of the terminal illness for Members who requires a prescription by law are receiving covered hospice care(refer to"Hospice • Drugs prescribed to shorten the duration of the Care") common cold • Durable medical equipment used to administer drugs • Prescription drugs for which there is an over-the- (refer to"Durable Medical Equipment for Home Use") counter equivalent(the same active ingredient, strength,and dosage form as the prescription drug). • Outpatient administered drugs(refer to"Outpatient This exclusion does not apply to: Care") ♦ insulin • Vaccines covered by Medicare Part B(refer to ♦ over-the-counter tobacco cessation drugs and "Preventive Services") contraceptive drugs Outpatient prescription drugs, supplies, and ♦ an entire class of prescription drugs when one drug supplements not covered by Medicare within that class becomes available over-the- limitations counter • Drugs when prescribed solely for the purposes of • The prescribing physician or dentist determines how losing weight,except when Medically Necessary for much of a drug,supply,item,or supplement to the treatment of morbid obesity.We may require prescribe.For purposes of day supply coverage limits, Members who are prescribed drugs for morbid Plan Physicians determine the amount of an item that Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 48 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. obesity to be enrolled in a covered comprehensive • Cardiovascular disease risk reduction visit(therapy weight loss program,for a reasonable period of time for cardiovascular disease): no charge prior to or concurrent with receiving the prescription Cardiovascular disease testing:no charge drug • Cervical and vaginal cancer screening: no charge Over-the-Counter (OTC) Health and • Colorectal cancer screening,including flexible Wellness sigmoidoscopies,colonoscopies,and fecal occult blood tests:no charge We cover OTC items listed in our OTC catalog for free • Depression screening: no charge home delivery at no charge.You may order OTC items • Diabetes screening,including fasting glucose tests: up to the$70 quarterly benefit limit.Each order must be no charge at least$25.Your order may not exceed your quarterly benefit limit.Any unused portion of the quarterly benefit • Diabetes self-management training: no charge limit doesn't carry forward to the next quarter.(Your • Glaucoma screening: no charge benefit limit resets on January 1,April 1,July 1,and • HIV screening: no charge October 1). • Immunizations(including the vaccine)covered by To view our catalog and place an order online,please Medicare Part B such as Hepatitis B,influenza, visit ky.org/otc/ca.You may place an order over the pneumococcal,and COVID-19 vaccines that are phone or request a printed catalog be mailed to you by administered to you in a Plan Medical Office: calling 1-833-569-2360(TTY 711),7 a.m.to 5 p.m. no charge PST,Monday through Friday. • Lung cancer screening: no charge • Medical nutrition therapy for kidney disease and Preventive Services diabetes: no charge • Medicare diabetes prevention program: no charge We cover a variety of Preventive Services in accord with Medicare guidelines.The list of Preventive Services is • Obesity screening and therapy to promote sustained subject to change by the Centers for Medicare& weight loss: no charge Medicaid Services.These Preventive Services are subject • Prostate cancer screening exams,including digital to all coverage requirements described in this"Benefits rectal exams and Prostate Specific Antigens(PSA) and Your Cost Share"section and all provisions in the tests: no charge "Exclusions,Limitations,Coordination of Benefits,and • Screening and counseling to reduce alcohol misuse: Reductions"section.If you have questions about no charge Preventive Services,please call Member Services. • Screening for sexually transmitted infections(STIs) Note:If you receive any other covered Services that are and counseling to prevent STIs: no charge not Preventive Services during or subsequent to a visit • Smoking and tobacco use cessation(counseling to that includes Preventive Services on the list,you will pay stop smoking or tobacco use): no charge the applicable Cost Share for those other Services.For . "Welcome to Medicare"preventive visit: no charge example,if laboratory tests or imaging Services ordered during a preventive office visit are not Preventive Services,you will pay the applicable Cost Share for Prosthetic and Orthotic Devices those Services. Prosthetic and orthotic devices coverage rules Your Cost Share.You pay the following for covered We cover the prosthetic and orthotic devices specified in Preventive Services: this"Prosthetic and Orthotic Devices"section if all of • Abdominal aortic aneurysm screening prescribed the following requirements are met: during the one-time"Welcome to Medicare" • The device is in general use,intended for repeated preventive visit: no charge use,and primarily and customarily used for medical • Annual Wellness visit: no charge purposes • Bone mass measurement:no charge • The device is the standard device that adequately • Breast cancer screening(mammograms): no charge meets your medical needs Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 49 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • You receive the device from the provider or vendor • Enteral formula for Members who require tube that we select feeding in accord with Medicare guidelines • The item has been approved for you through the • Enteral pump and supplies Plan's prior authorization process,as described in • Tracheostomy tube and supplies "Medical Group authorization procedure for certain referrals"under"Getting a Referral"in the"How to • Prostheses to replace all or part of an external facial Obtain Services"section body part that has been removed or impaired as a • The Services are provided inside our Service Area result of disease,injury,or congenital defect Other covered prosthetic and orthotic devices Coverage includes fitting and adjustment of these If all of the requirements described under"Prosthetic and devices,their repair or replacement,and Services to orthotic coverage rules"in this"Prosthetics and Orthotic determine whether you need a prosthetic or orthotic Devices"section are met,we cover the following items device.If we cover a replacement device,then you pay described in this"Other covered prosthetic and orthotic the Cost Share that you would pay for obtaining that devices"section: device. • Prosthetic devices required to replace all or part of an Base prosthetic and orthotic devices organ or extremity,in accord with Medicare If all of the requirements described under"Prosthetic and guidelines orthotic coverage rules"in this"Prosthetics and Orthotic • Vacuum erection device for sexual dysfunction Devices"section are met,we cover the items described • Certain surgical boots following surgery when in this"Base prosthetic and orthotic devices"section. provided during an outpatient visit Internally implanted devices.We cover prosthetic and • Orthotic devices required to support or correct a orthotic devices such as pacemakers,intraocular lenses, defective body part,in accord with Medicare cochlear implants,osseointegrated hearing devices,and guidelines hip joints,in accord with Medicare guidelines,if they are implanted during a surgery that we are covering under Your Cost Share.You pay the following for other another section of this"Benefits and Your Cost Share" covered prosthetic and orthotic devices: 20 percent section.We cover these devices at no charge. Coinsurance.For internally implanted prosthetic and orthotic devices,you pay the Cost Share for the External devices.We cover the following external procedure to implant the device.For example,see prosthetic and orthotic devices at 20 percent "Outpatient Care"in this"Benefits and Your Cost Coinsurance: Share"section for the Cost Share that applies for • Prosthetics and orthotics in accord with Medicare outpatient surgery. guidelines.These include,but are not limited to, For the following Services, refer to these braces,prosthetic shoes,artificial limbs,and sections therapeutic footwear for severe diabetes-related foot disease in accord with Medicare guidelines • Eyeglasses and contact lenses,including contact lenses to treat aniridia or aphakia(refer to"Vision • Prosthetic devices and installation accessories to restore a method of speaking following the removal Services") of all or part of the larynx(this coverage does not • Eyewear following cataract surgery(refer to"Vision include electronic voice-producing machines,which Services") are not prosthetic devices) • Hearing aids other than internally implanted devices • After Medically Necessary removal of all or part of a described in this section(refer to"Hearing Services") breast,prosthesis including custom-made prostheses • Injectable implants(refer to"Administered drugs and when Medically Necessary products"under"Outpatient Care") • Podiatric devices(including footwear)to prevent or treat diabetes-related complications when prescribed Prosthetic and orthotic devices exclusions by a Plan Physician or by a Plan Provider who is a • Dental appliances podiatrist • Nonrigid supplies not covered by Medicare,such as • Compression burn garments and lymphedema wraps elastic stockings and wigs,except as otherwise and garments described above in this"Prosthetic and Orthotic Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 50 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Devices"section and the"Ostomy,Urological,and • Any other outpatient procedures that do not require a Specialized Wound Care Supplies"section licensed staff member to monitor your vital signs as • Comfort,convenience,or luxury equipment or described above: the Cost Share that would features otherwise apply for the procedure in this"Benefits and Your Cost Share"section(for example,radiology • Repair or replacement of device due to misuse procedures that do not require a licensed staff • Shoes,shoe inserts,arch supports,or any other member to monitor your vital signs as described footwear,even if custom-made,except footwear above are covered under"Outpatient Imaging, described above in this"Prosthetic and Orthotic Laboratory,and Other Diagnostic and Treatment Devices"section for diabetes-related complications Services") • Prosthetic and orthotic devices not intended for • Hospital inpatient Services(including room and maintaining normal activities of daily living board,drugs,imaging,laboratory,other diagnostic (including devices intended to provide additional and treatment Services,and Plan Physician Services): support for recreational or sports activities) no charge • Nonconventional intraocular lenses(IOLs)following For the following Services, refer to these cataract surgery(for example,presbyopia-correcting sections IOLs).You may request and we may provide insertion of presbyopia-correcting IOLs or • Office visits not described in this"Reconstructive astigmatism-correcting IOLs following cataract Surgery"section(refer to"Outpatient Care") surgery in lieu of conventional IOLs.However,you • Outpatient imaging and laboratory(refer to must pay the difference between Charges for "Outpatient Imaging,Laboratory,and Other nonconventional IOLs and associated services and Diagnostic and Treatment Services") Charges for insertion of conventional IOLs following cataract surgery • Outpatient prescription drugs(refer to"Outpatient Prescription Drugs, Supplies,and Supplements") • Outpatient administered drugs(refer to"Outpatient Reconstructive Surgery Care") We cover the following reconstructive surgery Services: • Prosthetics and orthotics(refer to"Prosthetic and • Reconstructive surgery to correct or repair abnormal Orthotic Devices") structures of the body caused by congenital defects, • Telehealth Visits(refer to"Telehealth Visits") developmental abnormalities,trauma,infection, tumors,or disease,if a Plan Physician determines that Reconstructive surgery exclusions it is necessary to improve function,or create a normal • Surgery that,in the judgment of a Plan Physician appearance,to the extent possible specializing in reconstructive surgery,offers only a • Following Medically Necessary removal of all or part minimal improvement in appearance of a breast,we cover reconstruction of the breast, surgery and reconstruction of the other breast to produce a symmetrical appearance,and treatment of Religious Nonmedical Health Care physical complications,including lymphedemas Institution Services Your Cost Share.You pay the following for covered Care in a Medicare-certified Religious Nonmedical reconstructive surgery Services: Health Care Institution(RNHCI)is covered by our plan under certain conditions.Covered Services in an RNHCI • Outpatient surgery and outpatient procedures when are limited to nonreligious aspects of care.To be eligible provided in an outpatient or ambulatory surgery for covered Services in a RNHCI,you must have a center or in a hospital operating room,or if it is medical condition that would allow you to receive provided in any setting and a licensed staff member inpatient hospital or Skilled Nursing Facility care.You monitors your vital signs as you regain sensation after may get Services furnished in the home,but only items receiving drugs to reduce sensation or to minimize and Services ordinarily furnished by home health discomfort: a$50 Copayment per procedure agencies that are not RNHCIs.In addition,you must sign • Any other outpatient surgery that does not require a a legal document that says you are conscientiously licensed staff member to monitor your vital signs as opposed to the acceptance of"nonexcepted"medical described above: a$15 Copayment per procedure treatment.("Excepted"medical treatment is a Service or treatment that you receive involuntarily or that is Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 51 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. required under federal,state,or local law. cost-sharing in Original Medicare and your Cost Share as "Nonexcepted"medical treatment is any other Service or a Member of our plan.This means you will pay the same treatment.)Your stay in the RNHCI is not covered by us amount for the Services you receive as part of the study unless you obtain authorization(approval)in advance as you would if you received these Services from our from us. plan.However,you are required to submit documentation showing how much cost sharing you Note: Covered Services are subject to the same paid.Please see the"Requests for Payment"section for limitations and Cost Share required for Services provided more information for submitting requests for payment. by Plan Providers as described in this"Benefits and Your Cost Share"section. You can get more information about joining a clinical research study by visiting the Medicare website to read or download the publication"Medicare and Clinical Services Associated with Clinical Trials Research Studies."(The publication is available at httus://www.medicare.2ov.)You can also call If you participate in aMedicare-approved study,Original 1-800-MEDICARE(1-800-633-4227),24 hours a day, Medicare pays most of the costs for the covered Services seven days a week.TTY users call 1-877-486-2048. you receive as part of the study.If you tell us that you are in a qualified clinical trial,then you are only Services associated with clinical trials responsible for the in-network cost-sharing for the exclusions services in that trial.If you paid more,for example,if you already paid the Original Medicare cost-sharing When you are part of a clinical research study,neither amount,we will reimburse the difference between what Medicare nor our plan will pay for any of the following: you paid and the in-network cost-sharing.However,you • The new item or service that the study is testing, will need to provide documentation to show us how unless Medicare would cover the item or service even much you paid.When you are in a clinical research if you were not in a study study,you may stay enrolled in our plan and continue to • Items or services provided only to collect data,and get the rest of your care(the care that is not related to the not used in your direct health care study)through our plan. • Services that are customarily provided by the research If you want to participate in any Medicare-approved sponsors free of charge to enrollees in the clinical trial clinical research study,you do not need to tell us or to • Items and services provided solely to determine trial get approval from us or your Plan Provider.The eligibility providers that deliver your care as part of the clinical research study do not need to be part of our plan's network of providers.Although you do not need to get Skilled Nursing Facility Care our plan's permission to be in a clinical research study, we encourage you to notify us in advance when you Inside our Service Area,we cover up to 100 days per choose to participate in Medicare-qualified clinical trials. benefit period of skilled inpatient Services in a Plan Skilled Nursing Facility and in accord with Medicare If you participate in a study that Medicare has not guidelines.The skilled inpatient Services must be approved,you will be responsible for paying all costs for customarily provided by a Skilled Nursing Facility,and your participation in the study. above the level of custodial or intermediate care. Once you join a Medicare-approved clinical research A benefit period begins on the date you are admitted to a study,Original Medicare covers the routine items and hospital or Skilled Nursing Facility at a skilled level of Services you receive as part of the study,including: care(defined in accord with Medicare guidelines).A benefit period ends on the date you have not been an • Room and board for a hospital stay that Medicare inpatient in a hospital or Skilled Nursing Facility, would pay for even if you weren't in a study receiving a skilled level of care,for 60 consecutive days. • An operation or other medical procedure if it is part A new benefit period can begin only after any existing of the research study benefit period ends.A prior three-day stay in an acute care hospital is not required.Note: If your Cost Share • Treatment of side effects and complications of the changes during a benefit period,you will continue to pay new care the previous Cost Share amount until a new benefit After Medicare has paid its share of the cost for these period begins. Services,our plan will pay the difference between the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 52 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. We cover the following Services: Substance Use Disorder Treatment • Physician and nursing Services We cover Services specified in this"Substance Use • Room and board Disorder Treatment"section only when the Services are • Drugs prescribed by a Plan Physician as part of your for the preventive,diagnosis,or treatment of Substance plan of care in the Plan Skilled Nursing Facility in Use Disorders.A"Substance Use Disorder"is a accord with our drug formulary guidelines if they are condition identified as a"substance use disorder"in the administered to you in the Plan Skilled Nursing most recently issued edition of the Diagnostic and Facility by medical personnel Statistical Manual of Mental Disorders("DSM"). • Durable medical equipment in accord with our prior Outpatient substance use disorder treatment authorization procedure if Skilled Nursing Facilities ordinarily furnish the equipment(refer to"Medical We cover the following Services for treatment of Group authorization procedure for certain referrals" substance use disorders: under"Getting a Referral"in the"How to Obtain • Day-treatment programs Services"section) o Individual and group substance use disorder • Imaging and laboratory Services that Skilled Nursing counseling by a qualified clinician,including a Facilities ordinarily provide licensed marriage and family therapist(LMFT) • Medical social services • Intensive outpatient programs • Whole blood,red blood cells,plasma,platelets,and • Medical treatment for withdrawal symptoms their administration • Medical supplies Your Cost Share.You pay the following for these covered Services: • Physical,occupational,and speech therapy in accord with Medicare guidelines . Individual substance use disorder evaluation and • Respiratory therapy treatment: a$15 Copayment per visit • Group substance use disorder treatment: a Your Cost Share.We cover these Skilled Nursing $5 Copayment per visit Facility Services at no charge. • Intensive outpatient and day-treatment programs: a $5 Copayment per day For the following Services, refer to these sections Residential treatment • Outpatient imaging,laboratory,and other diagnostic Inside our Service Area,we cover the following Services and treatment Services(refer to"Outpatient Imaging, when the Services are provided in a licensed residential Laboratory,and Other Diagnostic and Treatment treatment facility that provides 24-hour individualized Services") substance use disorder treatment,the Services are generally and customarily provided by a substance use Non—Plan Skilled Nursing Facility care disorder residential treatment program in a licensed Generally,you will get your Skilled Nursing Facility residential treatment facility,and the Services are above care from Plan Facilities.However,under certain the level of custodial care: conditions listed below,you may be able to receive • Individual and group substance use disorder covered care from a non—Plan facility,if the facility counseling accepts our plan's amounts for payment. • Medical services • A nursing home or continuing care retirement • Medication monitoring community where you were living right before you went to the hospital(as long as it provides Skilled • Room and board Nursing Facility care) • Drugs prescribed by a Plan Provider as part of your • A Skilled Nursing Facility where your spouse is plan of care in the residential treatment facility in living at the time you leave the hospital accord with our drug formulary guidelines if they are administered to you in the facility by medical personnel(for discharge drugs prescribed when you are released from the residential treatment facility, refer to"Outpatient Prescription Drugs, Supplies,and Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 53 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Supplements"in this"Benefits and Your Cost Share" • Telehealth services for diagnosis,evaluation,and section) treatment of mental health disorders if- Discharge planning ♦ you have an in-person visit within 6 months prior to your first telehealth visit Your Cost Share.We cover residential substance use ♦ you have an in-person visit every 12 months while disorder treatment Services at no charge. receiving these telehealth services ♦ exceptions can be made to the above for certain Inpatient detoxification circumstances We cover hospitalization in a Plan Hospital only for • Telehealth services for mental health visits provided medical management of withdrawal symptoms,including room and board,Plan Physician Services,drugs, Rural Health Clinics and Federally Qualified H dependency recovery Services,education,and Health Centers counseling. • Virtual check-ins(for example,by phone or video chat)with your doctor for 5-10 minutes if: Your Cost Share.We cover inpatient detoxification ♦ you're not a new patient,and Services at no charge. ♦ the check-in isn't related to an office visit in the For the following Services, refer to these past 7 days,and sections ♦ the check-in doesn't lead to an office visit within 24 hours or the soonest available appointment • Outpatient laboratory(refer to"Outpatient Imaging, . Evaluation of video and/or images you send to your Laboratory,and Other Diagnostic and Treatment Services") doctor,and interpretation and follow-up by your doctor within 24 hours if: • Outpatient self-administered drugs(refer to ♦ you're not a new patient,and "Outpatient Prescription Drugs, Supplies,and Supplements") ♦ the evaluation isn't related to an office visit in the past 7 days,and • Telehealth Visits(refer to"Telehealth Visits") ♦ the evaluation doesn't lead to an office visit within 24 hours or the soonest available appointment Telehealth Visits • Consultation your doctor has with other doctors by phone,internet,or electronic health record Telehealth Visits between you and your provider are intended to make it more convenient for you to receive Your Cost Share.You pay the following types for covered Services,when a Plan Provider determines it is Telehealth Visits with Primary Care Physicians,Non- medically appropriate for your medical condition.You Physician Specialists,and Physician Specialists: have the option of receiving these services either through an in-person visit or via telehealth.You may receive • Interactive video visits: no charge covered Services via Telehealth Visits,when available e Scheduled telephone visits: no charge and if the Services would have been covered under this EOC if provided in person.If you choose to receive Services via telehealth,then you must use a Plan Transplant Services Provider that currently offers the service via telehealth. We offer the following telehealth Services: We cover transplants of organs,tissue,or bone marrow in accord with Medicare guidelines and if the Medical • Telehealth Services for monthly End-Stage Renal Group provides a written referral for care to a transplant Disease--related visits for home dialysis members in a facility as described in"Medical Group authorization hospital-based or critical access hospital-based renal procedure for certain referrals"under"Getting a dialysis center,renal dialysis facility,or the Referral"in the"How to Obtain Services"section. Member's home • Telehealth Services to diagnose,evaluate or treat After the referral to a transplant facility,the following symptoms of a stroke,regardless of your location applies: • Telehealth services for members with a substance use • If either the Medical Group or the referral facility disorder or co-occurring mental health disorder, determines that you do not satisfy its respective regardless of their location criteria for a transplant,we will only cover Services you receive before that determination is made Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 54 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Health Plan,Plan Hospitals,the Medical Group,and To request non-medical transportation(rideshare, Plan Physicians are not responsible for finding, taxi,or private transportation),please call our furnishing,or ensuring the availability of an organ, transportation provider at 1-877-930-1477(TTY 711), tissue,or bone marrow donor Monday through Friday, 5:00 a.m.to 6:00 p.m.You may also create an account with our transportation vendor and • In accord with our guidelines for Services for living schedule rides online at medicaltrip.net or via their transplant donors,we provide certain donation-related mobile app. Services for a donor,or an individual identified by the Medical Group as a potential donor,whether or not If you need to use non-emergency medical the donor is a Member. These Services must be transportation(wheelchair van or gurney van) directly related to a covered transplant for you,which because you physically or medically are not able to get to may include certain Services for harvesting the organ, your medical appointment by non-medical transportation tissue,or bone marrow and for treatment of (rideshare,taxi,or private transportation),please call complications.Please call Member Services for 1-833-226-6760(TTY 711),Monday through Friday, questions about donor Services 9:00 a.m.to 5:00 p.m. Your Cost Share.For covered transplant Services that Call at least three business days before your appointment you receive,you will pay the Cost Share you would pay or as soon as you can when you have an urgent if the Services were not related to a transplant.For appointment.Please have all of the following when you example,see"Hospital Inpatient Services"in this call: "Benefits and Your Cost Share"section for the Cost • Your Kaiser Permanente ID card Share that applies for hospital inpatient Services. • The date and time of your medical appointments We provide or pay for donation-related Services for • The address of where you need to be picked up and actual or potential donors(whether or not they are the address of where you are going Members)in accord with our guidelines for donor • If you will need a return trip Services at no charge. • If someone will be traveling with you(for example,a For the following Services, refer to these parent/legal guardian or caregiver) sections Your Cost Share:You pay the following for covered • Dental Services that are Medically Necessary to transportation: no charge. prepare for a transplant(refer to"Dental Services") • Outpatient imaging and laboratory(refer to For the following Services, refer to this section "Outpatient Imaging,Laboratory,and Other • Emergency and non-emergency ambulance Services Diagnostic and Treatment Services") (refer to"Ambulance Services") • Outpatient prescription drugs(refer to"Outpatient Prescription Drugs, Supplies,and Supplements") Transportation Services exclusion • Outpatient administered drugs(refer to"Outpatient Transportation will not be provided if- Care") • The ride is not for a service covered under this EOC Transportation Services Vision Services We cover transportation up to 24 one-way trips(50 miles We cover the following: per trip)per calendar year,if you meet the following • Routine eye exams with a Plan Optometrist to conditions: determine the need for vision correction(including • You are traveling to and from a network provider dilation Services when Medically Necessary)and to when provided by our designated transportation provide a prescription for eyeglass lenses: a provider.Each stop will count towards one trip $15 Copayment per visit • The ride is for Services covered under this EOC • Physician Specialist Visits to diagnose and treat injuries or diseases of the eye: a$15 Copayment per For trips greater than 50 miles,you will need an approval visit from a provider indicating medical necessity to travel to a location beyond this limit. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 55 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Non-Physician Specialist Visits to diagnose and treat with eyeglass lenses,we cover either one pair of injuries or diseases of the eye: a$15 Copayment per contact lenses(including fitting and dispensing)or an visit initial supply of disposable contact lenses(up to six months,including fitting and dispensing)in any 24 Optical Services months at no charge We cover the Services described in this"Optical Services"section when received from Plan Medical Eyeglasses and contact lenses Offices or Plan Optical Sales Offices. We provide a single$175 Allowance toward the purchase price of any or all of the following not more The date we provide an Allowance toward(or otherwise than once every 24 months when a physician or cover)an item described in this"Optical Services" optometrist prescribes an eyeglass lens(for eyeglass section is the date on which you order the item.For lenses and frames)or contact lens(for contact lenses): example,if we last provided an Allowance toward an • Eyeglass lenses when a Plan Provider puts the lenses item you ordered on May 1,2023,and if we provide an into a frame Allowance not more than once every 24 months for that we cover a clear balance lens when only one eye type of item,then we would not provide another needs correction Allowance toward that type of item until on or after May 1,2025.You can use the Allowances under this"Optical * we cover tinted lenses when Medically Necessary Services"section only when you first order an item. to treat macular degeneration or retinitis If you use part but not all of an Allowance when you first pigmentosa order an item,you cannot use the rest of that Allowance • Eyeglass frames when a Plan Provider puts two lenses later. (at least one of which must have refractive value)into the frame Eyeglasses and contact lenses following cataract • Contact lenses,fitting,and dispensing surgery We cover at no charge one pair of eyeglasses or contact We will not provide the Allowance if we have provided lenses(including fitting or dispensing)following each an Allowance toward(or otherwise covered)eyeglass cataract surgery that includes insertion of an intraocular lenses or frames within the previous 24 months. lens at Plan Medical Offices or Plan Optical Sales Offices when prescribed by a physician or optometrist. When multiple cataract surgeries are needed,and you do Replacement lenses not obtain eyeglasses or contact lenses between If you have a change in prescription of at least.50 procedures,we will only cover one pair of eyeglasses or diopter in one or both eyes within 12 months of the contact lenses after any surgery.If the eyewear you initial point of sale of an eyeglass lens or contact lens purchase costs more than what Medicare covers for that we provided an Allowance toward(or otherwise someone who has Original Medicare(also known as covered)we will provide an Allowance toward the "Fee-for-Service Medicare"),you pay the difference. purchase price of a replacement item of the same type (eyeglass lens,or contact lens,fitting,and dispensing) Special contact lenses for the eye that had the .50 diopter change.The Allowance toward one of these replacement lenses is$30 We cover the following: for a single vision eyeglass lens or for a contact lens • For aniridia(missing iris),we cover up to two (including fitting and dispensing)and$45 for a Medically Necessary contact lenses per eye multifocal or lenticular eyeglass lens. (including fitting and dispensing)in any 12-month period when prescribed by a Plan Physician or Plan For the following Services, refer to these Optometrist: no charge sections • In accord with Medicare guidelines,we cover Services related to the eye or vision other than corrective lenses(including contact lens fitting and Services covered under this"Vision Services" dispensing)and frames(and replacements)for section,such as outpatient surgery and outpatient Members who are aphakic(for example,who have prescription drugs,supplies,and supplements(refer to had a cataract removed but do not have an implanted the applicable heading in this"Benefits and Your intraocular lens(IOL)or who have congenital Cost Share"section) absence of the lens): no charge • For other specialty contact lenses that will provide a significant improvement in your vision not obtainable Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 56 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Vision Services exclusions structures of the body in order to improve appearance), • Eyeglass or contact lens adornment,such as except that this exclusion does not apply to any of the engraving,faceting,or jeweling following: • Services covered under"Reconstructive Surgery"in • Items that do not require a prescription by law(other the"Benefits and Your Cost Share"section than eyeglass frames),such as eyeglass holders, eyeglass cases,and repair kits • The following devices covered under"Prosthetic and • Lenses and sunglasses without refractive value, Orthotic Devices"in the"Benefits and Your Cost except as described in this"Vision Services"section Share section:testicular implants implanted as part of a covered reconstructive surgery,breast prostheses • Low vision devices needed after removal of all or part of a breast or • Replacement of lost,broken,or damaged contact lumpectomy,and prostheses to replace all or part of lenses,eyeglass lenses,and frames an external facial body part Custodial care Assistance with activities of daily living(for example: Exclusions, Limitations, walking,getting in and out of bed,bathing,dressing, Coordination of Benefits, and feeding,toileting,and taking medicine). Reductions This exclusion does not apply to assistance with activities of daily living that is provided as part of Exclusions covered hospice for Members who do not have Part A, Skilled Nursing Facility,or hospital inpatient care. The items and services listed in this"Exclusions"section are excluded from coverage.These exclusions apply to Dental care all Services that would otherwise be covered under this Dental care and dental X-rays,such as dental Services EOC regardless of whether the services are within the following accidental injury to teeth,dental appliances, scope of a provider's license or certificate.Additional dental implants,orthodontia,and dental Services exclusions that apply only to a particular benefit are resulting from medical treatment such as surgery on the listed in the description of that benefit in this EOC. jawbone and radiation treatment,except for Services These exclusions or limitations do not apply to Services covered in accord with Medicare guidelines or under that are Medically Necessary to treat Severe Mental "Dental Services"in the"Benefits and Your Cost Share" Illness or Serious Emotional Disturbance of a Child section. Under Age 18. Disposable supplies Certain exams and Services Disposable supplies for home use,such as bandages, Routine physical exams and other Services that are not gauze,tape,antiseptics,dressings,Ace-type bandages, Medically Necessary,such as when required(1)for and diapers,underpads,and other incontinence supplies. obtaining or maintaining employment or participation in employee programs,(2)for insurance,credentialing or This exclusion does not apply to disposable supplies licensing,(3)for travel,or(4)by court order or for covered in accord with Medicare guidelines or under parole or probation. "Durable Medical Equipment("DME")for Home Use," "Home Health Care,""Hospice Care,""Ostomy, Chiropractic Services Urological,and Wound Care Supplies,""Outpatient Chiropractic Services and the Services of a chiropractor, Prescription Drugs, Supplies,and Supplements,"and except for manual manipulation of the spine as described "Prosthetic and Orthotic Devices"in the"Benefits and under"Outpatient Care"in the"Benefits and Your Cost Your Cost Share"section. Share"section or unless you have coverage for supplemental chiropractic Services as described in an Experimental or investigational Services amendment to this EOC. A Service is experimental or investigational if we,in consultation with the Medical Group,determine that one Cosmetic Services of the following is true: Services that are intended primarily to change or Generally accepted medical standards do not maintain your appearance,including cosmetic surgery • recognize it as safe and effective for treating the (surgery that is performed to alter or reshape normal condition in question(even if it has been authorized Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 57 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. by law for use in testing or other studies on human Massage therapy patients) Massage therapy,and services of massage therapists. • It requires government approval that has not been obtained when the Service is to be provided Oral nutrition and weight loss aids Outpatient oral nutrition, such as dietary supplements, Hair loss or growth treatment herbal supplements,formulas,food,and weight loss aids. Items and services for the promotion,prevention,or other treatment of hair loss or hair growth. This exclusion does not apply to any of the following: • Amino acid—modified products and elemental dietary Intermediate care enteral formula covered under"Outpatient Care in a licensed intermediate care facility.This Prescription Drugs, Supplies,and Supplements"in exclusion does not apply to Services covered under the"Benefits and Your Cost Share"section "Durable Medical Equipment("DME")for Home Use," • Enteral formula covered under"Prosthetic and "Home Health Care,"and"Hospice Care"in the Orthotic Devices"in the`Benefits and Your Cost "Benefits and Your Cost Share"section. Share"section Items and services that are not health care items Residential care and services For example,we do not cover: Care in a facility where you stay overnight,except that this exclusion does not apply when the overnight stay is • Teaching manners and etiquette part of covered care in a hospital,a Skilled Nursing • Teaching and support services to develop planning Facility,inpatient respite care covered in the"Hospice skills such as daily activity planning and project or Care"section for Members who do not have Part A,or task planning residential treatment program Services covered in the "Substance Use Disorder Treatment"and"Mental Health • Items and services for the purpose of increasing Services"sections. academic knowledge or skills • Teaching and support services to increase intelligence Routine foot care items and services • Academic coaching or tutoring for skills such as Routine foot care items and services,except for grammar,math,and time management Medically Necessary Services covered in accord with Medicare guidelines. • Teaching you how to read,whether or not you have dyslexia Services not approved by the federal Food and • Educational testing Drug Administration • Teaching art,dance,horse riding,music,play,or Drugs,supplements,tests,vaccines,devices,radioactive swimming materials,and any other Services that by law require federal Food and Drug Administration("FDA")approval • Teaching skills for employment or vocational in order to be sold in the U.S.,but are not approved by purposes the FDA.This exclusion applies to Services provided • Vocational training or teaching vocational skills anywhere,even outside the U.S.,unless the Services are covered under the"Emergency Services and Urgent • Professional growth courses Care"section. • Training for a specific job or employment counseling • Aquatic therapy and other water therapy,except when Services and items not covered by Medicare ordered as part of a physical therapy program in Services and items that are not covered by Medicare, accord with Medicare guidelines including services and items that aren't reasonable and necessary,according to the standards of the Original Items and services to correct refractive defects Medicare plan,unless these Services are otherwise listed of the eye in this EOC as a covered Service. Items and services(such as eye surgery or contact lenses to reshape the eye)for the purpose of correcting Services performed by unlicensed people refractive defects of the eye such as myopia,hyperopia, Services that are performed safely and effectively by or astigmatism. people who do not require licenses or certificates by the state to provide health care services and where the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 58 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Member's condition does not require that the services be Additional limitations that apply only to a particular provided by a licensed health care provider. benefit are listed in the description of that benefit in this EOC. Services related to a noncovered Service When a Service is not covered,all Services related to the noncovered Service are excluded, except for Services we Coordination of Benefits would otherwise cover to treat complications of the If you have other medical or dental coverage,it is noncovered Service or if covered in accord with important to use your other coverage in combination Medicare guidelines.For example,if you have a with your coverage as a Senior Advantage Member to noncovered cosmetic surgery,we would not cover pay for the care you receive.This is called"coordination Services you receive in preparation for the surgery or for of benefits"because it involves coordinating all of the follow-up care.If you later suffer a life-threatening health benefits that are available to you.Using all of the complication such as a serious infection,this exclusion coverage you have helps keep the cost of health care would not apply and we would cover any Services that more affordable for everyone. we would otherwise cover to treat that complication. Surrogacy You must tell us if you have other health care coverage, and let us know whenever there are any changes in your Services for anyone in connection with a Surrogacy additional coverage.The types of additional coverage Arrangement,except for otherwise-covered Services that you might have include the following: provided to a Member who is a surrogate.Refer to "Surrogacy Arrangements"under"Reductions"in this • Coverage that you have from an employer's group "Exclusions,Limitations,Coordination of Benefits,and health care coverage for employees or retirees,either Reductions"section for information about your through yourself or your spouse obligations to us in connection with a Surrogacy • Coverage that you have under workers' compensation Arrangement,including your obligations to reimburse us because of a job-related illness or injury,or under the for any Services we cover and to provide information Federal Black Lung Program about anyone who may be financially responsible for • Coverage you have for an accident where no-fault Services the baby(or babies)receive. insurance or liability insurance is involved Travel and lodging expenses • Coverage you have through Medicaid Travel and lodging expenses,except as described in our . Coverage you have through the"TRICARE for Life" Travel and Lodging Program Description.The Travel program(veteran's benefits) and Lodging Program Description is available online at kp.or2/specialty-care/travel-reimbursements or by • Coverage you have for dental insurance or calling Member Services. prescription drugs • "Continuation coverage"you have through COBRA (COBRA is a law that requires employers with 20 or Limitations more employees to let employees and their dependents keep their group health coverage for a We will make a good faith effort to provide or arrange time after they leave their group health plan under for covered Services within the remaining availability of certain conditions) facilities or personnel in the event of unusual circumstances that delay or render impractical the When you have additional health care coverage,how we provision of Services under this EOC,such as a major coordinate your benefits as a Senior Advantage Member disaster,epidemic,war,riot,civil insurrection,disability with your benefits from your other coverage depends on of a large share of personnel at a Plan Facility,complete your situation.With coordination of benefits,you will or partial destruction of facilities,and labor dispute. often get your care as usual from Plan Providers,and the Under these circumstances,if you have an Emergency other coverage you have will simply help pay for the Medical Condition,call 911 or go to the nearest care you receive.In other situations,such as benefits that Emergency Department as described under"Emergency we don't cover,you may get your care outside of our Services"in the"Emergency Services and Urgent Care" plan directly through your other coverage. section,and we will provide coverage and reimbursement as described in that section. In general,the coverage that pays its share of your bills first is called the"primary payer."Then the other company or companies that are involved(called the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 59 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. "secondary payers")each pay their share of what is left mail or deliver a written notice of our exercise of this of your bills. Often your other coverage will settle its option to you or your attorney. share of payment directly with us and you will not have to be involved.However,if payment owed to us is sent To secure our rights,we will have a lien and directly to you,you are required under Medicare law to reimbursement rights to the proceeds of any judgment or give this payment to us.When you have additional settlement you or we obtain against a third party that coverage,whether we pay first or second,or at all, results in any settlement proceeds or judgment,from depends on what type or types of additional coverage other types of coverage that include but are not limited you have and the rules that apply to your situation.Many to: liability,uninsured motorist,underinsured motorist, of these rules are set by Medicare. Some of them take personal umbrella,workers' compensation,personal into account whether you have a disability or have End- injury,medical payments and all other first party types. Stage Renal Disease,or how many employees are The proceeds of any judgment or settlement that you or covered by an employer's group plan. we obtain shall first be applied to satisfy our lien, regardless of whether you are made whole and regardless If you have additional health coverage,please call of whether the total amount of the proceeds is less than Member Services to find out which rules apply to your the actual losses and damages you incurred.We are not situation,and how payment will be handled. required to pay attorney fees or costs to any attorney hired by you to pursue your damages claim.If you reimburse us without the need for legal action,we will Reductions allow a procurement cost discount.If we have to pursue Employer responsibility legal action to enforce its interest,there will be no procurement discount. For any Services that the law requires an employer to provide,we will not pay the employer,and,when we Within 30 days after submitting or filing a claim or legal cover any such Services,we may recover the value of the action against a third party,you must send written notice Services from the employer. of the claim or legal action to: Government agency responsibility The Rawlings Company For any Services that the law requires be provided only One Eden Parkway by or received only from a government agency,we will P.O.Box 2000 not pay the government agency,and,when we cover any LaGrange,KY 40031-2000 such Services,we may recover the value of the Services Fax: 1-502-214-1137 from the government agency. In order for us to determine the existence of any rights Injuries or illnesses alleged to be caused by we may have and to satisfy those rights,you must third parties complete and send us all consents,releases, Third parties who cause you injury or illness(and/or authorizations,assignments,and other documents, their insurance companies)usually must pay first before including lien forms directing your attorney,the third Medicare or our plan.Therefore,we are entitled to party,and the third party's liability insurer to pay us pursue these primary payments.If you obtain a judgment directly.You may not agree to waive,release,or reduce or settlement from or on behalf of a third party who our rights under this provision without our prior,written allegedly caused an injury or illness for which you consent. received covered Services,you must ensure we receive reimbursement for those Services.Note:This"Injuries or If your estate,parent,guardian,or conservator asserts a illnesses alleged to be caused by third parties"section claim against a third party based on your injury or does not affect your obligation to pay your Cost Share illness,your estate,parent,guardian,or conservator and for these Services. any settlement or judgment recovered by the estate, parent,guardian,or conservator shall be subject to our To the extent permitted or required by law,we shall be liens and other rights to the same extent as if you had subrogated to all claims,causes of action,and other asserted the claim against the third party.We may assign rights you may have against a third party or an insurer, our rights to enforce our liens and other rights. government program,or other source of coverage for monetary damages,compensation,or indemnification on Surrogacy Arrangements account of the injury or illness allegedly caused by the If you enter into a Surrogacy Arrangement and you or third party.We will be so subrogated as of the time we any other payee are entitled to receive monetary compensation under the Surrogacy Arrangement,you Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 60 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. must reimburse us for covered Services you receive reasonably necessary for us to determine the existence of related to conception,pregnancy,delivery,or postpartum any rights we may have under this"Surrogacy care in connection with that arrangement("Surrogacy Arrangements"section and to satisfy those rights.You Health Services")to the maximum extent allowed under may not agree to waive,release,or reduce our rights California Civil Code Section 3040.Note:This under this"Surrogacy Arrangements"section without "Surrogacy Arrangements"section does not affect your our prior,written consent. obligation to pay your Cost Share for these Services. After you surrender a baby to the legal parents,you are If your estate,parent,guardian,or conservator asserts a not obligated to reimburse us for any Services that the claim against another party based on the Surrogacy baby receives(the legal parents are financially Arrangement,your estate,parent,guardian,or responsible for any Services that the baby receives). conservator and any settlement or judgment recovered by the estate,parent,guardian,or conservator shall be By accepting Surrogacy Health Services,you subject to our liens and other rights to the same extent as automatically assign to us your right to receive payments if you had asserted the claim against the other party.We that are payable to you or any other payee under the may assign our rights to enforce our liens and other Surrogacy Arrangement,regardless of whether those rights. payments are characterized as being for medical expenses.To secure our rights,we will also have a lien If you have questions about your obligations under this on those payments and on any escrow account,trust,or provision,please call Member Services. any other account that holds those payments. Those payments(and amounts in any escrow account,trust,or U.S. Department of Veterans Affairs other account that holds those payments)shall first be For any Services for conditions arising from military applied to satisfy our lien. The assignment and our lien service that the law requires the Department of Veterans will not exceed the total amount of your obligation to us Affairs to provide,we will not pay the Department of under the preceding paragraph. Veterans Affairs,and when we cover any such Services we may recover the value of the Services from the Within 30 days after entering into a Surrogacy Department of Veterans Affairs. Arrangement,you must send written notice of the arrangement,including all of the following information: Workers' compensation or employer's liability • Names,addresses,and phone numbers of the other benefits parties to the arrangement Workers'compensation usually must pay first before • Names,addresses,and phone numbers of any escrow Medicare or our plan.Therefore,we are entitled to agent or trustee pursue primary payments under workers' compensation or employer's liability law.You may be eligible for • Names,addresses,and phone numbers of the intended payments or other benefits,including amounts received parents and any other parties who are financially as a settlement(collectively referred to as"Financial responsible for Services the baby(or babies)receive, Benefit"),under workers' compensation or employer's including names,addresses,and phone numbers for liability law.We will provide covered Services even if it any health insurance that will cover Services that the is unclear whether you are entitled to a Financial Benefit, baby(or babies)receive but we may recover the value of any covered Services • A signed copy of any contracts and other documents from the following sources: explaining the arrangement • From any source providing a Financial Benefit or • Any other information we request in order to satisfy from whom a Financial Benefit is due our rights • From you,to the extent that a Financial Benefit is provided or payable or would have been required to You must send this information to: be provided or payable if you had diligently sought to The Rawlings Company establish your rights to the Financial Benefit under One Eden Parkway any workers' compensation or employer's liability P.O.Box 2000 law LaGrange,KY 40031-2000 Fax: 1-502-214-1137 You must complete and send us all consents,releases, authorizations,lien forms,and other documents that are Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 61 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Requests for Payment bill,along with documentation of any payments you have already made ♦ if the provider is owed anything,we will pay the Requests for Payment of Covered provider directly Services or Part D drugs ♦ if you have already paid more than your share of If you pay our share of the cost of your covered the cost of the service,we will determine how services or Part D drugs, or if you receive a bill, much you owed and pay you back for our share ofthe cost you can ask us for payment Sometimes when you get medical care or a Part D drug, When a Plan Provider sends you a bill you think you you may need to pay the full cost. Other times,you may should not pay.Plan Providers should always bill us find that you have paid more than you expected under directly and ask you only for your share of the cost.But the coverage rules of our plan,or you may receive a bill sometimes they make mistakes and ask you to pay more from a provider.In these cases,you can ask us to pay than your share. you back(paying you back is often called"reimbursing" you).It is your right to be paid back by our plan • You only have to pay your Cost Share amount when whenever you've paid more than your share of the cost you get covered Services.We do not allow providers for medical services or Part D drugs that are covered by to add additional separate charges,called balance our plan.There may be deadlines that you must meet to billing.This protection(that you never pay more than get paid back. your Cost Share amount)applies even if we pay the provider less than the provider charges for a service, There may also be times when you get a bill from a and even if there is a dispute and we don't pay certain provider for the full cost of medical care you have provider charges received or possibly for more than your share of cost • Whenever you get a bill from a Plan Provider that you sharing as discussed in this document.First try to resolve think is more than you should pay,send us the bill. the bill with the provider.If that does not work,send the We will contact the provider directly and resolve the bill to us instead of paying it.We will look at the bill and billing problem decide whether the services should be covered.If we • If you have already paid a bill to a Plan Provider,but decide they should be covered,we will pay the provider you feel that you paid too much,send us the bill along directly.If we decide not to pay it,we will notify the with documentation of an payment you have made t provider.You should never pay more than plan-allowed y and ask us to pay you back the difference between the cost sharing. If this provider is contracted,you still have amount you paid and the amount you owed under our the right to treatment. plan Here are examples of situations in which you may need If you are retroactively enrolled in our plan. to ask us to pay you back or to pay a bill you have Sometimes a person's enrollment in our plan is received: retroactive. (This means that the first day of their enrollment has already passed. The enrollment date may When you've received emergency,urgent,or dialysis even have occurred last year.)If you were retroactively care from allon—Plan Provider.Outside the service enrolled in our plan and you paid out-of-pocket for any area,you can receive emergency or urgently needed of your covered Services or Part D drugs after your services from any provider,whether or not the provider enrollment date,you can ask us to pay you back for our is a Plan Provider.In these cases: share of the costs.You will need to submit paperwork • You are only responsible for paying your share of the such as receipts and bills for us to handle the cost for emergency or urgently needed services. reimbursement. Emergency providers are legally required to provide emergency care.If you pay the entire amount yourself When you use a Non—Plan Pharmacy to get a at the time you receive the care,ask us to pay you prescription filled.If you go to a Non-Plan Pharmacy, back for our share of the cost. Send us the bill,along the pharmacy may not be able to submit the claim with documentation of any payments you have made directly to us.When that happens,you will have to pay • You may get a bill from the provider asking for the full cost of your prescription. payment that you think you do not owe. Send us this Save your receipt and send a copy to us when you ask us to pay you back for our share of the cost.Remember that we only cover non-plan pharmacies in limited Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 62 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. circumstances.We may not pay you back the difference How to Ask Us to Pay You Back or to between what you paid for the drug at the Non-Plan Pay a Bill You Have Received Pharmacy and the amount that we would pay at a Plan Pharmacy. You may request us to pay you back by sending us a request in writing.If you send a request in writing,send When you pay the full cost for a prescription because your bill and documentation of any payment you have you don't have your plan membership card with you. made.It's a good idea to make a copy of your bill and If you do not have your plan membership card with you, receipts for your records.You must submit your claim to you can ask the pharmacy to call us or to look up your us within 12 months(for Part C medical claims)paid and plan enrollment information.However,if the pharmacy within 36 months(for Part D drug claims)of the date cannot get the enrollment information they need right you received the service,item,or drug. away,you may need to pay the full cost of the prescription yourself. To make sure you are giving us all the information we need to make a decision,you can fill out our claim form Save your receipt and send a copy to us when you ask us to make your request for payment.You don't have to use to pay you back for our share of the cost.We may not the form,but it will help us process the information pay you back the full cost you paid if the cash price you faster.You can file a claim to request payment by: paid is higher than our negotiated price for the prescription. To file a claim,this is what you need to do: When you pay the full cost for a prescription in other • Completing and submitting our electronic form at situations.You may pay the full cost of the prescription (kp.oro and upload supporting documentation because you find that the drug is not covered for some • Either download a copy of the form from our website reason. (kp.oro or call Member Services and ask them to • For example,the drug may not be on our 2025 send you the form.Mail the completed form to our Comprehensive Formulary or it could have a Claims Department address listed below requirement or restriction that you didn't know about • If you are unable to get the form,you can file your or don't think should apply to you.If you decide to request for payment by sending us the following get the drug immediately,you may need to pay the information to our Claims Department address listed full cost for it below: • Save your receipt and send a copy to us when you ask a statement with the following information: us to pay you back.In some situations,we may need — your name(member/patient name)and to get more information from your doctor in order to medical/health record number pay you back for our share of the cost.We may not — the date you received the services pay you back the full cost you paid if the cash price you paid is higher than our negotiated price for the — where you received the services prescription — who provided the services — why you think we should pay for the services When you pay copayments under a drug — your signature and date signed. (If you want manufacturer patient assistance program.If you get someone other than yourself to make the help from,and pay copayments under,a drug request,we will also need a completed manufacturer patient assistance program outside our "Appointment of Representative"form,which plan's benefit,you may submit a paper claim to have is available at or your out-of-pocket expense count toward qualifying you a copy of the bill,your medical record(s)for these for catastrophic coverage. services,and your receipt if you paid for the • Save your receipt and send a copy to us services • Mail your request for payment of medical care All of the examples above are types of coverage together with any bills or paid receipts to us at this decisions. This means that if we deny your request for address: payment,you can appeal our decision.The"Coverage Kaiser Permanente Decisions,Appeals,and Complaints"section has Claims Administration-NCAL information about how to make an appeal. P.O.Box 12923 Oakland,CA 94604-2923 Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 63 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. To request payment of a Part D drug that was prescribed Other Situations in Which You Should by a Plan Provider and obtained from a Plan Pharmacy, Save Your Receipts and Send Copies to write to the address below.For all other Part D requests, Us send your request to the address above. — Kaiser Foundation Health Plan,Inc. In some cases, you should send copies of your Medicare Part D Unit receipts to us to help us track your out-of- P.O.Box 1809 pocket drug costs Pleasanton,CA 94566 There are some situations when you should let us know about payments you have made for your covered Part D We Will Consider Your Request for prescription drugs.In these cases,you are not asking us Payment and Say Yes or No for payment.Instead,you are telling us about your payments so that we can calculate your out-of-pocket We check to see whether we should cover the costs correctly.This may help you to qualify for the service or Part D drug and how much we owe Catastrophic Coverage Stage more quickly. When we receive your request for payment,we will let Here is one situation when you should send us copies of you know if we need any additional information from receipts to let us know about payments you have made you.Otherwise,we will consider your request and make for your drugs: a coverage decision. • When you get a drug through a patient assistance • If we decide that the medical care or Part D drug is program offered by a drug manufacturer.Some covered and you followed all the rules,we will pay members are enrolled in a patient assistance program for our share of the cost.Our share of the cost might offered by a drug manufacturer that is outside our not be the full amount you paid(for example,if you plan benefits.If you get any drugs through a program obtained a drug at a Non-Plan Pharmacy or if the cash offered by a drug manufacturer,you may pay a price you paid for a drug is higher than our negotiated copayment to the patient assistance program price).If you have already paid for the service or ♦ save your receipt and send a copy to us so that we Part D drug,we will mail your reimbursement of our can have your out-of-pocket expenses count share of the cost to you.If you have not paid for the toward qualifying you for the Catastrophic service or Part D drug yet,we will mail the payment Coverage Stage directly to the provider ♦ note:Because you are getting your drug through • If we decide that the medical care or Part D drug is the patient assistance program and not through our not covered,or you did not follow all the rules,we plan's benefits,we will not pay for any share of will not pay for our share of the cost.We will send these drug costs.But sending a copy of the receipt you a letter explaining the reasons why we are not allows us to calculate your out-of-pocket costs sending the payment and your right to appeal that correctly and may help you qualify for the decision Catastrophic Coverage Stage more quickly If we tell you that we will not pay for all or part of Since you are not asking for payment in the case the medical care or Part D drug, you can make described above,this situation is not considered a an appeal coverage decision.Therefore,you cannot make an appeal If you think we have made a mistake in turning down if you disagree with our decision. your request for payment or the amount we are paying, you can make an appeal.If you make an appeal,it means you are asking us to change the decision we made when Your Rights and Responsibilities we turned down your request for payment. The appeals process is a formal process with detailed We must honor your rights and cultural procedures and important deadlines.For the details about sensitivities as a Member of our plan how to make this appeal,go to the"Coverage Decisions, Appeals,and Complaints"section. We must provide information in a way that works for you and consistent with your cultural sensitivities (in languages other than English, large font, braille, audio file, or data CD) Our plan is required to ensure that all services,both clinical and non-clinical,are provided in a culturally Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 64 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. competent manner and are accessible to all enrollees, prestaci6n de servicios de traducci6n,interpretaci6n, including those with limited English proficiency,limited teletipo o conexi6n TTY(tel6fono de texto o teletipo). reading skills,hearing incapacity,or those with diverse cultural and ethnic backgrounds.Examples of how our Nuestro plan tiene servicios de interpretaci6n gratuitos plan may meet these accessibility requirements include, disponibles para responder las preguntas de los but are not limited to:provision of translator services, miembros que no hablan ingl6s.Este documento esta interpreter services,teletypewriters,or TTY(text disponible en espaiiol y en chino llamando a Servicio a telephone or teletypewriter phone)connection. los Miembros. Si la necesita,tambi6n podemos darle,sin costo,informaci6n en letra grande,en braille,en archivo de audio o en CD de datos.Tenemos la obligaci6n de Our plan has free interpreter services available to answer darle informaci6n acerca de los beneficios de nuestro questions from non-English-speaking members.We can plan en un formato que sea accesible y adecuado para also give you information in large font,braille,audio usted.Para obtener informaci6n de una forma que se file,or data CD at no cost if you need it.We are required adapte a sus necesidades,llame a Servicio a los to give you information about our plan's benefits in a Miembros. format that is accessible and appropriate for you. To get information from us in a way that works for you,please Nuestro plan esta obligado a ofrecer a las mujeres call Member Services. inscritas la opci6n de acceder directamente a un especialista en salud de la mujer dentro de la red para los Our plan is required to give female enrollees the option servicios de atenci6n m6dica preventiva y de rutina para of direct access to a women's health specialist within the la mujer. network for women's routine and preventive health care Si los proveedores de nuestra red para una especialidad services. no estan disponibles,es nuestra responsabilidad buscar proveedores especializados fuera de la red que le If providers in our network for a specialty are not proporcionen la atenci6n necesaria.En este caso,usted available,it is our responsibility to locate specialty solo pagara el costo compartido dentro de la red. Si se providers outside the network who will provide you with encuentra en una situacion en la que no hay especialistas the necessary care.In this case,you will only pay in- dentro de nuestra red que cubran el servicio que necesita, network cost-sharing.If you find yourself in a situation llamenos para recibir information sobre a d6nde acudir where there are no specialists in our network that cover a para obtener este servicio con un costo compartido service you need,call us for information on where to go dentro de la red. to obtain this service at in-network cost-sharing. Si tiene algun problema para obtener informaci6n de If you have any trouble getting information from our nuestro plan en un formato que sea accesible y adecuado plan in a format that is accessible and appropriate for para usted,consultar a un especialista en salud de la you,seeing a women's health specialist or finding a mujer o encontrar un especialista de la red,por favor network specialist,please call to file a grievance with flame para presentar una queja formal ante Servicio a los Member Services.You may also file a complaint with Miembros.Tambi&n puede presentar una queja en Medicare by calling 1-800-MEDICARE(1-800-633- Medicare llamando al 1-800-MEDICARE(1-800-633- 4227)or directly with the Office for Civil Rights 1-800- 4227)o directamente en la Oficina de Derechos Civiles 368-1019 or TTY 1-800-537-7697. 1-800-368-1019 o al TTY 1-800-537-7697. Debemos proporcionar la informaci6n de un We must ensure that you get timely access to modo adecuado para usted y que sea coherente your covered services and Part D drugs con sus sensibilidades culturales (en idiomas You have the right to choose a primary care provider distintos al ingl6s, en letra grande, en braille, en (PCP)in our network to provide and arrange for your archivo de audio o en CD de datos) covered services.You also have the right to go to a Nuestro plan esta obligado a garantizar que todos los women's health specialist(such as a gynecologist),a servicios,tanto clinicos como no clinicos,se mental health services provider,and an optometrist proporcionen de una manera culturalmente competente y without a referral,as well as other providers described in que sean accesibles para todas las personas inscritas, the"How to Obtain Services"section. incluidas las que tienen un dominio limitado del ingl6s, capacidades limitadas para leer,una incapacidad auditiva You have the right to get appointments and covered o diversos antecedentes culturales y 6micos.Algunos services from our network of providers within a ejemplos de c6mo nuestro plan puede cumplir estos reasonable amount of time. This includes the right to get timely services from specialists when you need that care. requisitos de accesibilidad incluyen,entre otros, Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 65 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. You also have the right to get your prescriptions filled or information that uniquely identifies you not be refilled at any of our network pharmacies without long shared delays. You can see the information in your records and If you think that you are not getting your medical care or know how it has been shared with others Part D drugs within a reasonable amount of time,"How You have the right to look at your medical records held to make a complaint about quality of care,waiting times, by our plan,and to get a copy of your records.We are customer service,or other concerns"in the"Coverage allowed to charge you a fee for making copies.You also Decisions,Appeals,and Complaints"section tells what have the right to ask us to make additions or corrections you can do. to your medical records.If you ask us to do this,we will work with your health care provider to decide whether We must protect the privacy of your personal the changes should be made. health information Federal and state laws protect the privacy of your You have the right to know how your health information medical records and personal health information.We has been shared with others for any purposes that are not protect your personal health information as required by routine. these laws. • Your personal health information includes the If you have questions or concerns about the privacy of personal information you gave us when you enrolled your personal health information,please call Member in our plan as well as your medical records and other Services. medical and health information We must give you information about our plan, • You have rights related to your information and our Plan Providers, and your covered services controlling how your health information is used.We give you a written notice,called a Notice of Privacy As a Member of our plan,you have the right to get Practices,that tells about these rights and explains several kinds of information from us. how we protect the privacy of your health information If you want any of the following kinds of information, How do we protect the privacy of your health please call Member Services: information? • Information about our plan.This includes,for • We make sure that unauthorized people don't see or example,information about our plan's financial change your records condition • Except for the circumstances noted below,if we • Information about our network providers and intend to give your health information to anyone who pharmacies isn't providing your care or paying for your care,we ♦ you have the right to get information about the are required to get written permission from you or by qualifications of the providers and pharmacies in someone you have given legal power to make our network and how we pay the providers in our decisions for you first network • Your health information is shared with your Group • Information about your coverage and the rules only with your authorization or as otherwise you must follow when using your coverage permitted by law ♦ the"How to Obtain Services"and"Benefits and • There are certain exceptions that do not require us to Your Cost Share"sections provide information get your written permission first. These exceptions regarding medical services are allowed or required by law ♦ the"Outpatient Prescription Drugs, Supplies,and ♦ we are required to release health information to Supplements"in the"Benefits and Your Cost government agencies that are checking on quality Share"section provides information about of care coverage for certain drugs ♦ because you are a Member of our plan through ♦ if you have questions about the rules or Medicare,we are required to give Medicare your restrictions,please call Member Services health information,including information about • Information about why something is not covered your Part D prescription drugs.If Medicare and what you can do about it releases your information for research or other ♦ the"Coverage Decisions,Appeals,and uses,this will be done according to federal statutes Complaints"section provides information on and regulations;typically,this requires that asking for a written explanation on why a medical Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 66 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. service or Part D drug is not covered,or if your • Give your doctors written instructions about how you coverage is restricted want them to handle your medical care if you become ♦ the"Coverage Decisions,Appeals,and unable to make decisions for yourself Complaints"section also provides information on asking us to change a decision,also called an The legal documents that you can use to give your appeal directions in advance of these situations are called advance directives.There are different types of advance We must support your right to make decisions directives and different names for them.Documents about your care called living will and power of attorney for health care You have the right to know your treatment options are examples of advance directives. and participate in decisions about your health care If you want to use an advance directive to give your You have the right to get full information from your instructions,here is what to do: doctors and other health care providers when you go for medical care.Your providers must explain your medical • Get the form.You can get an advance directive,a condition and your treatment choices in a way that you form from your lawyer,from a social worker,or from can understand. some office supply stores.You can sometimes get advance directive forms from organizations that give You also have the right to participate fully in decisions people information about Medicare.You can also about your health care.To help you make decisions with contact Member Services to ask for the forms your doctors about what treatment is best for you,your • Fill it out and sign it.Regardless of where you get rights include the following: this form,keep in mind that it is a legal document. • To know about all of your choices.You have the You should consider having a lawyer help you right to be told about all of the treatment options that prepare it are recommended for your condition,no matter what • Give copies to appropriate people.You should give they cost or whether they are covered by our plan.It a copy of the form to your doctor and to the person also includes being told about programs our plan you name on the form who can make decisions for offers to help members manage their medications and you if you can't.You may want to give copies to use drugs safely close friends or family members.Keep a copy at • To know about the risks.You have the right to be home told about any risks involved in your care.You must be told in advance if any proposed medical care or If you know ahead of time that you are going to be treatment is part of a research experiment.You hospitalized,and you have signed an advance directive, always have the choice to refuse any experimental take a copy with you to the hospital. treatments • The hospital will ask you whether you have signed an • The right to say"no."You have the right to refuse advance directive form and whether you have it with any recommended treatment.This includes the right you to leave a hospital or other medical facility,even • If you have not signed an advance directive form,the if your doctor advises you not to leave.You also have hospital has forms available and will ask if you want the right to stop taking your medication.Of course, to sign one if you refuse treatment or stop taking a medication, you accept full responsibility for what happens to Remember,it is your choice whether you want to fill your body as a result out an advance directive(including whether you want to sign one if you are in the hospital).According to law, You have the right to give instructions about what is no one can deny you care or discriminate against you to be done if you are not able to make medical based on whether or not you have signed an advance decisions for yourself directive. Sometimes people become unable to make health care decisions for themselves due to accidents or serious What if your instructions are not followed? illness.You have the right to say what you want to If you have signed an advance directive,and you believe happen if you are in this situation.This means that, that a doctor or hospital did not follow the instructions in if you want to,you can: it,you may file a complaint with the Quality • Fill out a written form to give someone the legal Improvement Organization listed in the"Important authority to make medical decisions for you if you Phone Numbers and Resources"section. ever become unable to make decisions for yourself Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 67 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. You have the right to make complaints and to ♦ or you can call 1-800-MEDICARE(1-800-633- ask us to reconsider decisions we have made 4227),24 hours a day,seven days a week(TTY If you have any problems,concerns,or complaints and 1-877-486-2048) need to request coverage,or make an appeal,the "Coverage Decisions,Appeals,and Complaints"section Information about new technology assessments of this document tells what you can do. Rapidly changing technology affects health care and medicine as much as any other industry.To determine Whatever you do—ask for a coverage decision,make an whether a new drug or other medical development has appeal,or make a complaint—we are required to treat long-term benefits,our plan carefully monitors and you fairly. evaluates new technologies for inclusion as covered benefits.These technologies include medical procedures, What can you do if you believe you are being medical devices,and new drugs. treated unfairly or your rights are not being respected? You can make suggestions about rights and responsibilities If it is about discrimination,call the Office for Civil As a Member of our plan,you have the right to make Rights recommendations about the rights and responsibilities If you believe you have been treated unfairly,your included in this section.Please call Member Services dignity has not been recognized,or your rights have not with any suggestions. been respected due to your race,disability,religion,sex, health,ethnicity,creed(beliefs),age,sexual orientation, or national origin,you should call the Department of You have some responsibilities as a Health and Human Services' Office for Civil Rights at Member of our plan 1-800-368-1019(TTY users call 1-800-537-7697)or call your local Office for Civil Rights. Things you need to do as a Member of our plan are listed below.If you have any questions,please call Member Is it about something else? Services. If you believe you have been treated unfairly or your rights have not been respected,and it's not about • Get familiar with your covered services and the discrimination,you can get help dealing with the rules you must follow to get these covered services. problem you are having: Use this EOC to learn what is covered for you and the • You can call Member Services rules you need to follow to get your covered services ♦ the"How to Obtain Services"and`Benefits and • You can call the State Health Insurance Assistance Your Cost Share"sections give details about your Program.For details,go to the"Important Phone Numbers and Resources"section medical services ♦ the"Outpatient Prescription Drugs, Supplies,and • Or you can call Medicare at 1-800-MEDICARE Supplements"in the`Benefits and Your Cost (1-800-633-4227),24 hours a day,seven days a week Share"section gives details about your Part D (TTY 1-877-486-2048) prescription drug coverage How to get more information about your rights • If you have any other health insurance coverage or There are several places where you can get more prescription drug coverage in addition to our plan, information about your rights: you are required to tell us. • You can call Member Services ♦ the"Exclusion,Limitations,Coordination of Benefits,and Reductions"section tells you about • You can call the State Health Insurance Assistance coordinating these benefits Program.For details,go to the"Important Phone Numbers and Resources"section • Tell your doctor and other health care providers • You can contact Medicare: that you are enrolled in our plan.Show your plan ♦ you can visit the Medicare website to read or membership card whenever you get your medical care download the publication Medicare Rights& or Part D drugs Protections. (The publication is available at • Help your doctors and other providers help you by httus://www.medicare.2ov/Pubs/i)df/l1534- giving them information,asking questions,and Medicare-Rights-and-Protections.pdf) following through on your care ♦ to help get the best care,tell your doctors and other health care providers about your health Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 68 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. problems.Follow the treatment plans and The guide under"To Deal with Your Problem,Which instructions that you and your doctors agree upon Process Should You Use?"in this"Coverage Decisions, ♦ make sure your doctors know all of the drugs you Appeals,and Complaints"section will help you identify are taking,including over-the-counter drugs, the right process to use and what you should do. vitamins,and supplements ♦ if you have any questions,be sure to ask and get Hospice care an answer you can understand If you have Medicare Part A,your hospice care is covered by Original Medicare and it is not covered under • Be considerate.We expect all our members to this EOC. Therefore,any complaints related to the respect the rights of other patients.We also expect coverage of hospice care must be resolved directly with you to act in a way that helps the smooth running of Medicare and not through any complaint or appeal your doctor's office,hospitals,and other offices procedure discussed in this EOC.Medicare complaint • Pay what you owe.As a plan member,you are and appeal procedures are described in the Medicare responsible for these payments: handbook Medicare&You,which is available from your ♦ you must continue to pay a premium for your local Social Security office,at Medicare Part B to remain a Member of our plan httus://www.medicare.2ov,or by calling toll free 1-800- ♦ for most of your Services or Part D drugs covered MEDICARE(1-800-633-4227)(TTY users call 1-877- by our plan,you must pay your share of the cost 486-2048),24 hours a day,seven days a week.If you do when you get the Service or Part D drug not have Medicare Part A,Original Medicare does not ♦ if you are required to pay the extra amount for cover hospice care.Instead,we will provide hospice Part D because of your yearly income,you must care,and any complaints related to hospice care are continue to pay the extra amount directly to the subject to this"Coverage Decisions,Appeals,and government to remain a Member of our plan Complaints section. • If you move within your Home Region Service What about the legal terms? Area,we need to know so we can keep your There are legal terms for some of the rules,procedures, membership record up-to-date and know how to and types of deadlines explained in this"Coverage contact you Decisions,Appeals,and Complaints"section.Many of • If you move outside of your plan's Service Area, these terms are unfamiliar to most people and can be you cannot remain a member of our plan hard to understand. • If you move,it is also important to tell Social To make things easier,this section: Security(or the Railroad Retirement Board) . Uses simpler words in place of certain legal terms. For example,this section generally says making a complaint rather than filing a grievance,coverage Coverage Decisions, Appeals, and decision rather than organization determination or Complaints coverage determination,or at-risk determination,and independent review organization instead of Independent Review Entity. What to Do if You Have a Problem or . It also uses abbreviations as little as possible. Concern However,it can be helpful,and sometimes quite This section explains two types of processes for handling important,for you to know the correct legal terms. problems and concerns: Knowing which terms to use will help you communicate • For some problems,you need to use the process for more accurately to get the right help or information for coverage decisions and appeals your situation. To help you know which terms to use,we • For other problems,you need to use the process for include legal terms when we give the details for handling making complaints,also called grievances specific types of situations. Both of these processes have been approved by Where To Get More Information and Medicare.Each process has a set of rules,procedures, Personalized Assistance and deadlines that must be followed by us and by you. We are always available to help you.Even if you have a complaint about our treatment of you,we are obligated Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 69 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. to honor your right to complain.Therefore,you should A Guide to the Basics of Coverage always reach out to Member Services for help.But in Decisions and Appeals some situations you may also want help or guidance from someone who is not connected with us.Below are Asking for coverage decisions and making two entities that can assist you. appeals—the big picture Coverage decisions and appeals deal with problems State Health Insurance Assistance Program related to your benefits and coverage for your medical (SHIP) care(services,items and Part B prescription drugs, Each state has a government program with trained including payment). To keep things simple,we generally counselors.The program is not connected with us or with refer to medical items,services and Medicare Part B any insurance company or health plan.The counselors at prescription drugs as medical care.You use the coverage this program can help you understand which process you decision and appeals process for issues such as whether should use to handle a problem you are having. They can something is covered or not,and the way in which also answer your questions,give you more information, something is covered. and offer guidance on what to do. Asking for coverage decisions prior to receiving The services of SHIP counselors are free.You will find benefits phone numbers and website URLs in the"Important A coverage decision is a decision we make about your Phone Numbers and Resources"section. benefits and coverage or about the amount we will pay for your medical care.For example,if your Plan Medicare Physician refers you to a medical specialist not inside the You can also contact Medicare to get help.To contact network,this referral is considered a favorable coverage Medicare: decision unless either your Plan Physician can show that • You can call 1-800-MEDICARE(1-800-633-4227), you received a standard denial notice for this medical 24 hours a day, seven days a week(TTY 1-877-486- specialist,or the EOC makes it clear that the referred 2048) service is never covered under any condition.You or your doctor can also contact us and ask for a coverage • You can also visit the Medicare website decision,if your doctor is unsure whether we will cover a (htti)s://www.medicare.2ov) particular medical service or refuses to provide medical care you think that you need.In other words,if you want to know if we will cover a medical care before you To Deal with Your Problem, Which receive it,you can ask us to make a coverage decision Process Should You Use? for you. If you have a problem or concern,you only need to read We are making a coverage decision for you whenever we the parts of this section that apply to your situation.The decide what is covered for you and how much we pay.In guide that follows will help. some cases,we might decide medical care is not covered Is your problem or concern about your benefits or or is no longer covered by Medicare for you.If you coverage? disagree with this coverage decision,you can make an This includes problems about whether medical care appeal. (medical items,services and/or Part B prescription drugs)are covered or not,the way they are covered,and Making an appeal problems related to payment for medical care If we make a coverage decision,whether before or after a • Yes. Go on to"A Guide to the Basics of Coverage benefit is received,and you are not satisfied,you can Decisions and Appeals" appeal the decision.An appeal is a formal way of asking us to review and change a coverage decision we have • No. Skip ahead to"How to Make a Complaint About made.Under certain circumstances,which we discuss Quality of Care,Waiting Times,Customer Service,or later,you can request an expedited or fast appeal of a Other Concerns" coverage decision.Your appeal is handled by different reviewers than those who made the original decision. When you appeal a decision for the first time,this is called a Level 1 appeal.In this appeal,we review the coverage decision we have made to check to see if we Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 70 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. were properly following the rules.When we have Level 1,it will be automatically forwarded to completed the review,we give you our decision. Level 2 ♦ for Part D prescription drugs,your doctor or other In limited circumstances,a request for a Level 1 appeal prescriber can request a coverage decision or a will be dismissed,which means we won't review the Level 1 appeal on your behalf.If your Level 1 request.Examples of when a request will be dismissed appeal is denied,your doctor or prescriber can include if the request is incomplete,if someone makes request a Level 2 appeal the request on your behalf but isn't legally authorized to . You can ask someone to act on your behalf.If you do so or if you ask for your request to be withdrawn.If we dismiss a request for a Level 1 appeal,we will send a want to,you can name another person to act for you notice explaining why the request was dismissed and as your representative to ask for a coverage decision how to ask for a review of the dismissal. or make an appeal ♦ if you want a friend,relative,or other person to be If we say no to all or part of your Level 1 appeal for your representative,call Member Services and ask medical care,your appeal will automatically go on to a for the Appointment of Representative form. (The Level 2 appeal conducted by an independent review form is also available on Medicare's website at organization that is not connected to us. https://www.ems.2ov/Medicare/CMS-Forms/ CMS-Forms/downloads/cros1696.pdf or on our • You do not need to do anything to start a Level 2 website at kp.org.)The form gives that person appeal.Medicare rules require we automatically send permission to act on your behalf.It must be signed your appeal for medical care to Level 2 if we do not by you and by the person who you would like to fully agree with your Level 1 appeal act on your behalf.You must give us a copy of the • See"Step-by-step:How a Level 2 appeal is done"of signed form this chapter for more information about Level 2 ♦ while we can accept an appeal request without the appeals for medical care form,we cannot complete our review until we • Part D appeals are discussed further in"Your Part D receive it.If we do not receive the form before our Prescription Drugs:How to Ask for a Coverage deadline for making a decision on your appeal, Decision or Make an Appeal"of this section your appeal request will be dismissed.If this happens,we will send you a written notice If you are not satisfied with the decision at the Level 2 explaining your right to ask the independent appeal,you may be able to continue through additional review organization to review our decision to levels of appeal. ("Taking Your Appeal to Level 3 and dismiss your appeal Beyond"in this section explains the Level 3,4,and 5 • You also have the right to hire a lawyer.You may appeals processes). contact your own lawyer,or get the name of a lawyer from your local bar association or other referral How to get help when you are asking for a service. There are also groups that will give you free coverage decision or making an appeal legal services if you qualify.However,you are not Here are resources if you decide to ask for any kind of required to hire a lawyer to ask for any kind of coverage decision or appeal a decision: coverage decision or appeal a decision • You can call us at Member Services Which section gives the details for your • You can get free help from your State Health situation? Insurance Assistance Program There are four different situations that involve coverage • Your doctor can make a request for you.If your decisions and appeals. Since each situation has different doctor helps with an appeal past Level 2,they will rules and deadlines,we give the details for each one in a need to be appointed as your representative.Please separate section: call Member Services and ask for the Appointment • "Your Medical Care:How to Ask for a Coverage of Representative form.(The form is also available Decision or Make an Appeal of a Coverage Decision" on Medicare's website at htti)s://www.cros.2ov/Medicare/CMS-Forms/ • "Your Part D Prescription Drugs:How to Ask for a CMS-Forms/downloads/cros1696.ydf or on our Coverage Decision or Make an Appeal" website at k .or • "How to Ask Us to Cover a Longer Inpatient Hospital ♦ for medical care or Part B prescription drugs,your Stay if You Think the Doctor Is Discharging You Too doctor can request a coverage decision or a Level Soon" 1 appeal on your behalf.If your appeal is denied at Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 71 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • "How to Ask Us to Keep Covering Certain Medical (CORF)services,you need to read"How to Ask Us to Services if You Think Your Coverage is Ending Too Cover a Longer Inpatient Hospital Stay if You Think the Soon"(applies only to these services:home health Doctor Is Discharging You Too Soon"and"How to Ask care, Skilled Nursing Facility care,and Us to Keep Covering Certain Medical Services if You Comprehensive Outpatient Rehabilitation Facility Think Your Coverage is Ending Too Soon"of this (CORF)services) section. Special rules apply to these types of care. If you're not sure which section you should be using, Step-by-step: How to ask for a coverage please call Member Services.You can also get help or decision information from government organizations such as your When a coverage decision involves your medical care,it SHIP. is called an organization determination.A fast coverage decision is called an expedited determination. Your Medical Care: How to Ask for a Step 1: Decide if you need a standard coverage Coverage Decision or Make an Appeal decision or a fast coverage decision. of a Coverage Decision A standard coverage decision is usually made within 14 calendar days or 72 hours for Part B drugs.A fast This section tells what to do if you have coverage decision is generally made within 72 hours,for problems getting coverage for medical care or medical services,or 24 hours for Part B drugs.In order if you want us to pay you back for our share of to get a fast coverage decision,you must meet two the cost of your care requirements: This section is about your benefits for medical care. ♦ you may only ask for coverage for medical items These benefits are described in the`Benefits and Your and/or services not requests for payment for items Cost Share"section.In some cases,different rules apply and/or services already received to a request for a Part B prescription drug.In those cases, ♦ you can get a fast coverage decision only if using we will explain how the rules for Part B prescription the standard deadlines could cause serious harm to drugs are different from the rules for medical items and your health or hurt your ability to function services. • If your doctor tells us that your health requires a fast This section tells what you can do if you are in any of the coverage decision,we will automatically agree to following situations: give you a fast coverage decision • You are not getting certain medical care you want, • If you ask for a fast coverage decision on your own, and you believe that this is covered by our plan.Ask without your doctor's support,we will decide whether for a coverage decision your health requires that we give you a fast coverage decision.If we do not approve a fast coverage • We will not approve the medical care your doctor or decision,we will send you a letter that: other medical provider wants to give you,and you ♦ explains that we will use the standard deadlines believe that this care is covered by our plan.Ask for a coverage decision ♦ explains if your doctor asks for the fast coverage decision,we will automatically give you a fast • You have received medical care that you believe coverage decision should be covered by our plan,but we have said we will not pay for this care.Make an appeal ♦ explains that you can file a fast complaint about our decision to give you a standard coverage • You have received and paid for medical care that you decision instead of the fast coverage decision you believe should be covered by our plan,and you want requested to ask us to reimburse you for this care. Send us the bill Step 2: Ask our plan to make a coverage decision • You are being told that coverage for certain medical or fast coverage decision care you have been getting that we previously • Start by calling,writing,or faxing our plan to make approved will be reduced or stopped,and you believe your request for us to authorize or provide coverage that reducing or stopping this care could harm your for the medical care you want.You,your doctor,or health.Make an appeal your representative can do this.The"Important Phone Numbers and Resources"section has contact Note:If the coverage that will be stopped is for hospital information Services,home health care, Skilled Nursing Facility care, or Comprehensive Outpatient Rehabilitation Facility Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 72 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step 3: We consider your request for medical care ♦ If our answer is no to part or all of what you coverage and give you our answer requested,we will send you a written statement For standard coverage decisions,we use the standard that explains why we said no deadlines. Step 4: If we say no to your request for coverage This means we will give you an answer within 14 for medical care, you can appeal calendar days after we receive your request for a medical • If we say no,you have the right to ask us to item or service.If your request is for a Medicare Part B reconsider this decision by making an appeal.This prescription drug,we will give you an answer within 72 means asking again to get the medical care coverage hours after we receive your request. you want.If you make an appeal,it means you are ♦ however,if you ask for more time,or if we need going on to Level 1 of the appeals process more information that may benefit you,we can take up to 14 more calendar days if your request is Step-by-step: How to make a Level 1 appeal for a medical item or service.If we take extra An appeal to our plan about a medical care coverage days,we will tell you in writing.We can't take decision is called a plan reconsideration.A fast appeal extra time to make a decision if your request is for is also called an expedited reconsideration. a Medicare Part B prescription drug Step 1: Decide if you need a standard appeal or a ♦ if you believe we should not take extra days,you fast appeal can file a fast complaint.We will give you an answer to your complaint as soon as we make the A standard appeal is usually made within 30 calendar decision.(The process for making a complaint is days or 7 calendar days for Part B drugs.A fast different from the process for coverage decisions appeal is generally made within 72 hours. and appeals. See"How to Make a Complaint • If you are appealing a decision we made about About Quality of Care,Waiting Times,Customer coverage for care that you have not yet received,you Service,or Other Concerns"of this section for and/or your doctor will need to decide if you need a information on complaints.) fast appeal.If your doctor tells us that your health requires a fast appeal,we will give you a fast appeal For fast coverage decisions,we use an expedited time • The requirements for getting a fast appeal are the frame. same as those for getting a fast coverage decision in A fast coverage decision means we will answer within 72 "four Medical Care:How to Ask for a Coverage hours if your request is for a medical item or service.If Decision or Make an Appeal"of this section your request is for a Medicare Part B prescription drug, Step 2: Ask our plan for an appeal or a fast appeal we will answer within 24 hours. ♦ however,if you ask for more time,or if we need • If you are asking for a standard appeal,submit your more information that may benefit you we can standard appeal in writing.You may also ask for an take up to 14 more calendar days.If we take extra appeal by calling us. The"Important Phone Numbers days,we will tell you in writing.We can't take and Resources"section has contact information extra time to make a decision if your request is for • If you are asking for a fast appeal,make your appeal a Medicare Part B prescription drug in writing or call us.The"Important Phone Numbers ♦ if you believe we should not take extra days,you and Resources"section has contact information can file a fast complaint. See"How to Make a . You must make your appeal request within 65 Complaint About Quality of Care,Waiting Times, calendar days from the date on the written notice we Customer Service,or Other Concerns"of this sent to tell you our answer on the coverage decision. section for information on complaints.)We will If you miss this deadline and have a good reason for call you as soon as we make the decision missing it,explain the reason your appeal is late when ♦ if we do not give you our answer within 72 hours you make your appeal.We may give you more time (or if there is an extended time period,by the end to make your appeal.Examples of good cause may of that period),or within 24 hours if your request include a serious illness that prevented you from is for a Medicare Part B prescription drug,you contacting us or if we provided you with incorrect or have the right to appeal. "Step-by-step:How to incomplete information about the deadline for make a Level 1 Appeal"below tells you how to requesting an appeal make an appeal • You can ask for a copy of the information regarding your medical decision.You and your doctor may add Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 73 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. more information to support your appeal.We are ♦ however,if you ask for more time,or if we need allowed to charge a fee for copying and sending this more information that may benefit you,we can information to you take up to 14 more calendar days if your request is for a medical item or service.If we take extra Step 3: We consider your appeal and we give you days,we will tell you in writing.We can't take our answer extra time to make a decision if your request is for • When we are reviewing your appeal,we take a a Medicare Part B prescription drug careful look at all of the information.We check to see ♦ if you believe we should not take extra days,you if we were following all the rules when we said no to can file a fast complaint.When you file a fast your request complaint,we will give you an answer to your complaint within 24 hours.(See"How to Make a • We will gather more information if needed possibly Complaint About Quality of Care,Waiting Times, contacting you or your doctor Customer Service,or Other Concerns"in this "Coverage Decisions,Appeals,and Complaints" Deadlines for a fast appeal section) • For fast appeals,we must give you our answer within ♦ if we do not give you an answer by the deadline 72 hours after we receive your appeal.We will give (or by the end of the extended time period),we you our answer sooner if your health requires us to will send your request to a Level 2 appeal,where ♦ however,if you ask for more time,or if we need an independent review organization will review more information that may benefit you,we can the appeal.Later in this section,we talk about this take up to 14 more days if your request is for a review organization and explain the Level 2 medical item or service.If we take extra days,we appeal process will tell you in writing.We can't take extra time if • If our answer is yes to part or all of what you your request is for a Medicare Part B prescription requested,we must authorize or provide the coverage drug within 30 calendar days if your request is for a ♦ if we do not give you an answer within 72 hours medical item or service,or within 7 calendar days if (or by the end of the extended time period if we your request is for a Medicare Part B prescription took extra days),we are required to automatically drug send your request on to Level 2 of the appeals • If our plan says no to part or all of what your appeal, process,where it will be reviewed by an we will automatically send your appeal to the independent review organization. "Step-by-Step: independent review organization for a Level 2 appeal How a Level 2 Appeal is Done"explains the Level 2 appeal process Step-by-step: How a Level 2 appeal is done • If our answer is yes to part or all of what you The formal name for the independent review requested,we must authorize or provide the coverage organization is the Independent Review Entity.It is we have agreed to provide within 72 hours after we sometimes called the IRE. receive your appeal • If our answer is no to part or all of what you The independent review organization is an independent requested,we will send you our decision in writing organization hired by Medicare.It is not connected with and automatically forward your appeal to the us and is not a government agency.This organization independent review organization for a Level 2 appeal. decides whether the decision we made is correct or if it The independent review organization will notify you should be changed.Medicare oversees its work. in writing when it receives your appeal Step 1: The independent review organization Deadlines for a standard appeal reviews your appeal • For standard appeals,we must give you our answer • We will send the information about your appeal to within 30 calendar days after we receive your appeal. this organization.This information is called your case If your request is for a Medicare Part B prescription file.You have the right to ask us for a copy of your drug you have not yet received,we will give you our case file.We are allowed to charge you a fee for answer within 7 calendar days after we receive your copying and sending this information to you appeal.We will give you our decision sooner if your • You have a right to give the independent review health condition requires us to organization additional information to support your appeal Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 74 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Reviewers at the independent review organization date we receive the decision from the review will take a careful look at all of the information organization related to your appeal • If this organization says no to part or all of your appeal,it means they agree with us that your request If you had a fast appeal at Level 1,you will also have (or part of your request)for coverage for medical care a fast appeal at Level should not be approved. (This is called upholding the • For the fast appeal,the review organization must give decision or turning down your appeal) you an answer to your Level 2 appeal within 72 hours • In this care,the independent review organization will of when it receives your appeal send you a letter: • However,if your request is for a medical item or ♦ explaining its decision service and the independent review organization ♦ notifying you of the right to a Level 3 appeal if the needs to gather more information that may benefit dollar value of the medical care coverage meets a you,it can take up to 14 more calendar days.The certain minimum.The written notice you get from independent review organization can't take extra time the independent review organization will tell you to make a decision if your request is for a Medicare the dollar amount you must meet to continue the Part B prescription drug appeals process If you had a standard appeal at Level 1,you will also Step 3: If your case meets the requirements, you have a standard appeal at Level 2 choose whether you want to take your appeal • For the standard appeal,if your request is for a further medical item or service,the review organization must . There are three additional levels in the appeals give you an answer to your Level 2 appeal within 30 process after Level 2(for a total of five levels of calendar days of when it receives your appeal.If your appeal).If you want to go to a Level 3 appeal the request is for a Medicare Part B prescription drug,the details on how to do this are in the written notice you review organization must give you an answer to your get after your Level 2 appeal Level 2 appeal within 7 calendar days of when it receives your appeal • The Level 3 appeal is handled by an Administrative Law Judge or attorney adjudicator."Taking Your • However,if your request is for a medical item or Appeal to Level and Beyond"in this"Coverage service and the independent review organization Decisions,Appeals,and Complaints"section explains needs to gather more information that may benefit the Levels 3,4,and 5 appeals processes you,it can take up to 14 more calendar days.The independent review organization can't take extra time What if you are asking us to pay you for our to make a decision if your request is for a Medicare share of a bill you have received for medical Part B prescription drug care? Step 2: The independent review organization gives The"Requests for Payment"section describes when you you their answer may need to ask for reimbursement or to pay a bill you have received from a provider.It also tells how to send The independent review organization will tell you its us the paperwork that asks us for payment. decision in writing and explain the reasons for it. • If the review organization says yes to part or all of a Asking for reimbursement is asking for a request for a medical item or service,we must coverage decision from us authorize the medical care coverage within 72 hours If you send us the paperwork asking for reimbursement, or provide the service within 14 calendar days after you are asking for a coverage decision.To make this we receive the decision from the review organization decision,we will check to see if the medical care you for standard requests.For expedited requests,we have paid for is covered.We will also check to see if you 72 hours from the date we receive the decision from followed all the rules for using your coverage for the review organization medical care. • If the review organization says yes to part or all of a • If we say yes to your request:If the medical care is request for a Part B prescription drug,we must covered and you followed all the rules,we will send authorize or provide the Medicare Part B prescription you the payment for our share of the cost typically drug within 72 hours after we receive the decision within 30 calendar days,but no later than 60 calendar from the review organization for standard requests. days after we receive your request.If you haven't For expedited requests,we have 24 hours from the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 75 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. paid for the medical care,we will send the payment • If you do not know if a drug is covered or if you meet directly to the provider the rules,you can ask us. Some drugs require that you • If we say no to your request:If the medical care is not get approval from us before we will cover it covered,or you did not follow all the rules,we will • If your pharmacy tells you that your prescription not send payment.Instead,we will send you a letter cannot be filled as written,the pharmacy will give that says we will not pay for the medical care and the you a written notice explaining how to contact us to reasons why ask for a coverage decision If you do not agree with our decision to turn you down, Part D coverage decisions and appeals you can make an appeal.If you make an appeal,it means An initial coverage decision about your Part D drugs is you are asking us to change the coverage decision we called a coverage determination. made when we turned down your request for payment. A coverage decision is a decision we make about your To make this appeal,follow the process for appeals that benefits and coverage or about the amount we will pay we describe in"Step-by-step:How to make a Level 1 for your drugs.This section tells what you can do if you Appeal."For appeals concerning reimbursement,please are in any of the following situations: note: o Asking to cover a Part D drug that is not on our 2025 • We must give you our answer within 60 calendar days Comprehensive Formulary.Ask for an exception after we receive your appeal.If you are asking us to . Asking to waive a restriction on our plan's coverage pay you back for medical care you have already received and paid for yourself,you are not allowed to for a drug(such as limits on the amount of the drug ask fora fast appeal you can get,prior authorization,or the requirement to try another drug first).Ask for an exception • If the independent review organization decides we . Asking to pay a lower cost-sharing amount for a should pay,we must send you or the provider the payment within 30 calendar days.If the answer to covered drug on a higher cost-sharing tier.Ask for an your appeal is yes at any stage of the appeals process exception after Level 2,we must send the payment you • Asking to get pre-approval for a drug.Ask for a requested to you or to the provider within 60 calendar coverage decision days o Pay for a prescription drug you already bought.Ask us to pay you back Your Part D Prescription Drugs: How to If you disagree with a coverage decision we have made, Ask for a Coverage Decision or Make an you can appeal our decision. Appeal What to do if you have problems getting a Part D This section tells you both how to ask for coverage drug or you want us to pay you back for a Part D decisions and how to request an appeal. drug What is an exception? Your benefits include coverage for many prescription Asking for coverage of a drug that is not on our Drug drugs.To be covered,the drug must be used for a medically accepted indication.(A"medically accepted List is sometimes called asking for a formulary indication"is a use of the drug that is either approved by exception. the Food and Drug Administration or supported by certain reference books.)For details about Part D drugs, Asking for removal of a restriction on coverage for a rules,restrictions,and costs,please see"Outpatient drug is sometimes called asking for a formulary Prescription Drugs, Supplies,and Supplements"in the exception. "Benefits and Your Cost Share"section. This section is about your Part D drugs only.To keep things simple, If a drug is not covered in the way you would like it to be we generally say drug in the rest of this section,instead covered,you can ask us to make an exception.An of repeating covered outpatient prescription drug or exception is a type of coverage decision. Part D drug every time.We also use the term Drug List instead of List of Covered Drugs or 2025 For us to consider your exception request,your doctor or Comprehensive Formulary. other prescriber will need to explain the medical reasons why you need the exception approved.Here are two Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 76 Member Service:toll free 1-800-443-081 S(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. examples of exceptions that you or your doctor or other Step 1: Decide if you need a standard coverage prescriber can ask us to make: decision or a fast coverage decision • Covering a Part D drug for you that is not on our Standard coverage decisions are made within 72 hours Drug List.If we agree to cover a drug that is not on after we receive your doctor's statement.Fast coverage our Drug List,you will need to pay the Cost Share decisions are made within 24 hours after we receive amount that applies to drugs in the brand-name drug your doctor's statement. tier.You cannot ask for an exception to the Copayment or Coinsurance amount we require you to If your health requires it,ask us to give you a fast pay for the drug coverage decision.To get a fast coverage decision,you • Removing a restriction for a covered Part D drug. must meet two requirements: "Outpatient Prescription Drugs, Supplies,and • You must be asking for a drug you have not yet Supplements"in the"Benefits and Your Cost Share" received. (You cannot ask for a fast coverage decision section describes the extra rules or restrictions that to be paid back for a drug you have already bought) apply to certain drugs on our Drug List.If we agree to • Using the standard deadlines could cause serious make an exception and waive a restriction for you, harm to your health or hurt your ability to function you can ask for an exception to the Copayment or Coinsurance amount we require you to pay for the • If your doctor or other prescriber tells us that Part D drug your health requires a fast coverage decision,we will automatically give you a fast coverage decision Important things to know about asking for • If you ask for a fast coverage decision on your Part D exceptions own,without your doctor's or prescriber's support,we Your doctor must tell us the medical reasons will decide whether your health requires that we give you a fast coverage decision.If we do not approve a Your doctor or other prescriber must give us a statement fast coverage decision,we will send you a letter that: that explains the medical reasons for requesting a Part D exception.For a faster decision,include this medical ♦ explains that we will use the standard deadlines information from your doctor or other prescriber when ♦ explains if your doctor or other prescriber asks for you ask for the exception. the fast coverage decision,we will automatically give you a fast coverage decision Typically,our Drug List includes more than one drug for ♦ tells you how you can file a fast complaint about treating a particular condition. These different our decision to give you a standard coverage possibilities are called alternative drugs.If an decision instead of the fast coverage decision you alternative drug would be just as effective as the drug requested.We will answer your complaint within you are requesting and would not cause more side effects 24 hours of receipt or other health problems,we will generally not approve your request for an exception.If you ask us for a tiering Step 2: Request a standard coverage decision or a exception,we will generally not approve your request for fast coverage decision an exception unless all the alternative drugs in the lower Start by calling,writing,or faxing OptumRx Prior cost-sharing tier(s)won't work as well for you or are likely to cause an adverse reaction or other harm. Authorization Member Services Desk to make your request for us to authorize or provide coverage for the We can say yes or no to your request medical care you want.You can also access the coverage decision process through our website.We must accept • If we approve your request for a Part D exception,our any written request,including a request submitted on the approval usually is valid until the end of the plan CMS Model Coverage Determination Request form, year.This is true as long as your doctor continues to which is available on our website."How to contact us prescribe the drug for you and that drug continues to when you are asking for a coverage decision about your be safe and effective for treating your condition Part D prescription drugs"in the"Important Phone • If we say no to your request,you can ask for another Numbers and Resources"section has contact review by making an appeal information. To assist us in processing your request, please be sure to include your name,contact information, Step-by-step: How to ask for a coverage and information identifying which denied claim is being decision, including a Part D exception appealed. A fast coverage decision is called an expedited coverage You,or your doctor(or other prescriber),or your determination. representative can do this.You can also have a lawyer Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 77 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. act on your behalf. "How to Get Help When You are • If our answer is no to part or all of what you Asking for a Coverage Decision or Making an Appeal" requested,we will send you a written statement that of this section tells how you can give written permission explains why we said no.We will also tell you how to someone else to act as your representative. you can appeal • If you are requesting a Part D exception,provide the supporting statement which is the medical reasons for Deadlines for a standard coverage decision about the exception.Your doctor or other prescriber can fax payment for a drug you have already bought or mail the statement to us.Or your doctor or other . We must give you our answer within 14 calendar days prescriber can tell us on the phone and follow up by after we receive your request faxing or mailing a written statement if necessary ♦ if we do not meet this deadline,we are required to Step 3: We consider your request and we give you send your request to Level 2 of the appeals our answer process,where it will be reviewed by an independent review organization Deadlines for a fast coverage decision • If our answer is yes to part or all of what you • We must generally give you our answer within 24 requested,we are also required to make payment to hours after we receive your request. you within 14 calendar days after we receive your ♦ for exceptions,we will give you our answer within request 24 hours after we receive your doctor's supporting • If our answer is no to part or all of what you statement.We will give you our answer sooner requested,we will send you a written statement that if your health requires us to explains why we said no.We will also tell you how ♦ if we do not meet this deadline,we are required to you can appeal send your request to Level 2 of the appeals Step 4: If we say no to your coverage request, you process,where it will be reviewed by an decide if you want to make an appeal independent review organization • If our answer is yes to part or all of what you If we say no,you have the right to ask us to reconsider this decision by making an appeal.This means asking requested,we must provide the coverage we have again to get the drug coverage you want. If you make an agreed to provide within 24 hours after we receive appeal,it means you are going to Level 1 of the appeals your request or doctor's statement supporting your process. request • If our answer is no to part or all of what you Step-by-step: How to make a Level 1 appeal requested,we will send you a written statement that An appeal to our plan about a Part D drug coverage explains why we said no.We will also tell you how decision is called a plan redetermination.A fast appeal you can appeal is also called an expedited redetermination. Deadlines for a standard coverage decision about a Step 1: Decide if you need a standard appeal or a Part D drug you have not yet received fast appeal • We must generally give you our answer within 72 A standard appeal is usually made within 7 calendar hours after we receive your request days.A fast appeal is generally made within 72 hours. ♦ for exceptions,we will give you our answer within If your health requires it,ask for a fast appeal 72 hours after we receive your doctor's supporting statement.We will give you our answer sooner • If you are appealing a decision we made about a drug if your health requires us to you have not yet received,you and your doctor or other prescriber will need to decide if you need a fast ♦ if we do not meet this deadline,we are required to appeal send your request on to Level 2 of the appeals process,where it will be reviewed by an • The requirements for getting a"fast appeal"are the independent review organization same as those for getting a fast coverage decision in "Step-by-step:How to ask for a coverage decision, • If our answer is yes to part or all of what you including a Part D exception"of this section requested,we must provide the coverage we have agreed to provide within 72 hours after we receive your request or doctor's statement supporting your request Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 78 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step 2: You, your representative, doctor, or other agreed to provide within 72 hours after we receive prescriber must contact us and make your Level 1 your appeal appeal. If your health requires a quick response, If our answer is no to part or all of what you you must ask for a fast appeal requested,we will send you a written statement that • For standard appeals,submit a written request. explains why we said no and how you can appeal our "Important Phone Numbers and Resources"has decision contact information Deadlines for a standard appeal for a drug you have • For fast appeals either submit your appeal in writing not yet received or call us at 1-800-443-0815."Important Phone Numbers and Resources"has contact information • For standard appeals,we must give you our answer within 7 calendar days after we receive your appeal. • We must accept any written request,including a We will give you our decision sooner if you have not request submitted on the CMS Model received the drug yet and your health condition Redetermination Request Form,which is available on requires us to do so our website.Please be sure to include your name, contact information,and information regarding your ♦ if we do not give you a decision within 7 calendar claim to assist us in processing your request days,we are required to send your request on to Level 2 of the appeals process,where it will be • You must make your appeal request within 65 reviewed by an independent review organization calendar days from the date on the written notice we sent to tell you our answer on the coverage decision. • If our answer is yes to part or all of what you If you miss this deadline and have a good reason for requested,we must provide the coverage as quickly as missing it,explain the reason your appeal is late when your health requires,but no later than 7 calendar days you make your appeal.We may give you more time after we receive your appeal to make your appeal.Examples of good cause may • If our answer is no to part or all of what you include a serious illness that prevented you from requested,we will send you a written statement that contacting us or if we provided you with incorrect or explains why we said no and how you can appeal our incomplete information about the deadline for decision requesting an appeal Deadlines for a standard appeal about payment for a • You can ask for a copy of the information in your drug you have already bought appeal and add more information.You and your doctor may add more information to support your • We must give you our answer within 14 calendar days appeal.We are allowed to charge a fee for copying after we receive your request and sending this information to you ♦ If we do not meet this deadline,we are required to send your request to Level 2 of the appeals Step 3: We consider your appeal and we give you process,where it will be reviewed by an our answer independent review organization • When we are reviewing your appeal,we take another . If our answer is yes to part or all of what you careful look at all of the information about your requested,we are also required to make payment to coverage request.We check to see if we were you within 30 calendar days after we receive your following all the rules when we said no to your request request.We may contact you or your doctor or other • If our answer is no to part or all of what you prescriber to get more information requested,we will send you a written statement that Deadlines for a fast appeal explains why we said no.We will also tell you how you can appeal our decision • For fast appeals,we must give you our answer within 72 hours after we receive your appeal.We will give Step 4: If we say no to your appeal, you decide you our answer sooner if your health requires us to if you want to continue with the appeals process ♦ if we do not give you an answer within 72 hours, and make another appeal we are required to send your request on to Level 2 . If you decide to make another appeal,it means your of the appeals process,where it will be reviewed appeal is going on to Level of the appeals process by an independent review organization • If our answer is yes to part or all of what you requested,we must provide the coverage we have Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 79 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step-by-step: How to make a Level 2 appeal Deadlines for standard appeal The formal name for the independent review • For standard appeals,the review organization must organization is the Independent Review Entity.It is give you an answer to your Level 2 appeal within 7 sometimes called the IRE. calendar days after it receives your appeal if it is for a drug you have not yet received.If you are requesting The independent review organization is an that we pay you back for a drug you have already independent organization hired by Medicare.It is not bought,the review organization must give you an connected with us and is not a government agency. This answer to your Level appeal within 14 calendar organization decides whether the decision we made is days after it receives your request correct or if it should be changed.Medicare oversees its work. Step 3: The independent review organization give Step 1: You (or your representative or your doctor you their answer or other prescriber) must contact the independent For fast appeals: review organization and ask for a review of your . If the independent review organization says yes to case part or all of what you requested,we must provide the • If we say no to your Level 1 appeal,the written notice drug coverage that was approved by the review we send you will include instructions on how to make organization within 24 hours after we receive the a Level 2 appeal with the independent review decision from the review organization organization. These instructions will tell who can For standard appeals: make this Level 2 appeal,what deadlines you must follow,and how to reach the review organization.If, • If the independent review organization says yes to however,we did not complete our review within the part or all of your request for coverage,we must applicable timeframe,or make an unfavorable provide the drug coverage that was approved by the decision regarding at-risk determination under our review organization within 72 hours after we receive drug management program,we will automatically the decision from the review organization forward your claim to the IRE • If the independent review organization says yes to • We will send the information about your appeal to part or all of your request to pay you back for a drug this organization.This information is called your case you already bought,we are required to send payment file.You have the right to ask us for a copy of your to you within 30 calendar days after we receive the case file.We are allowed to charge you a fee for decision from the review organization copying and sending this information to you • You have a right to give the independent review What if the review organization says no to your organization additional information to support your appeal? appeal If this organization says no to your appeal,it means the organization agrees with our decision not to approve Step 2: The independent review organization your request(or part of your request.)(This is called reviews your appeal upholding the decision.It is also called turning down Reviewers at the independent review organization will your appeal.)In this case,the independent review take a careful look at all of the information related to organization will send you a letter: your appeal. • Explaining its decision • Notifying you of the right to a Level 3 appeal if the Deadlines for fast appeal dollar value of the drug coverage you are requesting • If your health requires it,ask the independent review meets a certain minimum.If the dollar value of the organization for a fast appeal drug coverage you are requesting is too low,you cannot make another appeal and the decision at Level • If the organization agrees to give you a fast appeal, 2 is final the organization must give you an answer to your Level 2 appeal within 72 hours after it receives your • Telling you the dollar value that must be in dispute to appeal request continue with the appeals process Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 80 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step 4: If your case meets the requirements, you these services are,who will pay for them,and choose whether you want to take your appeal where you can get them further ♦ your right to be involved in any decisions about • There are three additional levels in the appeals your hospital stay process after Level 2(for a total of five levels of ♦ where to report any concerns you have about the appeal) quality of your hospital Services • If you want to go on to a Level 3 appeal the details on ♦ your right to request an immediate review of the how to do this are in the written notice you get after decision to discharge you if you think you are your Level 2 appeal decision being discharged from the hospital too soon.This is a formal,legal way to ask for a delay in your • The Level appeal is handled by an Administrative discharge date so that we will cover your hospital Law Judge or attorney adjudicator."Taking Your care for a longer time Appeal to Level and Beyond"tells more about .Levels 3,4,and 5 of the appeals process you will be asked to sign the written notice to show that you received it and understand your rights How to Ask Us to Cover a Longer ♦ you or someone who is acting on your behalf will Inpatient Hospital Stay if You Think You be asked to sign the notice Are Being Discharged Too Soon ♦ signing the notice shows only that you have received the information about your rights.The When you are admitted to a hospital,you have the right notice does not give your discharge date. Signing to get all of your covered hospital Services that are the notice does not mean you are agreeing on a necessary to diagnose and treat your illness or injury. discharge date • Keep your copy of the notice handy so you will have During your covered hospital stay,your doctor and the the information about making an appeal(or reporting hospital staff will be working with you to prepare for the a concern about quality of care)if you need it day when you will leave the hospital. They will help arrange for care you may need after you leave. ♦ if you sign the notice more than two calendar days before your discharge date,you will get another • The day you leave the hospital is called your copy before you are scheduled to be discharged discharge date ♦ to look at a copy of this notice in advance,you can • When your discharge date is decided,your doctor or call Member Services or 1-800-MEDICARE the hospital staff will tell you (1-800-633-4227)(TTY users call 1-877-486- • If you think you are being asked to leave the hospital 2048),24 hours a day,seven days a week.You too soon,you can ask for a longer hospital stay and can also see the notice online at your request will be considered httus://www.cros.aov/medicare/forms- notices/beneficiary-notices-initiative/ffs-ma-im During your inpatient hospital stay,you will get a written notice from Medicare that tells about Step-by-step: How to make a Level 1 appeal to your rights change your hospital discharge date Within two calendar days of being admitted to the If you want to ask for your inpatient hospital services to hospital,you will be given a written notice called An be covered by us for a longer time,you will need to use Important Message from Medicare About Your Rights. the appeals process to make this request.Before you Everyone with Medicare gets a copy of this notice If you start,understand what you need to do and what the do not get the notice from someone at the hospital(for deadlines are. example,a caseworker or nurse),ask any hospital • Follow the process employee for it.If you need help,please call Member e Meet the deadlines Services or 1-800-MEDICARE(1-800-633-4227),24 hours a day,seven days a week(TTY 1-877-486-2048). • Ask for help if you need it.If you have questions or Read this notice carefully and ask questions if you need help at any time,please call Member Services. • Or call your State Health Insurance Assistance don't understand it.It tells you: Program,a government organization that provides ♦ your right to receive Medicare-covered services personalized assistance during and after your hospital stay,as ordered by your doctor. This includes the right to know what Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 81 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. During a Level 1 appeal,the Quality Improvement httus://www.ems.eov/medicare/forms- Organization reviews your appeal.It checks to see notices beneficiary-notices-initiative/ffs-ma-im if your planned discharge date is medically appropriate for you. Step 2: The Quality Improvement Organization conducts an independent review of your case The Quality Improvement Organization is a group of doctors and other health care professionals paid by the • Health professionals at the Quality Improvement federal government to check on and help improve the Organization(the reviewers)will ask you(or your representative)why you believe coverage for the quality of care for people with Medicare.This includes reviewing hospital discharge dates for people with services should continue.You don't have to prepare anything in writing,but you may do so if you wish Medicare. These experts are not part of our plan. • The reviewers will also look at your medical Step 1: Contact the Quality Improvement information,talk with your doctor,and review Organization for your state and ask for an information that the hospital and we have given to immediate review of your hospital discharge. You them must act quickly • By noon of the day after the reviewers told us of your How can you contact this organization? appeal,you will get a written notice from us that gives your planned discharge date. This notice also • The written notice you received(An Important explains in detail the reasons why your doctor,the Message from Medicare About Your Rights)tells you hospital,and we think it is right(medically how to reach this organization.Or find the name, appropriate)for you to be discharged on that date address,and phone number of the Quality Improvement Organization for your state in the Step 3: Within one full day after it has all the "Important Phone Numbers and Resources"section needed information, the Quality Improvement Organization will give you its answer to your appeal Act quickly What happens if the answer is yes? • To make your appeal,you must contact the Quality Improvement Organization before you leave the • If the review organization says yes,we must keep hospital and no later than midnight the day of your providing your covered inpatient hospital services for discharge as long as these services are medically necessary ♦ if you meet this deadline,you may stay in the • You will have to keep paying your share of the costs hospital after your discharge date without paying (such as Cost Share,if applicable). In addition,there for it while you wait to get the decision from the may be limitations on your covered hospital services Quality Improvement Organization ♦ if you do not meet this deadline,contact us.If you What happens if the answer is no? decide to stay in the hospital after your planned • If the review organization says no,they are saying discharge date,you may have to pay all of the that your planned discharge date is medically costs for hospital Services you receive after your appropriate.If this happens,our coverage for your planned discharge date inpatient hospital services will end at noon on the day after the Quality Improvement Organization gives Once you request an immediate review of your hospital you its answer to your appeal discharge,the Quality Improvement Organization will • If the review organization says no to your appeal and contact us.By noon of the day after we are contacted,we will give you a Detailed Notice of Discharge.This notice you decide to stay in the hospital,then you may have gives your planned discharge date and explains in detail to pay the full cost of hospital Services you receive the reasons why your doctor,the hospital,and we think it after noon on the day after the Quality Improvement is right(medically appropriate)for you to be discharged Organization gives you its answer to your appeal on that date. Step 4: If the answer to your Level 1 appeal is no, You can get a sample of the Detailed Notice of you decide if you want to make another appeal Discharge by calling Member Services or 1-800- • If the Quality Improvement Organization has said no MEDICARE(1-800-633-4227)24 hours a day,seven to your appeal,and you stay in the hospital after your days a week(TTY users call 1-877-486-2048).Or you planned discharge date,then you can make another can see a sample notice online at Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 82 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. appeal.Making another appeal means you are going Step 4: If the answer is no, you will need to decide on to Level 2 of the appeals process whether you want to take your appeal further by going on to Level 3 Step-by-step: How to make a Level 2 appeal to There are three additional levels in the appeals change your hospital discharge date process after Level(for a total of five levels of During a Level appeal,you ask the Quality appeal).If you want to go to a Level appeal,the Improvement Organization to take another look at their decision on your first appeal.If the Quality Improvement details on how to do this are in the written notice you Organization turns down your Level 2 appeal,you may get after your Level appeal decision have to pay the full cost for your stay after your planned • The Level 3 appeal is handled by an Administrative discharge date. Law Judge or attorney adjudicator.The"Taking Your Appeal to Level 3 and Beyond"section tells more Step 1: Contact the Quality Improvement about Levels 3,4,and 5 of the appeals process Organization again and ask for another review • You must ask for this review within 60 calendar days How to Ask Us to Keep Covering Certain after the day the Quality Improvement Organization Medical Services if You Think Your said no to your Level 1 appeal.You can ask for this Coverage Is Ending Too Soon review only if you stay in the hospital after the date that your coverage for the care ended Home health care, Skilled Nursing Facility care, and Comprehensive Outpatient Rehabilitation Step 2: The Quality Improvement Organization Facility (CORF) services does a second review of your situation • Reviewers at the Quality Improvement Organization When you are getting covered home health services, will take another careful look at all of the information Skilled Nursing Facility care,or rehabilitation care related to your appeal (Comprehensive Outpatient Rehabilitation Facility), you have the right to keep getting your services for that Step 3: Within 14 calendar days of receipt of your type of care for as long as the care is needed to diagnose request for a Level 2 appeal, the reviewers will and treat your illness or injury. decide on your appeal and tell you their decision When we decide it is time to stop covering any of the If the review organization says yes three types of care for you,we are required to tell you in advance.When your coverage for that care ends,we will • We must reimburse you for our share of the costs of stop paying our share of the cost for your care. hospital Services you have received since noon on the day after the date your first appeal was turned down If you think we are ending the coverage of your care too by the Quality Improvement Organization.We must soon,you can appeal our decision.This section tells you continue providing coverage for your inpatient how to ask for an appeal. hospital Services for as long as it is medically necessary We will tell you in advance when your coverage • You must continue to pay your share of the costs,and will be ending coverage limitations may apply The Notice of Medicare Non-Coverage tells how you can request a fast-track appeal.Requesting a fast-track If the review organization says no appeal is a formal,legal way to request a change to our • It means they agree with the decision they made on coverage decision about when to stop your care. your Level 1 appeal. This is called upholding the • You receive a notice in writing at least two calendar decision days before our plan is going to stop covering your • The notice you get will tell you in writing what you care. The notice tells you: can do if you wish to continue with the review ♦ the date when we will stop covering the care for process you ♦ how to request a fast-track appeal to request us to keep covering your care for a longer period of time Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 83 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • You,or someone who is acting on your behalf,will Step 2: The Quality Improvement Organization be asked to sign the written notice to show that conducts an independent review of your case you received it. Signing the notice shows only that The Detailed Explanation of Non-Coverage provides you have received the information about when your details on reasons for ending coverage. coverage will stop. Signing it does not mean you agree with the plan's decision to stop care What happens during this review? • Health professionals at the Quality Improvement Step-by-step: How to make a Level 1 appeal to Organization(the reviewers)will ask you or your have our plan cover your care for a longer time representative why you believe coverage for the If you want to ask us to cover your care for a longer services should continue.You don't have to prepare period of time,you will need to use the appeals process anything in writing,but you may do so if you wish to make this request.Before you start,understand what you need to do and what the deadlines are. • The review organization will also look at your medical information,talk with your doctor,and • Follow the process review information that our plan has given to them • Meet the deadlines • By the end of the day the reviewers tell us of your • Ask for help if you need it.If you have questions or appeal,you will get the Detailed Explanation of need help at any time,please call Member Services. Non-Coverage from us that explains in detail our Or call your State Health Insurance Assistance reasons for ending our coverage for your services. Program,a government organization that provides personalized assistance Step 3: Within one full day after they have all the information they need, the reviewers will tell you During a Level 1 appeal,the Quality Improvement their decision Organization reviews your appeal.It decides if the end date for your care is medically appropriate. What happens if the reviewers say yes? • If the reviewers say yes to your appeal,then we must The Quality Improvement Organization is a group of keep providing your covered services for as long as it doctors and other health care experts paid by the federal is medically necessary government to check on and help improve the quality of . You will have to keeppaying our share of the costs care for people with Medicare.This includes reviewing p y g y (such as Cost Share,if applicable).There may be plan decisions about when it's time to stop covering certain kinds of medical care. These experts are not part limitations on your covered services of our plan. What happens if the reviewers say no? Step 1: Make your Level 1 appeal: contact the • If the reviewers say no,then your coverage will end Quality Improvement Organization and ask for a on the date we have told you fast-track appeal. You must act quickly • If you decide to keep getting the home health care,or How can you contact this organization? Skilled Nursing Facility care,or Comprehensive Outpatient Rehabilitation Facility(CORF)services • The written notice you received(Notice of Medicare after this date when your coverage ends,then you will Non-Coverage)tells you how to reach this have to pay the full cost of this care yourself organization. Or find the name,address,and phone number of the Quality Improvement Organization for Step 4: If the answer to your Level 1 appeal is no, your state in the"Important Phone Numbers and you decide if you want to make another appeal Resources"section If reviewers say no to your Level 1 appeal,and you choose to continue getting care after your coverage Act quickly for the care has ended,then you can make a Level 2 • You must contact the Quality Improvement appeal Organization to start your appeal by noon of the day before the effective date on the Notice of Medicare Step-by-step: How to make a Level 2 appeal to N have our plan cover your care for a longer time Non-Coverage.If you miss the deadline,and you wish to file an appeal,you still have appeal rights. During a Level 2 appeal,you ask the Quality Contact your Quality Improvement Organization Improvement Organization to take another look at the decision on your first appeal.If the Quality Improvement Organization turns down your Level 2 appeal,you may Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 84 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. have to pay the full cost for your home health care,or Taking Your Appeal to Level 3 and Skilled Nursing Facility care,or Comprehensive Beyond Outpatient Rehabilitation Facility(CORF)services after the date when we said your coverage would end. Levels of Appeal 3, 4, and 5 for Medical Service Requests Step 1: Contact the Quality Improvement This section may be appropriate for you if you have Organization again and ask for another review made a Level 1 appeal and a Level 2 appeal,and both of • You must ask for this review within 60 calendar days your appeals have been turned down. after the day when the Quality Improvement Organization said no to your Level 1 appeal.You can If the dollar value of the item or medical service you ask for this review only if you continued getting care have appealed meets certain minimum levels,you may after the date that your coverage for the care ended be able to go on to additional levels of appeal.If the dollar value is less than the minimum level,you cannot Step 2: The Quality Improvement Organization appeal any further. The written response you receive to does a second review of your situation your Level 2 appeal will explain how to make a Level 3 Reviewers at the Quality Improvement Organization will appeal. take another careful look at all of the information related to your appeal. For most situations that involve appeals,the last three levels of appeal work in much the same way.Here is Step 3: Within 14 calendar days of receipt of your who handles the review of your appeal at each of these appeal request, reviewers will decide on your levels. appeal and tell you their decision Level 3 appeal: An Administrative Law Judge or What happens if the review organization says yes? an attorney adjudicator who works for the • We must reimburse you for our share of the costs of federal government will review your appeal and care you have received since the date when we said give you an answer your coverage would end.We must continue • If the Administrative Law Judge or attorney providing coverage for the care for as long as it is adjudicator says yes to your appeal,the appeals medically necessary process may or may not be over.Unlike a decision • You must continue to pay your share of the costs and at a Level 2 appeal,we have the right to appeal a Level 3 decision that is favorable to you.If we decide there may be coverage limitations that apply to appeal,it will go to a Level 4 appeal What happens if the review organization says no? ♦ if we decide not to appeal,we must authorize or • It means they agree with the decision we made to provide you with the medical care within 60 your Level 1 appeal calendar days after receiving the Administrative • The notice you get will tell you in writing what you Law Judge's or attorney adjudicator's decision can do if you wish to continue with the review ♦ if we decide to appeal the decision,we will send process.It will give you the details about how to go you a copy of the Level 4 appeal request with any on to the next level of appeal,which is handled by an accompanying documents.We may wait for the Administrative Law Judge or attorney adjudicator Level 4 appeal decision before authorizing or providing the medical care in dispute Step 4: If the answer is no, you will need to decide • If the Administrative Law Judge or attorney whether you want to take your appeal further adjudicator says no to your appeal,the appeals • There are three additional levels of appeal after Level process may or may not be over 2,for a total of five levels of appeal.If you want to go ♦ if you decide to accept this decision that turns on to a Level 3 appeal,the details on how to do this down your appeal,the appeals process is over are in the written notice you get after your Level 2 ♦ if you do not want to accept the decision,you can appeal decision continue to the next level of the review process. • The Level 3 appeal is handled by an Administrative The notice you get will tell you what to do for a Law Judge or attorney adjudicator."Taking Your Level 4 appeal Appeal to Level 3 and Beyond"in this"Coverage Decisions,Appeals,and Complaints"section tells more about Levels 3,4,and 5 of the appeals process Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 85 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Level 4 appeal: The Medicare Appeals Council Level 3 appeal: An Administrative Law Judge or (Council)will review your appeal and give you an attorney adjudicator who works for the an answer.The Council is part of the federal federal government will review your appeal and government give you an answer • If the answer is yes,or if the Council denies our • If the answer is yes,the appeals process is over.We request to review a favorable Level 3 appeal must authorize or provide the drug coverage that was decision,the appeals process may or may not be approved by the Administrative Law Judge or over.Unlike a decision at Level 2,we have the right attorney adjudicator within 72 hours(24 hours for to appeal a Level 4 decision that is favorable to you. expedited appeals)or make payment no later than 30 We will decide whether to appeal this decision to calendar days after we receive the decision Level 5 • If the answer is no,the appeals process may or may ♦ if we decide not to appeal the decision,we must not be over authorize or provide you with the medical care ♦ If you decide to accept this decision that turns within 60 calendar days after receiving the down your appeal,the appeals process is over Council's decision ♦ If you do not want to accept the decision,you can ♦ if we decide to appeal the decision,we will let you continue to the next level of the review process. know in writing The notice you get will tell you what to do for a • If the answer is no or if the Council denies the Level 4 appeal review request,the appeals process may or may not be over Level 4 appeal: The Medicare Appeals Council ♦ if you decide to accept this decision that turns (Council) will review your appeal and give you down your appeal,the appeals process is over an answer. The Council is part of the federal ♦ if you do not want to accept the decision,you may government be able to continue to the next level of the review • If the answer is yes,the appeals process is over.We process.If the Council says no to your appeal,the must authorize or provide the drug coverage that was notice you get will tell you whether the rules allow approved by the Council within 72 hours(24 hours you to go on to a Level 5 appeal and how to for expedited appeals)or make payment no later than continue with a Level 5 appeal 30 calendar days after we receive the decision • If the answer is no,the appeals process may or may Level 5 appeal: A judge at the Federal District not be over Court will review your appeal ♦ if you decide to accept this decision that turns • A judge will review all of the information and decide down your appeal,the appeals process is over yes or no to your request. This is a final answer. ♦ if you do not want to accept the decision,you may There are no more appeal levels after the Federal be able to continue to the next level of the review District Court process.If the Council says no to your appeal or denies your request to review the appeal,the Appeal Levels 3, 4, and 5 for Part D Drug notice will tell you whether the rules allow you to Requests go on to a Level 5 appeal.It will also tell you who This section may be appropriate for you if you have to contact and what to do next if you choose to made a Level 1 appeal and a Level 2 appeal,and both of continue with your appeal your appeals have been turned down. Level 5 appeal: A judge at the Federal District If the value of the Part D drug you have appealed meets a Court will review your appeal certain dollar amount,you may be able to go on to . A judge will review all of the information and decide additional levels of appeal.If the dollar amount is less, yes or no to your request. This is a final answer. you cannot appeal any further.The written response you There are no more appeal levels after the Federal receive to your Level 2 appeal will explain who to District Court contact and what to do to ask for a Level 3 appeal. For most situations that involve appeals,the last three levels of appeal work in much the same way.Here is who handles the review of your appeal at each of these levels. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 86 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. How to Make a Complaint About Quality • You believe we are not meeting the deadlines for of Care, Waiting Times, Customer coverage decisions or appeals;you can make a Service, or Other Concerns complaint • You believe we are not meeting deadlines for covering or reimbursing you for certain medical What kinds of problems are handled by the services or Part D drugs that were approved;you can complaint process? make a complaint The complaint process is only used for certain types of • You believe we failed to meet required deadlines for problems. This includes problems related to quality of forwarding your case to the independent review care,waiting times,and customer service.Here are organization;you can make a complaint examples of the kinds of problems handled by the complaint process: Step-by-step: making a complaint • Quality of your medical care • A complaint is also called a grievance ♦ are you unhappy with the quality of care you have • Making a complaint is also called filing a grievance received(including care in the hospital)? • Using the process for complaints is also called • Respecting your privacy using the process for filing a grievance ♦ did someone not respect your right to privacy or share confidential information? • A fast complaint is also called an expedited grievance • Disrespect,poor customer service,or other negative behaviors Step 1: Contact us promptly—either by phone or in ♦ has someone been rude or disrespectful to you? writing ♦ are you unhappy with our Member Services? • Usually calling Member Services is the first step. ♦ do you feel you are being encouraged to leave our If there is anything else you need to do,Member plan? Services will let you know • Waiting times • If you do not wish to call(or you called and were not ♦ are you having trouble getting an appointment,or satisfied),you can put your complaint in writing and waiting too long to get it? send it to us.If you put your complaint in writing,we will respond to you in writing.We will also respond ♦ have you been kept waiting too long by doctors, in writing when you make a complaint by phone pharmacists,or other health professionals?Or by if you request a written response or your complaint is Member Services or other staff at our plan? related to quality of care — Examples include waiting too long on the • If you have a complaint,we will try to resolve your phone,in the waiting or exam room,or getting complaint over the phone.If we cannot resolve your a prescription complaint over the phone,we have a formal • Cleanliness procedure to review your complaints.Your grievance ♦ are you unhappy with the cleanliness or condition must explain your concern,such as why you are of a clinic,hospital,or doctor's office? dissatisfied with the services you received.Please see the"Important Phone Numbers and Resources" • Information you get from our plan section for whom you should contact if you have a ♦ did we fail to give you a required notice? complaint ♦ is our written information hard to understand? ♦ you must submit your grievance to us(orally or in writing)within 60 calendar days of the event or Timeliness (these types of complaints are all incident.We must address your grievance as related to the timeliness of our actions related to quickly as your health requires,but no later than coverage decisions and appeals) 30 calendar days after receiving your complaint. If you have asked for a coverage decision or made an We may extend the time frame to make our appeal,and you think that we are not responding quickly decision by up to 14 calendar days if you ask for enough,you can make a complaint about our slowness. an extension,or if we justify a need for additional Here are examples: information and the delay is in your best interest • You asked us for a"fast coverage decision"or a"fast ♦ you can file a fast grievance about our decision not appeal,"and we have said no,you can make a to expedite a coverage decision or appeal for complaint medical care or items,or if we extend the time we Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 87 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. need to make a decision about a coverage decision (1-800-633-4227).TTY/TDD users should call 1-877- or appeal for medical care or items.We must 486-2048. respond to your fast grievance within 24 hours • The deadline for making a complaint is 60 calendar Additional Review days from the time you had the problem you want to complain about You may have certain additional rights if you remain dissatisfied after you have exhausted our internal claims Step 2: We look into your complaint and give you and appeals procedure,and if applicable,external our answer review: • If possible,we will answer you right away.If you • If your Group's benefit plan is subject to the call us with a complaint,we may be able to give you Employee Retirement Income Security Act(ERISA), an answer on the same phone call you may file a civil action under section 502(a)of • Most complaints are answered within 30 calendar ERISA.To understand these rights,you should check days. If we need more information and the delay is in with your Group or contact the Employee Benefits your best interest or if you ask for more time,we can Security Administration(part of the U.S.Department take up to 14 more calendar days(44 calendar days of Labor)at 1-866-444-EBSA(1-866-444-3272) total)to answer your complaint.If we decide to take • If your Group's benefit plan is not subject to ERISA extra days,we will tell you in writing (for example,most state or local government plans • If you are making a complaint because we denied and church plans),you may have a right to request your request for a fast coverage decision or a fast review in state court appeal,we will automatically give you a fast complaint.If you have a fast complaint,it means we will give you an answer within 24 hours Binding Arbitration • If we do not agree with some or all of your For all claims subject to this`Binding Arbitration" complaint or don't take responsibility for the problem section,both Claimants and Respondents give up the you are complaining about,we will include our right to a jury or court trial and accept the use of binding reasons in the response to you arbitration.Insofar as this"Binding Arbitration"section applies to claims asserted by Kaiser Permanente Parties, You can also make complaints about quality of it shall apply retroactively to all unresolved claims that care to the Quality Improvement Organization accrued before the effective date of this EOC. Such When your complaint is about quality of care,you also retroactive application shall be binding only on the have two extra options: Kaiser Permanente Parties. • You can make your complaint directly to the Scope of arbitration Quality Improvement Organization. The Quality Any dispute shall be submitted to binding arbitration if Improvement Organization is a group of practicing doctors and other health care experts paid by the all of the following requirements are met: federal government to check and improve the care • The claim arises from or is related to an alleged given to Medicare patients. The"Important Phone violation of any duty incident to or arising out of or Numbers and Resources"section has contact relating to this EOC or a Member Party's relationship information to Kaiser Foundation Health Plan,Inc.("Health • Or you can make your complaint to both the Plan"),including any claim for medical or hospital Quality Improvement Organization and us at the malpractice(a claim that medical services or items same time were unnecessary or unauthorized or were improperly,negligently,or incompetently rendered), for premises liability,or relating to the coverage for, You can also tell Medicare about your or delivery of,services or items,irrespective of the complaint legal theories upon which the claim is asserted • The claim is asserted by one or more Member Parties You can submit a complaint about our plan directly to against one or more Kaiser Permanente Parties or by Medicare. To submit a complaint to Medicare,go to one or more Kaiser Permanente Parties against one or https://www.medicare.2ov/MedicareComplaintForm/ more Member Parties home.asux.You may also call 1-800-MEDICARE • Governing law does not prevent the use of binding arbitration to resolve the claim Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 88 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Members enrolled under this EOC thus give up their Initiating arbitration right to a court or jury trial,and instead accept the use of Claimants shall initiate arbitration by serving a Demand binding arbitration except that the following types of for Arbitration. The Demand for Arbitration shall include claims are not subject to binding arbitration: the basis of the claim against the Respondents;the • Claims within the jurisdiction of the Small Claims amount of damages the Claimants seek in the arbitration; Court the names,addresses,and phone numbers of the Claimants and their attorney,if any;and the names of all • Claims subject to a Medicare appeal procedure as Respondents. Claimants shall include in the Demand for applicable to Kaiser Permanente Senior Advantage Arbitration all claims against Respondents that are based Members on the same incident,transaction,or related • Claims that cannot be subject to binding arbitration circumstances. under governing law Serving demand for arbitration As referred to in this"Binding Arbitration"section, Health Plan,Kaiser Foundation Hospitals,The "Member Parties"include: Permanente Medical Group,Inc., Southern California • A Member Permanente Medical Group,The Permanente Federation, LLC,and The Permanente Company,LLC,shall be • A Member's heir,relative,or personal representative served with a Demand for Arbitration by mailing the • Any person claiming that a duty to them arises from a Demand for Arbitration addressed to that Respondent in Member's relationship to one or more Kaiser care of: Permanente Parties Kaiser Foundation Health Plan,Inc. Legal Department,Professional&Public Liability "Kaiser Permanente Parties"include: 1 Kaiser Plaza, 19th Floor • Kaiser Foundation Health Plan,Inc. Oakland,CA 94612 • Kaiser Foundation Hospitals Service on that Respondent shall be deemed completed • The Permanente Medical Group,Inc. when received.All other Respondents,including • Southern California Permanente Medical Group individuals,must be served as required by the California • The Permanente Federation,LLC Code of Civil Procedure for a civil action. • The Permanente Company,LLC Filing fee • Any Southern California Permanente Medical Group The Claimants shall pay a single,nonrefundable filing or The Permanente Medical Group physician fee of$150 per arbitration payable to"Arbitration • Any individual or organization whose contract with Account"regardless of the number of claims asserted in the Demand for Arbitration or the number of Claimants any of the organizations identified above requires or Respondents named in the Demand for Arbitration. arbitration of claims brought by one or more Member Parties Any Claimant who claims extreme hardship may request • Any employee or agent of any of the foregoing that the Office of the Independent Administrator waive the filing fee and the neutral arbitrator's fees and "Claimant"refers to a Member Party or a Kaiser expenses.A Claimant who seeks such waivers shall Permanente Party who asserts a claim as described complete the Fee Waiver Form and submit it to the above."Respondent"refers to a Member Party or a Office of the Independent Administrator and Kaiser Permanente Party against whom a claim is simultaneously serve it upon the Respondents.The Fee asserted. Waiver Form sets forth the criteria for waiving fees and is available by calling Member Services. Rules of Procedure Arbitrations shall be conducted according to the Rules Number of arbitrators for Kaiser Permanente Member Arbitrations Overseen The number of arbitrators may affect the Claimants' by the Office of the Independent Administrator("Rules responsibility for paying the neutral arbitrator's fees and of Procedure")developed by the Office of the expenses(see the Rules of Procedure). Independent Administrator in consultation with Kaiser Permanente and the Arbitration Oversight Board. Copies If the Demand for Arbitration seeks total damages of of the Rules of Procedure may be obtained from Member $200,000 or less,the dispute shall be heard and Services. determined by one neutral arbitrator,unless the parties Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 89 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. otherwise agree in writing after a dispute has arisen and a proceed to determine the controversy in the party's request for binding arbitration has been submitted that absence. the arbitration shall be heard by two party arbitrators and one neutral arbitrator.The neutral arbitrator shall not The California Medical Injury Compensation Reform have authority to award monetary damages that are Act of 1975 (including any amendments thereto), greater than$200,000. including sections establishing the right to introduce evidence of any insurance or disability benefit payment If the Demand for Arbitration seeks total damages of to the patient,the limitation on recovery for non- more than$200,000,the dispute shall be heard and economic losses,and the right to have an award for determined by one neutral arbitrator and two party future damages conformed to periodic payments,shall arbitrators,one jointly appointed by all Claimants and apply to any claims for professional negligence or any one jointly appointed by all Respondents.Parties who are other claims as permitted or required by law. entitled to select a party arbitrator may agree to waive this right.If all parties agree,these arbitrations will be Arbitrations shall be governed by this"Binding heard by a single neutral arbitrator. Arbitration"section, Section 2 of the Federal Arbitration Act,and the California Code of Civil Procedure Payment of arbitrators'fees and expenses provisions relating to arbitration that are in effect at the Health Plan will pay the fees and expenses of the neutral time the statute is applied,together with the Rules of arbitrator under certain conditions as set forth in the Procedure,to the extent not inconsistent with this Rules of Procedure.In all other arbitrations,the fees and "Binding Arbitration"section.In accord with the rule expenses of the neutral arbitrator shall be paid one-half that applies under Sections 3 and 4 of the Federal by the Claimants and one-half by the Respondents. Arbitration Act,the right to arbitration under this "Binding Arbitration"section shall not be denied,stayed, If the parties select party arbitrators,Claimants shall be or otherwise impeded because a dispute between a responsible for paying the fees and expenses of their Member Party and a Kaiser Permanente Parry involves party arbitrator and Respondents shall be responsible for both arbitrable and nonarbitrable claims or because one paying the fees and expenses of their party arbitrator. or more parties to the arbitration is also a party to a pending court action with another party that arises out of Costs the same or related transactions and presents a possibility Except for the aforementioned fees and expenses of the of conflicting rulings or findings. neutral arbitrator,and except as otherwise mandated by laws that apply to arbitrations under this"Binding Arbitration"section,each party shall bear the party's Termination of Membership own attorneys' fees,witness fees,and other expenses incurred in prosecuting or defending against a claim Your Group is required to inform the Subscriber of the regardless of the nature of the claim or outcome of the date your membership terminates.Your membership arbitration. termination date is the first day you are not covered(for General provisions example,if your termination date is January 1,2026, your last minute of coverage was at 11:59 p.m.on A claim shall be waived and forever barred if(1)on the December 31,2025).When a Subscriber's membership date the Demand for Arbitration of the claim is served, ends,the memberships of any Dependents end at the the claim,if asserted in a civil action,would be barred as same time.You will be billed as a non-Member for any to the Respondent served by the applicable statute of Services you receive after your membership terminates. limitations,(2)Claimants fail to pursue the arbitration Health Plan and Plan Providers have no further liability claim in accord with the Rules of Procedure with or responsibility under this EOC after your membership reasonable diligence,or(3)the arbitration hearing is not terminates,except: commenced within five years after the earlier of(a)the date the Demand for Arbitration was served in accord • As provided under"Payments after Termination"in with the procedures prescribed herein,or(b)the date of this"Termination of Membership"section filing of a civil action based upon the same incident, • If you are receiving covered Services as an acute care transaction,or related circumstances involved in the hospital inpatient on the termination date,we will claim.A claim may be dismissed on other grounds by the continue to cover those hospital Services(but not neutral arbitrator based on a showing of a good cause.If physician Services or any other Services)until you a party fails to attend the arbitration hearing after being are discharged given due notice thereof,the neutral arbitrator may Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 90 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Until your membership terminates,you remain a Senior Termination of Agreement Advantage Member and must continue to receive your medical care from us,except as described in the If your Group's Agreement with us terminates for any "Emergency Services and Urgent Care"section about reason,your membership ends on the same date.Your Emergency Services,Post-Stabilization Care,and Out- Group is required to notify Subscribers in writing if its of-Area Urgent Care and the"Benefits and Your Cost Agreement with us terminates. Share"section about out-of-area dialysis care. Note:If you enroll in another Medicare Health Plan or a Disenrolling from Senior Advantage prescription drug plan,your Senior Advantage You may terminate(disenroll from)your Senior membership will terminate as described under Advantage membership at any time.However,before "Disenrolling from Senior Advantage"in this you request disenrollment,please check with your Group "Termination of Membership"section. to determine if you are able to continue your Group membership. Termination Due to Loss of Eligibility If you request disenrollment during your Group's open If you no longer meet the eligibility requirements enrollment,your disenrollment effective date is described under"Who Is Eligible"in the"Premiums, determined by the date your written request is received Eligibility,and Enrollment"section your Group will by us and the date your Group coverage ends. The notify you of the date that your membership will end. effective date will not be earlier than the first day of the Your membership termination date is the first day you following month after we receive your written request, are not covered.For example,if your termination date is and no later than three months after we receive your January 1,2026,your last minute of coverage was at request. 11:59 p.m. on December 31,2025. If you request disenrollment at a time other than your Also,we will terminate your Senior Advantage Group's open enrollment,your disenrollment effective membership on the last day of the month if you: date will be the first day of the month following our • Are temporarily absent from our Service Area for receipt of your disenrollment request. more than six months in a row You may request disenrollment by calling toll free • Permanently move from our Service Area 1-800-MEDICARE/1-800-633-4227(TTY users call • No longer have Medicare Part B 1-877-486-2048),24 hours a day,seven days a week,or • Enroll in another Medicare Health Plan(for example, sending written notice to the following address: a Medicare Advantage Plan or a Medicare Kaiser Foundation Health Plan,Inc. prescription drug plan).The Centers for Medicare& California Service Center Medicaid Services will automatically terminate your P.O.Box 232400 Senior Advantage membership when your enrollment San Diego,CA 92193-2400 in the other plan becomes effective • Are not a U.S. citizen or lawfully present in the Other Medicare Health Plans.If you want to enroll in United States.The Centers for Medicare&Medicaid another Medicare Health Plan or a Medicare prescription Services will notify us if you are not eligible to drug plan,you should first confirm with the other plan remain a Member on this basis.We must disenroll and your Group that you are able to enroll.Your new you if you do not meet this requirement plan or your Group will tell you the date when your membership in the new plan begins and your Senior In addition,if you are required to pay the extra Part D Advantage membership will end on that same day(your amount because of your income and you do not pay it, disenrollment date). Medicare will disenroll you from our Senior Advantage Plan and you will lose prescription drug coverage. The Centers for Medicare&Medicaid Services will let us know if you enroll in another Medicare Health Plan, Note:If you lose eligibility for Senior Advantage due to so you will not need to send us a disenrollment request. any of these circumstances,you may be eligible to transfer your membership to another Kaiser Permanente Original Medicare.If you request disenrollment from plan offered by your Group.Please contact your Group Senior Advantage and you do not enroll in another for information. Medicare Health Plan,you will automatically be enrolled Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 91 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. in Original Medicare when your Senior Advantage • You commit theft from Health Plan,from a Plan membership terminates(your disenrollment date).On Provider,or at a Plan Facility your disenrollment date,you can start using your red, • You intentionally misrepresent membership status or white,and blue Medicare card to get services under commit fraud in connection with your obtaining Original Medicare.You will not get anything in writing membership.We cannot make you leave our Senior that tells you that you have Original Medicare after you Advantage Plan for this reason unless we get disenroll.If you choose Original Medicare and you want permission from Medicare first to continue to get Medicare Part D prescription drug coverage,you will need to enroll in a prescription drug • If you become incarcerated(go to prison) plan. • You knowingly falsify or withhold information about other parties that provide reimbursement for your If you receive Extra Help from Medicare to pay for your prescription drug coverage prescription drugs,and you switch to Original Medicare and do not enroll in a separate Medicare Part D If we terminate your membership for cause,you will not prescription drug plan,Medicare may enroll you in a be allowed to enroll in Health Plan in the future until you drug plan,unless you have opted out of automatic have completed a Member Orientation and have signed a enrollment. statement promising future compliance.We may report fraud and other illegal acts to the authorities for Note: If you disenroll from Medicare prescription drug prosecution. coverage and go without creditable prescription drug coverage for 63 or more days in a row,you may need to pay a Part D late enrollment penalty if you join a Termination for Nonpayment of Medicare drug plan later. Premiums If we do not receive Premiums for your Family,we may Termination of Contract with the terminate the memberships of everyone in your Family. Centers for Medicare & Medicaid Services Termination of a Product or all Products If our contract with the Centers for Medicare&Medicaid Services to offer Senior Advantage terminates,your We may terminate a particular product or all products Senior Advantage membership will terminate on the offered in the group market as permitted or required by same date.We will send you advance written notice and law.If we discontinue offering a particular product in the advise you of your health care options.Also,you may be group market,we will terminate just the particular product by sending you written notice at least 90 days eligible to transfer your membership to another Kaiser Permanente plan offered by your Group. before the product terminates.If we discontinue offering all products in the group market,we may terminate your Group's Agreement by sending you written notice at Termination for Cause least 180 days before the Agreement terminates. We may terminate your membership by sending you advance written notice if you commit one of the Payments after Termination following acts: If we terminate your membership for cause or for • If you continuously behave in a way that is disruptive, nonpayment,we will: to the extent that your continued enrollment seriously impairs our ability to arrange or provide medical care • Refund any amounts we owe for Premiums paid after for you or for our other members.We cannot make the termination date you leave our Senior Advantage Plan for this reason • Pay you any amounts we have determined that we unless we get permission from Medicare first owe you for claims during your membership in • If you let someone else use your plan membership accord with the"Requests for Payment"section.We card to get medical care.We cannot make you leave will deduct any amounts you owe Health Plan or Plan our Senior Advantage Plan for this reason unless we Providers from any payment we make to you get permission from Medicare first.If you are disenrolled for this reason,the Centers for Medicare &Medicaid Services may refer your case to the Inspector General for additional investigation Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 92 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Review of Membership Termination while the Subscriber was employed by your Group,and your Group's Agreement with us terminates and is not If you believe that we terminated your Senior Advantage renewed,we will cover Services for your totally membership because of your ill health or your need for disabling condition until the earliest of the following care,you may file a complaint as described in the events occurs: "Coverage Decisions,Appeals,and Complaints"section. • 12 months have elapsed since your Group's Agreement with us terminated • You are no longer Totally Disabled Continuation of Membership • Your Group's Agreement with us is replaced by If your membership under this Senior Advantage EOC another group health plan without limitation as to the ends,you may be eligible to continue Health Plan disabling condition membership without a break in coverage.You may be able to continue Group coverage under this Senior Your coverage will be subject to the terms of this EOC, Advantage EOC as described under"Continuation of including Cost Share,but we will not cover Services for Group Coverage."Also,you may be able to continue any condition other than your totally disabling condition. membership under an individual plan as described under "Conversion from Group Membership to an Individual For Subscribers and adult Dependents,"Totally Plan."If at any time you become entitled to continuation Disabled"means that,in the judgment of a Medical of Group coverage,please examine your coverage Group physician,an illness or injury is expected to result options carefully before declining this coverage. in death or has lasted or is expected to last for a Individual plan premiums and coverage will be different continuous period of at least 12 months,and makes the from the premiums and coverage under your Group plan. person unable to engage in any employment or occupation,even with training,education,and experience. Continuation of Group Coverage For Dependent children,"Totally Disabled"means that, COBRA in the judgment of a Medical Group physician,an illness You may be able to continue your coverage under this or injury is expected to result in death or has lasted or is Senior Advantage EOC for a limited time after you expected to last for a continuous period of at least 12 would otherwise lose eligibility,if required by the months and the illness or injury makes the child unable federal Consolidated Omnibus Budget Reconciliation to substantially engage in any of the normal activities of Act("COBRA").COBRA applies to most employees children in good health of like age. (and most of their covered family Dependents)of most employers with 20 or more employees. To request continuation of coverage for your disabling condition,you must call Member Services within 30 If your Group is subject to COBRA and you are eligible days after your Group's Agreement with us terminates. for COBRA coverage,in order to enroll,you must submit a COBRA election form to your Group within the COBRA election period.Please ask your Group for Conversion from Group Membership to details about COBRA coverage,such as how to elect an Individual Plan coverage,how much you must pay for coverage,when coverage and Premiums may change,and where to send After your Group notifies us to terminate your Group your Premium payments. membership,we will send a termination letter to the Subscriber's address of record.The letter will include As described in"Conversion from Group Membership to information about options that may be available to you to an Individual Plan"in this"Continuation of remain a Health Plan Member. Membership"section,you may be able to convert to an individual(nongroup)plan if you don't apply for Kaiser Permanente Conversion Plan COBRA coverage,or if you enroll in COBRA and your If you want to remain a Health Plan Member,one option COBRA coverage ends. that may be available is our Senior Advantage Individual Plan.You may be eligible to enroll in our individual plan Coverage for a disabling condition if you no longer meet the eligibility requirements If you became Totally Disabled while you were a described under"Who Is Eligible"in the"Premiums, Member under your Group's Agreement with us and Eligibility,and Enrollment"section.Individual plan Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 93 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. coverage begins when your Group coverage ends. The Attorney and Advocate Fees and premiums and coverage under our individual plan are Expenses different from those under this EOC and will include Medicare Part D prescription drug coverage. In any dispute between a Member and Health Plan,the Medical Group,or Kaiser Foundation Hospitals,each However,if you are no longer eligible for Senior party will bear its own fees and expenses,including Advantage and Group coverage,you may be eligible to attorneys' fees,advocates' fees,and other expenses. convert to our non-Medicare individual plan,called "Kaiser Permanente Individual—Conversion Plan."You may be eligible to enroll in our Individual—Conversion Claims Review Authority Plan if we receive your enrollment application within 63 days of the date of our termination letter or of your We are responsible for determining whether you are membership termination date(whichever date is later). entitled to benefits under this EOC and we have the discretionary authority to review and evaluate claims that You may not be eligible to convert if your membership arise under this EOC.We conduct this evaluation ends for the reasons stated under"Termination for independently by interpreting the provisions of this EOC. We may use medical experts to help us review claims. Cause"or"Termination of Agreement"in the If coverage under this EOC is subject to the Employee "Termination of Membership"section. Retirement Income Security Act("ERISA")claims procedure regulation(29 CFR 2560.503-1),then we are a "named claims fiduciary"to review claims under this Miscellaneous Provisions EOC. Administration of Agreement EOC Binding on Members We may adopt reasonable policies,procedures,and By electing coverage or accepting benefits under this interpretations to promote orderly and efficient EOC,all Members legally capable of contracting,and administration of your Group's Agreement,including this the legal representatives of all Members incapable of EOC. contracting,agree to all provisions of this EOC. Amendment of Agreement ERISA Notices Your Group's Agreement with us will change This"ERISA Notices"section applies only if your periodically.If these changes affect this EOC,your Group's health benefit plan is subject to the Employee Group is required to inform you in accord with Retirement Income Security Act("ERISA").We provide applicable law and your Group's Agreement. these notices to assist ERISA-covered groups in complying with ERISA.Coverage for Services described in these notices is subject to all provisions of this EOC. Applications and Statements Newborns' and Mothers' Health Protection Act You must complete any applications,forms,or Group health plans and health insurance issuers generally statements that we request in our normal course of may not,under Federal law,restrict benefits for any business or as specified in this EOC. hospital length of stay in connection with childbirth for the birthing person or newborn child to less than 48 Assignment hours following a vaginal delivery,or less than 96 hours following a cesarean section.However,Federal law You may not assign this EOC or any of the rights, generally does not prohibit the birthing person's or interests,claims for money due,benefits,or obligations newborn's attending provider,after consulting with the hereunder without our prior written consent. birthing person,from discharging the birthing person or their newborn earlier than 48 hours(or 96 hours as applicable).In any case,plans and issuers may not,under Federal law,require that a provider obtain authorization from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours(or 96 hours). Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 94 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Women's Health and Cancer Rights Act Subscriber within 30 days after receiving the information If you have had or are going to have a mastectomy,you from us.The Subscriber is also responsible for notifying may be entitled to certain benefits under the Women's Group of any change in contact information. Health and Cancer Rights Act.For individuals receiving mastectomy-related benefits,coverage will be provided in a manner determined in consultation with the Notice about Medicare Secondary Paver attending physician and the patient,for all stages of Subrogation Rights reconstruction of the breast on which the mastectomy was performed,surgery and reconstruction of the other We have the right and responsibility to collect for breast to produce a symmetrical appearance,prostheses, covered Medicare services for which Medicare is not the and treatment of physical complications of the primary payer.According to CMS regulations at 42 CFR mastectomy,including lymphedemas.These benefits will sections 422.108 and 423.462,Kaiser Permanente Senior be provided subject to the same Cost Share applicable to Advantage,as a Medicare Advantage Organization,will other medical and surgical benefits provided under this exercise the same rights of recovery that the Secretary plan. exercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules established in this section supersede any state laws. Governing Law Except as preempted by federal law,this EOC will be Overpayment Recovery governed in accord with California law and any provision that is required to be in this EOC by state or We may recover any overpayment we make for Services federal law shall bind Members and Health Plan whether from anyone who receives such an overpayment or from or not set forth in this EOC. any person or organization obligated to pay for the Services. Group and Members Not Our Agents Public Policy Participation Neither your Group nor any Member is the agent or representative of Health Plan. The Kaiser Foundation Health Plan,Inc.,Board of Directors establishes public policy for Health Plan.A list of the Board of Directors is available on our website at No Waiver ky.om or from Member Services.If you would like to provide input about Health Plan public policy for Our failure to enforce any provision of this EOC will not consideration by the Board,please send written constitute a waiver of that or any other provision,or comments to: impair our right thereafter to require your strict Kaiser Foundation Health Plan,Inc. performance of any provision. Office of Board and Corporate Governance Services Notices Regarding Your Coverage One Kaiser Plaza, 19th Floor Oakland,CA 94612 Our notices to you will be sent to the most recent address we have for the Subscriber.The Subscriber is responsible for notifying us of any change in address. Subscribers who move should call Member Services and Social Security toll free at 1-800-772-1213(TTY users call 1-800-325-0778)as soon as possible to give us their new address.If a Member does not reside with the Subscriber, or needs to have confidential information sent to an address other than the Subscriber's address,they should contact Member Services to discuss alternate delivery options. Note:When we tell your Group about changes to this EOC or provide your Group other information that affects you,your Group is required to notify the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 95 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Telephone Access (TTY) Coverage decisions, appeals, or complaints for Services—contact information If you use a text telephone device(TTY,also known as TDD)to communicate by phone,you can use the Call 1-800-443-0815 California Relay Service by calling 711. Calls to this number are free. Seven days a week,8 a.m.to 8 p.m. Important Phone Numbers and If your coverage decision,appeal,or complaint qualifies for a fast decision as described in the Resources "Coverage Decisions,Appeals,and Complaints"section,call the Expedited Review Unit at 1-888-987-7247, 8:30 a.m.to 5 p.m., Kaiser Permanente Senior Advantage Monday through Saturday. How to contact our plan's Member Services TTY 711 For assistance,please call or write to our plan's Member Calls to this number are free. Services.We will be happy to help you. Seven days a week,8 a.m.to 8 p.m. Member Services—contact information Fax If your coverage decision,appeal,or complaint Call 1-800-443-0815 qualifies for a fast decision,fax your request to Calls to this number are free. our Expedited Review Unit at 1-888-987-2252. Write For a standard coverage decision or Seven days a week,8 a.m.to 8 p.m. complaint,write to your local Member Services Member Services also has free language office(see the Provider Directory for locations). interpreter services available for non-English For a standard appeal,write to the address speakers. shown on the denial notice we send you. TTY 711 If your coverage decision,appeal,or complaint Calls to this number are free. qualifies for a fast decision,write to: Kaiser Permanente Seven days a week,8 a.m.to 8 p.m. Expedited Review Unit Write Your local Member Services office(see the P.O.Box 1809 Provider Directory for locations). Pleasanton,CA 94566 Website kp•or2 Medicare Website.You can submit a complaint about our plan directly to Medicare.To submit an online How to contact us when you are asking for a complaint to Medicare,go to coverage decision or making an appeal or https://www.medicare.2ov/MedicareComplaintForm/ complaint about your Services home.aspx. • A coverage decision is a decision we make about your How to contact us when you are asking for a benefits and coverage or about the amount we will coverage decision about your Part D pay for your medical services prescription drugs • An appeal is a formal way of asking us to review and . A coverage decision is a decision we make about your change a coverage decision we have made benefits and coverage or about the amount we will • You can make a complaint about us or one of our pay for your prescription drugs covered under the network providers,including a complaint about the Part D benefit included in your plan quality of your care.This type of complaint does not involve coverage or payment disputes For more information about asking for coverage decisions about your Part D prescription drugs,see For more information about asking for coverage the"Coverage Decisions,Appeals,and Complaints" decisions or making appeals or complaints about your section. medical care,see the"Coverage Decisions,Appeals,and Complaints"section. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 96 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Coverage decisions for Part D prescription is about our plan's coverage or payment,you should look drugs—contact information at the section above about requesting coverage decisions or making appeals.)For more information about making Call 1-877-645-1282 a complaint about your Part D prescription drugs,see the Calls to this number are free. "Coverage Decisions,Appeals,and Complaints"section. Seven days a week,8 a.m.to 8 p.m. Complaints for Part D prescription drugs— TTY 711 contact information Calls to this number are free. Call 1-800-443-0815 Seven days a week,8 a.m.to 8 p.m. Calls to this number are free. Fax 1-844-403-1028 Seven days a week,8 a.m.to 8 p.m. Write OptumRx If your complaint qualifies for a fast decision, c/o Prior Authorization call the Part D Unit at 1-866-206-2973,8:30 P.O.Box 2975 a.m.to 5 p.m.,seven days a week. See the Mission,KS 66201 "Coverage Decisions,Appeals,and Website ky.ore Complaints"section to find out if your issue qualifies for a fast decision. How to contact us when you are making an TTY 711 appeal about your Part D prescription drugs Calls to this number are free. • An appeal is a formal way of asking us to review and change a coverage decision we have made Seven days a week,8 a.m.to 8 p.m. For more information on asking for appeals about Fax If your complaint qualifies for a fast review,fax your Part D prescription drugs,see the"Coverage your request to our Part D Unit at 1-866-206- Decisions,Appeals,and Complaints"section.You 2974. may call us if you have questions about our appeals process. Write For a standard complaint,write to your local Member Services office(see the Provider Appeals for Part D prescription drugs—contact Directory for locations). information If your complaint qualifies for a fast decision, Call 1-866-206-2973 write to: Kaiser Permanente Calls to this number are free. Medicare Part D Unit Seven days a week,8:30 a.m.to 5 p.m. P.O.Box 1809 TTY 711 Pleasanton,CA 94566 Medicare Website.You can submit a complaint about Calls to this number are free. our plan directly to Medicare.To submit an online Seven days a week,8:30 a.m. to 5 p.m. complaint to Medicare,go to httips://www.medicare.2ov/MedicareComi)laintForm/ Fax 1-866-206-2974 home.aspx. Write Kaiser Permanente Medicare Part D Unit Where to send a request asking us to pay for P.O.Box 1809 our share of the cost for Services or a Part D Pleasanton,CA 94566 drug you have received Website kp.or2 If you have received a bill or paid for services(such as a provider bill)that you think we should pay for,you may How to contact us when you are making a need to ask us for reimbursement or to pay the provider complaint about your Part D prescription drugs bill. See the"Requests for Payment"section. You can make a complaint about us or one of our network pharmacies,including a complaint about the Note:If you send us a payment request and we deny any quality of your care.This type of complaint does not part of your request,you can appeal our decision. See the involve coverage or payment disputes.(If your problem Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 97 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. "Coverage Decisions,Appeals,and Complaints"section Write Your local Member Services office(see the for more information. Provider Directory for locations). Payment Requests—contact information Website ky.org Call 1-800-443-0815 Medicare Calls to this number are free. Seven days a week,8 a.m.to 8 p.m. How to get help and information directly from the federal Medicare program Note:If you are requesting payment of a Part D Medicare is the federal health insurance program for drug that was prescribed by a Plan Provider and people 65 years of age or older,some people under age obtained from a Plan Pharmacy,call our Part D 65 with disabilities,and people with End-Stage Renal unit at 1-866-206-2973,8:30 a.m.to 5 p.m., Disease(permanent kidney failure requiring dialysis or a seven days a week. kidney transplant).The federal agency in charge of TTY 711 Medicare is the Centers for Medicare&Medicaid Services(sometimes called CMS).This agency contracts Calls to this number are free. with Medicare Advantage organizations,including our Seven days a week,8 a.m.to 8 p.m. plan. Write For medical care: Medicare—contact information Kaiser Permanente Call 1-800-MEDICARE or 1-800-633-4227 Claims Department P.O.Box 12923 Calls to this number are free.24 hours a day, Oakland,CA 94604-2923 seven days a week. For Part D drugs: TTY 1-877-486-2048 If you are requesting payment of a Part D drug This number requires special telephone that was prescribed and provided by a Plan equipment and is only for people who have Provider,you can fax your request to 1-866- difficulties with hearing or speaking. Calls to 206-2974 or mail it to: this number are free. Kaiser Permanente Website htti)s://www.Medicare.2ov Medicare Part D Unit P.O.Box 1809 This is the official government website for Medicare.It Pleasanton,CA 94566 gives you up-to-date information about Medicare and current Medicare issues.It also has information about Website kp.org hospitals,nursing homes,physicians,home health agencies,and dialysis facilities.It includes documents The Medicare Prescription Payment Plan— you can print directly from your computer.You can also contact information find Medicare contacts in your state. Call 1-800-443-0815 The Medicare website also has detailed information Calls to this number are free. about your Medicare eligibility and enrollment options Seven days a week,8 a.m.to 8 p.m. with the following tools: Member Services also has free language Medicare Eligibility Tool:Provides Medicare eligibility interpreter services available for non-English status information. speakers. TTY 711 Medicare Plan Finder: Provides personalized information about available Medicare prescription drug Calls to this number are free. plans,Medicare Health Plans,and Medigap(Medicare Seven days a week,8 a.m.to 8 p.m. Supplement Insurance)policies in your area.These tools provide an estimate of what your out-of-pocket costs might be in different Medicare plans. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 98 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. You can also use the website to tell Medicare about any Health Insurance Counseling and Advocacy complaints you have about our plan. Program (California's State Health Insurance Assistance Program)—contact information Tell Medicare about your complaint:You can submit Call 1-800-434-0222 a complaint about our plan directly to Medicare.To submit a complaint to Medicare,go to Calls to this number are free. httus://www.medicare.2ov/MedicareComi)laintForm/ TTY 711 home.asvx.Medicare takes your complaints seriously and will use this information to help improve the quality Write Your HICAP office for your county. of the Medicare program. Website www.a2ina.ca.2ov/HICAP/ If you don't have a computer,your local library or senior center may be able to help you visit this website using its Quality Improvement Organization computer. Or,you can call Medicare and tell them what information you are looking for.They will find the Paid by Medicare to check on the quality of care information on the website and review the information for people with Medicare with you.You can call Medicare at 1-800-MEDICARE There is a designated Quality Improvement Organization (1-800-633-4227)(TTY users call 1-877-486-2048),24 for serving Medicare beneficiaries in each state.For hours a day,7 days a week. California,the Quality Improvement Organization is called Livanta. State Health Insurance Assistance Livanta has a group of doctors and other health care Program professionals who are paid by Medicare to check on and Free help, information, and answers to your help improve the quality of care for people with questions about Medicare Medicare.Livanta is an independent organization.It is The State Health Insurance Assistance Program(SHIP) not connected with our plan. is a government program with trained counselors in You should contact Livanta in any of these situations: every state.In California,the State Health Insurance Assistance Program is called the Health Insurance • You have a complaint about the quality of care you Counseling and Advocacy Program(HICAP). have received • You think coverage for your hospital stay is ending HICAP is an independent(not connected with any too soon insurance company or health plan)state program that o You think coverage for your home health care, gets money from the federal government to give free Skilled Nursing Facility care,or Comprehensive local health insurance counseling to people with Outpatient Rehabilitation Facility(CORF)services Medicare. are ending too soon HICAP counselors can help you understand your Livanta (California's Quality Improvement Medicare rights,help you make complaints about your Organization)—contact information Services or treatment,and help you straighten out problems with your Medicare bills.HICAP counselors Call 1-877-588-1123 can also help you with Medicare questions or problems Calls to this number are free.Monday through and help you understand your Medicare plan choices and Friday,9 a.m.to 5 p.m Weekends and holidays answer questions about switching plans. 11 a.m.to 3 p.m. Method to access SHIP and other resources: TTY 1-855-887-6668 • Visit httys://www.shii)heli).ort! This number requires special telephone • Click on SHIP Locator in middle of page equipment and is only for people who have difficulties with hearing or speaking. • Select your state from the list.This will take you to a page with phone numbers and resources Write Livanta specific to your state BFCC—QIO Program Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 99 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. 10820 Guilford Road, Suite 202 Medicaid Annapolis Junction,MD 20701-1105 A joint federal and state program that helps with Website www.livantapio.com/en medical costs for some people with limited income and resources Social Security Medicaid is a joint federal and state government program that helps with medical costs for certain people with Social Security is responsible for determining eligibility limited incomes and resources. Some people with and handling enrollment for Medicare.U.S.citizens and Medicare are also eligible for Medicaid. lawful permanent residents who are 65 or older,or who have a disability or end stage renal disease and meet In addition,there are programs offered through Medicaid certain conditions,are eligible for Medicare.If you are that help people with Medicare pay their Medicare costs, already getting Social Security checks,enrollment into such as their Medicare premiums.These"Medicare Medicare is automatic.If you are not getting Social Savings Programs"help people with limited income and Security checks,you have to enroll in Medicare. To resources save money each year: apply for Medicare,you can call Social Security or visit • Qualified Medicare Beneficiary(QMB):Helps pay your local Social Security office. Medicare Part A and Part B premiums,and other Cost Share. Some people with QMB are also eligible for Social Security is also responsible for determining who full Medicaid benefits(QMB+) has to pay an extra amount for their Part D drug coverage because they have a higher income.If you got a letter • Specified Low-Income Medicare Beneficiary from Social Security telling you that you have to pay the (SLMB):Helps pay Part B premiums. Some people extra amount and have questions about the amount or with SLMB are also eligible for full Medicaid if your income went down because of a life-changing benefits(SLMB+) event,you can call Social Security to ask for . Qualifying Individual(QI):Helps pay Part B reconsideration. premiums • Qualified Disabled&Working Individuals If you move or change your mailing address,it is (QDWI):Helps pay Part A premiums important that you contact Social Security to let them know. To find out more about Medicaid and its programs, Social Security—contact information contact Medi-Cal. Call 1-800-772-1213 Medi-Cal (California's Medicaid program)— Calls to this number are free.Available 8 a.m. contact information to 7 p.m.,Monday through Friday. Call 1-800-430-4263 You can use Social Security's automated Calls to this number are free.Monday through telephone services and get recorded information Friday,8 a.m.to 6 p.m. 24 hours a day. TTY 1-800-430-7077 TTY 1-800-325-0778 This number requires special telephone This number requires special telephone equipment and is only for people who have equipment and is only for people who have difficulties with hearing or speaking. difficulties with hearing or speaking. Calls to Write CA Department of Health Care Services this number are free.Available 8 a.m.to 7 p.m., Health Care Options Monday through Friday. P.O.Box 989009 Website www.ssa.gov West Sacramento,CA 95798-9850 Website www.healthcareoutions.dhcs.ca.2ov/ Railroad Retirement Board The Railroad Retirement Board is an independent federal agency that administers comprehensive benefit programs Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 100 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. for the nation's railroad workers and their families. If you have questions regarding your benefits from the Railroad Retirement Board,contact the agency. If you receive your Medicare through the Railroad Retirement Board,it is important that you let them know if you move or change your mailing address. Railroad Retirement Board—contact information Call 1-877-772-5772 Calls to this number are free.If you press"0," you may speak with an RRB representative from 9 a.m.to 3:30 p.m.,Monday,Tuesday, Thursday,and Friday,and from 9 a.m.to 12 p.m.on Wednesday. If you press"1,"you may access the automated RRB HelpLine and recorded information 24 hours a day,including weekends and holidays. TTY 1-312-751-4701 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are not free. Website rrb.gov/ Group Insurance or Other Health Insurance from an Employer If you have any questions about your employer- sponsored Group plan,please contact your Group's benefits administrator.You can ask about your employer or retiree health benefits,any contributions toward the Group's premium,eligibility,and enrollment periods. If you have other prescription drug coverage through your(or your spouse's)employer or retiree group,please contact that group's benefits administrator.The benefits administrator can help you determine how your current prescription drug coverage will work with our plan. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#2 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 101 Notice of Nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters. o Written information in other formats, such as large print, audio, and accessible electronic formats. • Provide no cost language services to people whose primary language is not English, such as: o Qualified interpreters. o Information written in other languages. If you need these services, call Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., seven days a week. If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612 or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.htmi. KAISER PERMANEWE® 1126306860 CA June 2023 Form Approved OMB# 0938-1421 Multi-Language Insert Multi-language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-443-0815 (TTY 711). Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de interprete sin costo alguno pars responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un interprete, por favor Ilame al 1-800-443-0815 (TTY 711). Alguien que hable espanol le podra ayudar. Este es un servicio gratuito. Chinese Mandarin: WOJUtt",n 4qR*, '2kTf* �T�T7 ip7o p � _�UL JMR*, i�RF� 1-800-443-0815 (TTY 711)0 Rfl� 7�1'�CZT`> ��r;Ta Chinese Cantonese: 7,H,Ev7gmrm, ono 0� ai�kk� tT 1-800-443-0815 (TTY711)0 frigxrp7z J k�w�k ! rE fA Y�-' FO0 i �t—MtW M Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-443-0815 (TTY 711). Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interpretation pour repondre a toutes vos questions relatives a notre regime de sante ou d'assurance- medicaments. Pour acceder au service d'interpretation, it vous suffit de nous appeler au 1-800-443-0815 (TTY 711). Un interlocuteur parlant Frangais pourra vous cider. Ce service est gratuit. Vietnamese: Chung toi co dich vu thong dich mien phi d6 tra Idi cac cau hoi ve chtfdng stYc khoe va chudng trinh thuoc men. Neu qui vi can thong dich vien xin goi 1-800-443-0815 (TTY 711) se co nhan vien not tieng Viet giup dd qui vi. flay la dich vu mien phi . German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- and Arzneimittel plan. Unsere Dolmetscher erreichen Sie unter 1-800-443-0815 (TTY 711). Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Form CMS-10802 KAISER PERMANENTE® (Expires 12/31/25) Y0043_N00036258_C Form Approved OMB# 0938-1421 Korean: °l VLp�Il j,4tt -NL1 rt-1oN —,-- i!]--1-7,4 �� o A] HI�z A]o o} c}, o A]111 oI o=o}BIl mil } 1-800-443-0815 (TTY 711) T1° i �N Russian: ECrim y BaC B03HMKHyT BOnpOCbl OTHOCHTeIlbHo CTpaXOBOro wnw McAMKaMeHTHOro nllaHa, Bbl moweTe BOcnOJlb3OBaTbCA Hawomm 6ecniiaTHb[MM yCllyramm nepeBOA4HKOB. yT06bi BOCnOJlb3OBaTbCA ycnyramM nepeBOAL4MKa, n03BOHWTe Ham n0 TeneCpOHy 1-800-443-0815 (TTY 711). BaM OKa)KeT nOMOLLtb COTpyAHWK, KOTOpblO rOBOPHT nO-pyCCKM. AaHHaA ycnyra 6ecnnaTHaA. 1y�1 a�S��I J9 v 91 as,alb all S I1, avL�mil S,S 911 �,�11 �,l.o v Div l;;l :Arabic vas P .1-800-443-0815 (TTY 711) rlr- ly JL-�VI cs cSJ9� Hindi: yqr�7m-�zgqT-(Tm-qft t7yl-T-cr zft# f45tift-q%�7Ei� t-q-6 lwriwi #ZlT�3q-�W t. ITcF-q f I M qI Wric W\T�21T t , ZM-�A 1-80 0-443-0815 (TTY 711)TF IF)7;:r . ci f6-4 t fffltaMTC-fft Trj�q-qR UWTt. Zg��cr#dT . Italian: E disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare it numero 1-800-443-0815 (TTY 711). Un nostro incaricato the parla Italianovi fornira I'assistenza necessaria. E un servizio gratuito. Portuguese: Dispomos de servigos de interpretagao gratuitos pars responder a qualquer questao que tenha acerca do nosso plano de saude ou de medicagao. Para obter um interprete, contacte-nos atraves do numero 1-800-443-0815 (TTY 711). Ira encontrar alguem que fale o idioma Portugues pars o ajudar. Este servigo e gratuito. French Creole: Nou genyen sevis entepret gratis you reponn tout kesyon ou to genyen konsenan plan medikal oswa dwog nou an. Pou jwenn you entepret, jis rele nou nan 1-800-443-0815 (TTY 711). Yon moun ki pale Kreyol kapab ede w. Sa a se you sevis ki gratis. Polish: Umozliwiamy bezpkatne skorzystanie z uskug t+umacza ustnego, ktory pomo2e w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekow. Aby skorzystac z pomocy tkumacza znajacego jQzyk polski, nale2y zadzwonic pod numer 1-800-443-0815 (TTY 711). Ta uskuga jest bezpkatna. Japanese: �Yf 9)1 W, I W, fXrA L A� �J-L) ? rA ID W,N1I:- z fi 11-8'{0}-0-443-0815 (TTY 711) 6�-- �3 1M:K AQ �Au Au < �' � �>o F1 * l-A A bi�M L 11- 41 Y 9)-ft 7� 0 Form CMS-10802 (Expires 12/31/25) 1140823727 June 2023 KAISER PERMANEWE® Kaiser Foundation Health Plan, Inc. Northern California Region EOC #3 - Chiropractic Services Amendment of the Kaiser Foundation Health Plan, Inc. Evidence of Coverage for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 36 EOC Number: 3 Issue Date: October 30, 2024 January 1,2025,through December 31, 2025 ASH Plans Customer Service Department Monday through Friday, 5 a.m. to 6 p.m. 1-800-678-9133 (TTY users call 711)toll free ashlink.com/ash/kp TABLE OF CONTENTS FOR EOC #3 BenefitHighlights..................................................................................................................................................................I Introduction............................................................................................................................................................................2 Definitions..............................................................................................................................................................................2 ASHParticipating Providers..................................................................................................................................................3 Howto Obtain Services......................................................................................................................................................3 CoveredServices....................................................................................................................................................................3 OfficeVisits.......................................................................................................................................................................4 LaboratoryTests and X-rays..............................................................................................................................................4 ChiropracticSupports and Appliances...............................................................................................................................4 SecondOpinions.................................................................................................................................................................4 Emergency and Urgent Services Covered Under this Amendment...................................................................................5 Exclusions..............................................................................................................................................................................5 CustomerService...................................................................................................................................................................5 Grievances..............................................................................................................................................................................6 Benefit Highlights 0 - We cover the Services described below,subject to exclusions described in the"Exclusions"section,only if all of the following conditions are satisfied: • You are a Member on the date that you receive the Services • ASH Plans has determined that the Services are Medically Necessary,except as described in this Amendment • You receive the Services from ASH Participating Providers or other licensed providers that ASH contracts to provide covered care,except as described in this Amendment Professional Services(ASH Participating Provider office visits) You Pay Chiropractic office visits(up to a total of 30 visits per 12-month period).. $10 per visit Other You Pay X-rays and laboratory tests that are covered Chiropractic Services............ No charge Chiropractic supports and appliances.......................................................... Amounts in excess of the$50 Allowance This is a summary of the most frequently asked-about benefits. This chart does not explain benefits,Cost Share,out-of- pocket maximums,exclusions,or limitations,nor does it list all benefits and Cost Share amounts.For a complete explanation,refer to the"Covered Services"and"Exclusions"sections. Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:36 EOC#3 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 1 Introduction ASH Plans:American Specialty Health Plans of California,Inc.,a California corporation. This document amends your Kaiser Foundation Health Plan,Inc.(Health Plan)EOC to add coverage Chiropractic Services:Chiropractic services include for Chiropractic Services as described in this spinal and extremity manipulation and adjunctive Chiropractic Services Amendment("Amendment"). therapies such as ultrasound,therapeutic exercise,or All provisions of the EOC apply to coverage described in electrical muscle stimulation,when provided during the this document except for the following sections: same course of treatment and in conjunction with chiropractic manipulative services,and other services • "How to Obtain Services"(except that the provided or prescribed by a chiropractor(including "Completion of Services from Non—Plan Providers" laboratory tests,X-rays,and chiropractic supports and section,or for Kaiser Permanente Senior Advantage appliances)for the treatment of your Musculoskeletal Members,the"Termination of a Plan Provider's and Related Disorder. contract and completion of Services"section,does apply to coverage described in this document) Emergency Chiropractic Services: Covered • "Plan Facilities" Chiropractic Services provided for the treatment of a • "Emergency Services and Urgent Care" Musculoskeletal and Related Disorder which manifests itself by acute symptoms of sufficient severity(including • "Benefits" severe pain)such that you could expect the absence of immediate Chiropractic Services to result in serious Kaiser Foundation Health Plan,Inc. contracts with jeopardy to your health or body functions or organs. American Specialty Health Plans of California,Inc. ("ASH Plans")to make the network of ASH Musculoskeletal and Related Disorders: Conditions Participating Providers available to you. with signs and symptoms related to the nervous, muscular,and/or skeletal systems.Musculoskeletal and When you need chiropractic care,you have direct access Related Disorders are conditions typically categorized as to more than 3,400 licensed chiropractors in California. structural,degenerative,or inflammatory disorders;or You can obtain covered Services from any ASH biomechanical dysfunction of the joints of the body Participating Provider without a referral from a Plan and/or related components of the muscle or skeletal Physician.Your Cost Share is due when you receive systems(muscles,tendons,fascia,nerves, covered Services. ligaments/capsules,discs and synovial structures)and related manifestations or conditions. Definitions Non—Participating Provider: A provider other than an ASH Participating Provider. In addition to the terms defined in the"Definitions" Treatment Plan: The course of treatment for your section of your Health Plan EOC,the following terms, Musculoskeletal and Related Disorder,which may when capitalized and used in any part of this include laboratory tests,X-rays,chiropractic supports Amendment,have the following meanings: and appliances,and a specific number of visits for chiropractic manipulations(adjustments)and adjunctive ASH Participating Provider:A chiropractor who is therapies that are Medically Necessary Chiropractic licensed to provide chiropractic services in California Services for you. and who has a contract with ASH Plans to provide Medically Necessary Chiropractic Services to you.A list of ASH Participating Providers is available on the ASH Urgent Chiropractic Services: Chiropractic Services Plans website at ashlink.com/ash/kaisercamedicare for that meet all of the following requirements: Kaiser Permanente Senior Advantage Members,or • They are necessary to prevent serious deterioration of ashlink.com/ash/ky for all other Members,or from the your health resulting from an unforeseen illness, ASH Plans Customer Service Department toll free at injury,or complication of an existing condition, 1-800-678-9133(TTY users call 711).The list of ASH including pregnancy Participating Providers is subject to change at any time, • They cannot be delayed until you return to the Service without notice.If you have questions,please call the Area ASH Plans Customer Service Department. Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:36 EOC#3 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 2 ASH Participating Providers -M will be informed of the scope of the authorized Services. If ASH Plans does not authorize all of the Services,ASH PLEASE READ THE FOLLOWING Plans will send you a written decision and explanation, INFORMATION SO YOU WILL KNOW FROM including the rationale for the decision and the criteria WHOM OR WHAT GROUP OF PROVIDERS used to make the decision,within two business days after HEALTH CARE MAY BE OBTAINED. the decision is made.The letter will also include information about your appeal rights,which are described in the"Coverage Decisions,Appeals,and ASH Plans contracts with ASH Participating Providers Complaints"section of your Health Plan EOC for Kaiser and other licensed providers to provide the Services permanente Senior Advantage Members,and"Dispute covered under this Amendment(including laboratory Resolution"section of your Health Plan EOC for all tests,X-rays,and chiropractic supports and appliances). other Members.Any written criteria that ASH Plans uses You must receive Services covered under this to make the decision to authorize,modify,delay,or deny Amendment from an ASH Participating Provider or the request for authorization will be made available to another licensed provider with which ASH contracts to you upon request.If you have questions or concerns, provide covered care,except for Services covered under please contact ASH Plans or Kaiser Permanente as "Emergency and Urgent Services Covered Under this described under"Customer Service"in this Amendment. Amendment"in the"Covered Services"section and Services that are not available from contracted providers and that are authorized in advance by ASH Plans. Covered Services How to Obtain Services We cover the Services listed in this"Covered Services" To obtain Services covered under this Amendment call section,subject to exclusions described in the an ASH Participating Provider to schedule an initial "Exclusions"section,only if all of the following examination.If additional Services are required after the conditions are satisfied: initial examination,verification that the Services are • You are a Member on the date that you receive the Medically Necessary may be required,as described Services under"Decision time frames"below.Your ASH • ASH Plans has determined that the Services are Participating Provider will request any required medical Medically Necessary,except for: necessity determinations.An ASH Plans clinician in the same or similar specialty as the provider of Services ♦ the initial examination described under"Office under review will determine whether the Services are or Visits"in this"Covered Services"section were Medically Necessary Services. ♦ Services covered under"Emergency and Urgent Services Covered Under this Amendment"in this Decision time frames "Covered Services"section The ASH Plans' clinician will make the authorization • You receive the Services from ASH Participating decision within the time frame appropriate for your Providers or other licensed providers with which condition,but no later than five business days after ASH contracts to provide covered care,except for: receiving all of the information(including additional ♦ Services covered under"Emergency and Urgent examination and test results)reasonably necessary to Services Covered Under this Amendment"in this make the decision,except that decisions about urgent "Covered Services"section Services will be made no later than 72 hours after receipt of the information reasonably necessary to make the ♦ Services that are not available from ASH decision.If ASH Plans needs more time to make the Participating Providers or other licensed providers decision because it doesn't have information reasonably with which ASH contracts to provide covered care necessary to make the decision,or because it has and that are authorized in advance by ASH Plans requested consultation by a particular specialist,you and your ASH Participating Provider will be informed in When you receive covered Services,you must pay the writing about the additional information,testing,or Cost Share listed in this"Covered Services"section.If specialist that is needed,and the date that ASH Plans you receive Services that are not covered under this expects to make a decision. Amendment,you may be liable for the full price of those Services. Your ASH Participating Provider will be informed of the decision within 24 hours after the decision is made.If the Services are authorized,your ASH Participating Provider Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:36 EOC#3 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 3 Note:If Charges for Services are less than the Laboratory Tests and X-rays Copayment described in this"Covered Services"section, you will pay the lesser amount. We cover Medically Necessary laboratory tests and X- rays when prescribed as part of covered chiropractic care The Cost Share you pay for Services covered under this described under"Office Visits"in this"Covered Amendment does not apply toward any Plan Deductible Services"section at no charge when an ASH or Plan Out-of-Pocket Maximum described in your Participating Provider provides the Services or refers you Health Plan EOC. to another licensed provider with which ASH contracts to provide covered Services. If you have questions about your Cost Share for specific Services that you are scheduled to receive or that your provider orders during a visit or procedure,please call Chiropractic Supports and Appliances the ASH Plans Customer Service Department toll free at We provide a$50 Allowance per 12-month period 1-800-678-9133(TTY users call 711)weekdays from 5 toward the ASH Plans fee schedule price for chiropractic a.m.to 6 p.m. appliances listed in this paragraph when the item is prescribed and provided to you by an ASH Participating If you are a Kaiser Permanente Senior Advantage Provider as part of covered chiropractic care described Member,refer to your Health Plan EOC for information under"Office Visits"in this"Covered Services"section. about the chiropractic Services that we cover in accord If the price of the items in the ASH Plans fee schedule with Medicare guidelines,which are separate from the exceeds$50(the Allowance),you will pay the amount in Services covered under this Amendment. excess of$50(and that payment does not apply toward the Plan Out-of-Pocket Maximum described in your Office Visits Health Plan EOC).Covered chiropractic appliances are limited to: elbow supports,back supports(thoracic), We cover the following: cervical collars,cervical pillows,heel lifts,hot or cold packs,lumbar braces and supports,lumbar cushions, • Initial chiropractic examination:An examination orthotics,wrist supports,rib belts,home traction units performed by an ASH Participating Provider to (cervical or lumbar),ankle braces,knee braces,rib determine the nature of your problem(and,if supports,and wrist braces. appropriate,to prepare a Treatment Plan),and to provide Medically Necessary Chiropractic Services, which may include an adjustment and adjunctive Second Opinions therapy.We cover an initial examination only if you have not already received covered Chiropractic You may request a second opinion in regard to covered Services from an ASH Participating Provider in the Services by contacting another ASH Participating same 12-month period for your Musculoskeletal and Provider.Your visit to another ASH Participating Related Disorder Provider for a second opinion generally will count • Subsequent chiropractic office visits: Subsequent toward any visit limit,if applicable.An ASH ASH Participating Provider office visits for Participating Provider may also request a second opinion Chiropractic Services that are determined to be in regard to covered Services by referring you to another Medically Necessary by an ASH Plans clinician. ASH Participating Provider in the same or similar These subsequent office visits may include an specialty.When you are referred by an ASH adjustment adjunctive therapy, Participating Provider to another ASH Participating and a re-examination to assess the need to continue,extend,or change a Provider for a second opinion,your visit to the other Treatment Plan ASH Participating Provider will not count toward any visit limit,if applicable.An authorization or denial of Each office visit counts toward any visit limit,if your request for a second opinion will be provided in an applicable. expeditious manner,as appropriate for your condition.If your request for a second opinion is denied,you will be notified in writing of the reasons for the denial,and of You pay the following for these covered Services(up to your right to file a grievance as described under 30 visits per 12 month period): a$10 Copayment per "Grievances"in this Amendment. visit Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:36 EOC#3 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 4 Emergency and Urgent Services • Thermography Covered Under this Amendment • Experimental or investigational Services.If coverage for a Service is denied because it is experimental or We cover Emergency Chiropractic Services and Urgent investigational and you want to appeal the denial, Chiropractic Services provided by an ASH Participating refer to your Health Plan EOC for information about Provider or a Non—Participating Provider at a the appeal process $10 Copayment per visit.We do not cover follow-up or continuing care from a Non-Participating Provider unless • CT scans,MRIs,PET scans,bone scans,nuclear ASH Plans has authorized the Services in advance.Also, medicine,and any other type of diagnostic imaging or we do not cover Services from a Non-Participating radiology other than X-rays covered under the Provider that ASH Plans determines are not Emergency "Covered Services"section of this Amendment Chiropractic Services or Urgent Chiropractic Services. . Ambulance and other transportation • Education programs,non-medical self-care or self- How to file a claim help,any self-help physical exercise training,and any As soon as possible after receiving Emergency related diagnostic testing Chiropractic Services or Urgent Chiropractic Services, you must file an ASH Plans claim form.To request a • Services for pre-employment physicals or vocational claim form or for more information,please call ASH rehabilitation Plans toll free at 1-800-678-9133(TTY users call 711)or • Drugs and medicines,including non-legend or visit the ASH Plans website at ashlink.com.You must proprietary drugs and medicines send the completed claim form to: o Services you receive outside the state of California, ASH Plans except for Services covered under"Emergency and P.O.Box 509002 Urgent Services Covered Under this Amendment"in San Diego,CA 92150-9002 the"Covered Services"section • Hospital services,anesthesia,manipulation under anesthesia,and related services Exclusions • Dietary and nutritional supplements,such as vitamins, minerals,herbs,herbal products,injectable The items and services listed in this"Exclusions"section supplements,and similar products are excluded from coverage under this Amendment. • Massage therapy (Note: Some items and services listed in this "Exclusions"section may be covered Services under • Maintenance care(services provided to Members your Health Plan EOC.Please refer to your Health Plan whose treatment records indicate that they have EOC for details.)These exclusions apply to all Services reached maximum therapeutic benefit) that would otherwise be covered under this Amendment regardless of whether the services are within the scope of a provider's license or certificate: Customer Service ■ • Services provided by a chiropractor that are not within the scope of licensure for a chiropractor If you have a question or concern regarding the Services licensed in California you received from an ASH Participating Provider or any • Adjunctive therapy not associated with spinal, other licensed provider with which ASH contracts to muscle,or joint manipulations provide covered Services,you may call the ASH Plans Customer Service Department toll free at 1-800-678- • Air conditioners,air purifiers,therapeutic mattresses, 9133(TTY users call 711)weekdays from 5 a.m.to 6 chiropractic appliances,durable medical equipment, p.m.,or write ASH Plans at: supplies,devices,appliances,and any other item except those listed as covered under"Chiropractic ASH Plans Supports and Appliances"in the"Covered Services" Customer Service Department section of this Amendment P.O.Box 509002 • Services for asthma or addiction,such as nicotine San Diego,CA 92150-9002 addiction • Hypnotherapy,behavior training,sleep therapy,and weight programs Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:36 EOC#3 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 5 Grievances You can file a grievance with Kaiser Permanente regarding any issue.Your grievance must explain your issue,such as the reasons why you believe a decision was in error or why you are dissatisfied about Services you received.If you are a Kaiser Permanente Senior Advantage Member,you may submit your grievance orally or in writing to Kaiser Permanente as described in the"Coverage Decisions,Appeals,and Complaints" section of your Health Plan EOC. Otherwise,you may submit your grievance orally or in writing to Kaiser Permanente as described in the"Dispute Resolution" section of your Health Plan EOC. Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:36 EOC#3 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 6 KAISER PERMANEWE® Kaiser Foundation Health Plan, Inc. Northern California Region A nonprofit corporation and a Medicare Advantage Organization EOC #4 - Kaiser Permanente Senior Advantage (HMO) with Part D Evidence of Coverage for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: I Version: 36 EOC Number: 4 Issue Date: October 30, 2024 January 1,2025,through December 31, 2025 Member Services Seven days a week, 8 a.m.-8 p.m. 1-800-443-0815(TTY users call 711) kp.org This document is available for free in Spanish. Please contact our Member Services number at 1-800-443-0815 for additional information. (TTY users should call 711.) Hours are 8 a.m. to 8 p.m., 7 days a week. Este documento estd disponible de manera gratuita en espanol. Si desea informacion adicional, llame al ntimero de nuestro Servicio a los Miembros al 1-800-443-0815. (Los usuarios de TTYdeben llamar al 711). El horario de atencion es de 8 a. m. a 8 p. m., los 7 dias de la semana. This document explains your benefits and rights. Use this document to understand about: • Your cost sharing • Your medical and prescription drug benefits • How to file a complaint if you are not satisfied with a service or treatment • How to contact us if you need further assistance • Other protections required by Medicare law TABLE OF CONTENTS FOR EOC #4 BenefitHighlights..................................................................................................................................................................1 Introduction............................................................................................................................................................................3 AboutKaiser Permanente...................................................................................................................................................3 Termof this EOC...............................................................................................................................................................3 Definitions..............................................................................................................................................................................4 Premiums,Eligibility,and Enrollment.................................................................................................................................10 Premiums..........................................................................................................................................................................10 MedicarePremiums..........................................................................................................................................................10 WhoIs Eligible.................................................................................................................................................................11 Howto Enroll and When Coverage Begins.....................................................................................................................13 Howto Obtain Services........................................................................................................................................................15 RoutineCare.....................................................................................................................................................................16 UrgentCare......................................................................................................................................................................16 OurAdvice Nurses...........................................................................................................................................................16 YourPersonal Plan Physician..........................................................................................................................................16 Gettinga Referral.............................................................................................................................................................17 Travel and Lodging for Certain Services.........................................................................................................................18 SecondOpinions...............................................................................................................................................................18 Contractswith Plan Providers..........................................................................................................................................19 Receiving Care Outside of Your Home Region Service Area.........................................................................................19 YourID Card....................................................................................................................................................................19 GettingAssistance............................................................................................................................................................20 PlanFacilities.......................................................................................................................................................................20 ProviderDirectory............................................................................................................................................................20 PharmacyDirectory..........................................................................................................................................................20 Emergency Services and Urgent Care..................................................................................................................................21 EmergencyServices.........................................................................................................................................................21 UrgentCare......................................................................................................................................................................21 Paymentand Reimbursement...........................................................................................................................................22 Benefitsand Your Cost Share..............................................................................................................................................22 YourCost Share...............................................................................................................................................................23 OutpatientCare.................................................................................................................................................................25 HospitalInpatient Services...............................................................................................................................................27 AmbulanceServices.........................................................................................................................................................28 BariatricSurgery..............................................................................................................................................................28 DentalServices.................................................................................................................................................................29 DialysisCare....................................................................................................................................................................29 Durable Medical Equipment("DME")for Home Use.....................................................................................................30 FertilityServices...............................................................................................................................................................32 Fitnessbenefit(One PassTM)............................................................................................................................................33 HealthEducation..............................................................................................................................................................33 HearingServices...............................................................................................................................................................33 Home-Delivered Meals....................................................................................................................................................34 HomeHealth Care............................................................................................................................................................34 Home Medical Care Not Covered by Medicare for Members Who Live in Certain Counties(Advanced Care at Home).............................................................................................................................................................................3 5 HospiceCare....................................................................................................................................................................35 MentalHealth Services....................................................................................................................................................37 OpioidTreatment Program Services................................................................................................................................38 Ostomy,Urological,and Specialized Wound Care Supplies...........................................................................................38 Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services............................................................38 Outpatient Prescription Drugs,Supplies,and Supplements.............................................................................................39 Over-the-Counter(OTC)Health and Wellness................................................................................................................49 PreventiveServices..........................................................................................................................................................49 Prostheticand Orthotic Devices.......................................................................................................................................50 ReconstructiveSurgery....................................................................................................................................................51 Religious Nonmedical Health Care Institution Services..................................................................................................52 Services Associated with Clinical Trials..........................................................................................................................52 SkilledNursing Facility Care...........................................................................................................................................53 Substance Use Disorder Treatment..................................................................................................................................53 TelehealthVisits...............................................................................................................................................................54 TransplantServices..........................................................................................................................................................55 TransportationServices....................................................................................................................................................55 VisionServices.................................................................................................................................................................56 Exclusions,Limitations,Coordination of Benefits,and Reductions...................................................................................57 Exclusions........................................................................................................................................................................57 Limitations........................................................................................................................................................................59 Coordinationof Benefits..................................................................................................................................................59 Reductions........................................................................................................................................................................60 Requestsfor Payment...........................................................................................................................................................62 Requests for Payment of Covered Services or Part D drugs............................................................................................62 How to Ask Us to Pay You Back or to Pay a Bill You Have Received...........................................................................63 We Will Consider Your Request for Payment and Say Yes or No...................................................................................64 Other Situations in Which You Should Save Your Receipts and Send Copies to Us......................................................64 YourRights and Responsibilities.........................................................................................................................................65 We must honor your rights and cultural sensitivities as a Member of our plan...............................................................65 You have some responsibilities as a Member of our plan................................................................................................69 Coverage Decisions,Appeals,and Complaints....................................................................................................................69 What to Do if You Have a Problem or Concern..............................................................................................................69 Where To Get More Information and Personalized Assistance.......................................................................................70 To Deal with Your Problem,Which Process Should You Use?......................................................................................70 A Guide to the Basics of Coverage Decisions and Appeals.............................................................................................70 Your Medical Care:How to Ask for a Coverage Decision or Make an Appeal of a Coverage Decision.......................72 Your Part D Prescription Drugs:How to Ask for a Coverage Decision or Make an Appeal..........................................76 How to Ask Us to Cover a Longer Inpatient Hospital Stay if You Think You Are Being Discharged Too Soon..........81 How to Ask Us to Keep Covering Certain Medical Services if You Think Your Coverage Is Ending Too Soon..........84 Taking Your Appeal to Level 3 and Beyond...................................................................................................................85 How to Make a Complaint About Quality of Care,Waiting Times,Customer Service,or Other Concerns..................87 You can also tell Medicare about your complaint............................................................................................................88 AdditionalReview............................................................................................................................................................88 BindingArbitration..........................................................................................................................................................89 Terminationof Membership.................................................................................................................................................91 Termination Due to Loss of Eligibility............................................................................................................................91 Terminationof Agreement................................................................................................................................................91 Disenrolling from Senior Advantage...............................................................................................................................91 Termination of Contract with the Centers for Medicare&Medicaid Services...............................................................92 Terminationfor Cause......................................................................................................................................................92 Termination for Nonpayment of Premiums.....................................................................................................................93 Termination of a Product or all Products.........................................................................................................................93 Paymentsafter Termination.............................................................................................................................................93 Reviewof Membership Termination...............................................................................................................................93 Continuationof Membership................................................................................................................................................93 Continuation of Group Coverage.....................................................................................................................................93 Conversion from Group Membership to an Individual Plan............................................................................................94 MiscellaneousProvisions.....................................................................................................................................................94 Administrationof Agreement...........................................................................................................................................94 Amendmentof Agreement................................................................................................................................................94 Applicationsand Statements............................................................................................................................................94 Assignment.......................................................................................................................................................................94 Attorney and Advocate Fees and Expenses.....................................................................................................................94 ClaimsReview Authority.................................................................................................................................................94 EOCBinding on Members...............................................................................................................................................95 ERISANotices.................................................................................................................................................................95 GoverningLaw.................................................................................................................................................................95 Groupand Members Not Our Agents..............................................................................................................................95 NoWaiver........................................................................................................................................................................95 NoticesRegarding Your Coverage...................................................................................................................................95 Notice about Medicare Secondary Payer Subrogation Rights.........................................................................................95 OverpaymentRecovery....................................................................................................................................................95 PublicPolicy Participation...............................................................................................................................................96 TelephoneAccess(TTY).................................................................................................................................................96 Important Phone Numbers and Resources...........................................................................................................................96 Kaiser Permanente Senior Advantage..............................................................................................................................96 Medicare...........................................................................................................................................................................98 State Health Insurance Assistance Program.....................................................................................................................99 QualityImprovement Organization..................................................................................................................................99 SocialSecurity................................................................................................................................................................100 Medicaid.........................................................................................................................................................................100 RailroadRetirement Board.............................................................................................................................................101 Group Insurance or Other Health Insurance from an Employer....................................................................................101 Benefit Highlights Accumulation Period The Accumulation Period for this plan is l/l/25 through 12/31/25 (calendar year). Plan Out-of-Pocket Maximum For Services subject to the maximum,you will not pay any more Cost Share for the rest of the calendar year if the Copayments and Coinsurance you pay for those Services add up to the following amount: For any one Member.................................................................................$1,000 per calendar year Plan Deductible None Plan Provider Office Visits You Pay Most Primary Care Visits and most Non-Physician Specialist Visits.......... $25 per visit Most Physician Specialist Visits................................................................... $25 per visit Annual Wellness visit and the"Welcome to Medicare"preventive visit.... No charge Routine physical exams................................................................................ No charge Routine eye exams with a Plan Optometrist................................................. $25 per visit Urgent care consultations,evaluations,and treatment................................. $25 per visit Physical,occupational,and speech therapy.................................................. $25 per visit Telehealth Visits I You Pay Primary Care Visits and Non-Physician Specialist Visits by interactive video........................................................................................................... No charge Physician Specialist Visits by interactive video........................................... No charge Primary Care Visits and Non-Physician Specialist Visits by telephone...... No charge Physician Specialist Visits by telephone...................................................... No charge Outpatient Services You Pay Outpatient surgery and certain other outpatient procedures......................... $25 per procedure Allergy injections(including allergy serum)................................................ $3 per visit Most immunizations(including the vaccine)............................................... No charge Most X-rays and laboratory tests.................................................................. No charge Manual manipulation of the spine................................................................ $20 per visit Hospitalization Services You Pay Room and board,surgery,anesthesia,X-rays,laboratory tests,and drugs.. $250 per admission Emergency Health Coverage You Pay Emergency Department visits....................................................................... $75 per visit Note:If you are admitted directly to the hospital as an inpatient for covered Services,you will pay the inpatient Cost Share instead of the Emergency Department Cost Share(see"Hospitalization Services"for inpatient Cost Share). Ambulance and Transportation Services You Pay Ambulance Services..................................................................................... $100 per trip Other transportation Services when provided by our designated No charge for up to 24 one-way trips(50 miles per transportation provider as described in this EOC....................................... trip)per calendar year Prescription Drug Coverage You Pay This plan covers Medicare Part D prescription drugs in accord with our Part D formulary. Initial coverage stage—until you have spent$2,000 in 2025. (If you spend$2,000,you move on to the catastrophic coverage stage): Generic drugs at a Plan Pharmacy...................................................... $10 for up to a 30-day supply,$20 for a 31-to 60- day supply,or$30 for a 61-to 100-day supply Generic refills through our mail-order service................................... $10 for up to a 30-day supply or$20 for a 31-to 100-day supply Group ID:604334 Kaiser Pennanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOCW 4 Effective:1/1/25-12/31/25 Issue Date:October 30,2024 Page 1 Prescription Drug Coverage You Pay Brand-name drugs at a Plan Pharmacy.............................................. $25 for up to a 30-day supply,$50 for a 3 1-to 60- day supply,or$75 for a 61-to 100-day supply Brand-name refills through our mail-order service............................ $25 for up to a 30-day supply or$50 for a 3 1-to 100-day supply Catastrophic coverage stage................................................................... No charge Durable Medical Equipment(DME) You Pay Covered durable medical equipment for home use as described in this EOC............................................................................................................. 20 percent Coinsurance Mental Health Services You Pay Inpatient psychiatric hospitalization............................................................. $250 per admission Individual outpatient mental health evaluation and treatment...................... $25 per visit Group outpatient mental health treatment.................................................... $12 per visit Substance Use Disorder Treatment You Pay Inpatient detoxification................................................................................. $250 per admission Individual outpatient substance use disorder evaluation and treatment....... $25 per visit Group outpatient substance use disorder treatment...................................... $5 per visit Home Health Services You Pay Home health care(part-time,intermittent)................................................... No charge Other You Pay Eyeglasses or contact lenses every 24 months............................................. Amount in excess of$175 Allowance Hearing aid(s)every 36 months.................................................................... Amount in excess of$1,000 Allowance for each ear Skilled Nursing Facility care(up to 100 days per benefit period)................ No charge External prosthetic and orthotic devices as described in this EOC.............. 20 percent Coinsurance Ostomy,urological,and specialized wound care supplies........................... 20 percent Coinsurance Meals delivered to your home immediately following discharge from a No charge up to three meals per day in a Plan Hospital or Skilled Nursing Facility as an inpatient........................... consecutive four-week period,once per calendar year Over-the-Counter(OTC)Health and Wellness items obtained through our catalog......................................................................................................... No charge up to a quarterly benefit of$70 Fitness benefit—One PassTM(includes access to in-network gyms and one home fitness kit per calendar year)............................................................. No charge This is a summary of the most frequently asked-about benefits. This chart does not explain benefits,Cost Share,out-of- pocket maximums,exclusions,or limitations,nor does it list all benefits and Cost Share amounts.For a complete explanation,refer to the"Benefits and Your Cost Share"and"Exclusions,Limitations,Coordination of Benefits,and Reductions"sections. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOCW 4 Effective:1/1/25-12/31/25 Issue Date:October 30,2024 Page 2 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Introduction ERE" FROM WHOM OR WHAT GROUP OF PROVIDERS YOU MAY GET HEALTH CARE. Kaiser Foundation Health Plan,Inc. (Health Plan)has a contract with the Centers for Medicare&Medicaid Kaiser Permanente provides Services directly to our Services as a Medicare Advantage Organization. Members through an integrated medical care program. Health Plan,Plan Hospitals,and the Medical Group This contract provides Medicare Services(including work together to provide our Members with quality care. Medicare Part D prescription drug coverage)through Our medical care program gives you access to all of the "Kaiser Permanente Senior Advantage covered Services you may need,such as routine care (HMO)with Part D"(Senior Advantage),except for with your own personal Plan Physician,hospital hospice care for Members with Medicare Part A,which Services,laboratory and pharmacy Services,Emergency is covered under Original Medicare.Enrollment in this Services,Urgent Care,and other benefits described in Senior Advantage plan means that you are automatically this EOC.Plus,our health education programs offer you enrolled in Medicare Part D.Kaiser Permanente is an great ways to protect and improve your health. HMO plan with a Medicare contract.Enrollment in Kaiser Permanente depends on contract renewal. We provide covered Services to Members using Plan Providers located in our Service Area,which is described This Evidence of Coverage("EOC")describes our in the"Definitions"section.You must receive all Senior Advantage health care coverage provided under covered care from Plan Providers inside our Service the Group Agreement(Agreement)between Health Plan Area,except as described in the sections listed below for (Kaiser Foundation Health Plan,Inc.("Health Plan")and the following Services: your Group(the entity with which Health Plan has • Authorized referrals as described under"Getting a entered into the Agreement). Referral"in the"How to Obtain Services"section • Covered Services received outside of your Home This EOC is part of the Agreement between Health Plan Region Service Area as described under"Receiving and your Group.The Agreement contains additional Care Outside of Your Home Region Service Area"in terms such as Premiums,when coverage can change,the the"How to Obtain Services"section effective date of coverage,and the effective date of • Emergency ambulance Services as described under termination.The Agreement must be consulted to determine the exact terms of coverage.A copy of the "Ambulance Services"in the"Benefits and Your Cost Agreement is available from your Group. Share"section • Emergency Services,Post-Stabilization Care,and For benefits provided under any other program,refer to Out-of-Area Urgent Care as described in the that other plan's evidence of coverage.For benefits "Emergency Services and Urgent Care"section provided under any other program offered by your Group o Out-of-area dialysis care as described under"Dialysis (for example,workers compensation benefits),refer to Care"in the"Benefits and Your Cost Share"section your Group's materials. e Prescription drugs from Non—Plan Pharmacies as In this EOC,Health Plan is sometimes referred to as described under"Outpatient Prescription Drugs, "we"or"us."Members are sometimes referred to as Supplies,and Supplements"in the"Benefits and "you."Some capitalized terms have special meaning in Your Cost Share"section this EOC;please see the"Definitions"section for terms • Routine Services associated with Medicare-approved you should know. clinical trials as described under"Services Associated with Clinical Trials"in the"Benefits and Your Cost It is important to familiarize yourself with your coverage Share"section by reading this EOC completely,so that you can take full advantage of your Health Plan benefits.Also,if you have special health care needs,please carefully read the Term of this EOC sections that apply to you. This EOC is for the period January 1,2025,through December 31,2025,unless amended.Benefits, About Kaiser Permanente Copayments,and Coinsurance may change on January 1 of each year and at other times in accord with your PLEASE READ THE FOLLOWING Group's Agreement with us.Your Group can tell you INFORMATION SO THAT YOU WILL KNOW Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 3 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. whether this EOC is still in effect and give you a current dispensing drugs,the direct and indirect costs of one if this EOC has been amended. providing Kaiser Permanente pharmacy Services to Members,and the pharmacy program's contribution to the net revenue requirements of Health Plan) Definitions • For all other Services,the payments that Kaiser Some terms have special meaning in this EOC.When we Permanente makes for the Services or,if Kaiser use a term with special meaning in only one section of Permanente subtracts your Cost Share from its this EOC,we define it in that section.The terms in this payment,the amount Kaiser Permanente would have "Definitions"section have special meaning when paid if it did not subtract your Cost Share capitalized and used in any section of this EOC. Coinsurance:A percentage of Charges that you must Accumulation Period:A period of time no greater than pay when you receive a covered Service under this EOC. 12 consecutive months for purposes of accumulating Complaint:The formal name for"making a complaint" amounts toward any deductibles(if applicable)and out- is"filing a grievance."The complaint process is used of-pocket maximums. The Accumulation Period for this only for certain types of problems.This includes EOC is from 1/l/25 through 12/31/25. problems related to quality of care,waiting times,and Allowance:A specified credit amount that you can use the customer service you receive.It also includes toward the cost of an item.If the cost of the item(s)or complaints if your plan does not follow the time periods Service(s)you select exceeds the Allowance,you will in the appeal process. pay the amount in excess of the Allowance,which does Comprehensive Formulary(Formulary or Drug not apply to the maximum out-of-pocket amount. List):A list of Medicare Part D prescription drugs Catastrophic Coverage Stage: The stage in the Part D covered by our plan. The drugs on this list are selected drug benefit that begins when you(or other qualified by us with the help of doctors and pharmacists.The list parties on your behalf)have spent$2,000 for Part D includes both brand-name and generic drugs. covered drugs during the covered year.During this Comprehensive Outpatient Rehabilitation Facility payment stage,you pay nothing for your covered Part D (CORF):A facility that mainly provides rehabilitation drugs. Services after an illness or injury,including physician's Centers for Medicare&Medicaid Services(CMS): Services,physical therapy,social or psychological The federal agency that administers the Medicare Services,and outpatient rehabilitation. program. Copayment:A specific dollar amount that you must pay Ancillary Coverage: Optional benefits such as when you receive a covered Service under this EOC. acupuncture,chiropractic,or dental coverage that may be Note:The dollar amount of the Copayment can be$0(no available to Members enrolled under this EOC. If your charge). plan includes Ancillary Coverage,this coverage will be Cost Share: The amount you are required to pay for described in an amendment to this EOC or a separate covered Services.For example,your Cost Share may be agreement from the issuer of the coverage. a Copayment or Coinsurance.Cost Share also means any Charges: "Charges"means the following: Charges you are required to pay for covered Medicare Part D drugs.If your coverage includes a Plan • For Services provided by the Medical Group or Deductible and you receive Services that are subject to Kaiser Foundation Hospitals,the charges in Health the Plan Deductible,your Cost Share for those Services Plan's schedule of Medical Group and Kaiser will be Charges until you reach the Plan Deductible. Foundation Hospitals charges for Services provided to Members Coverage Determination:An initial determination we make about whether a Part D drug prescribed for you is • For Services for which a provider(other than the covered under Part D and the amount,if any,you are Medical Group or Kaiser Foundation Hospitals)is required to pay for the prescription.In general,if you compensated on a capitation basis,the charges in the bring your prescription for a Part D drug to a Plan schedule of charges that Kaiser Permanente Pharmacy and the pharmacy tells you the prescription negotiates with the capitated provider isn't covered by us,that isn't a Coverage Determination. • For items obtained at a pharmacy owned and operated You need to call or write us to ask for a formal decision by Kaiser Permanente,the amount the pharmacy about the coverage.Coverage Determinations are called would charge a Member for the item if a Member's "coverage decisions"in this EOC. benefit plan did not cover the item(this amount is an Dependent:A Member who meets the eligibility estimate of:the cost of acquiring,storing,and requirements as a Dependent(for Dependent eligibility Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 4 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. requirements,see"Who Is Eligible"in the"Premiums, (HMO)with Part D"under Health Plan's Agreement Eligibility,and Enrollment"section). with your Group. Durable Medical Equipment(DME): Certain medical "Extra Help":A Medicare program to help people with equipment that is ordered by your doctor for medical limited income and resources pay Medicare prescription reasons.Examples include walkers,wheelchairs, drug program costs,such as premiums,deductibles,and crutches,powered mattress systems,diabetic supplies,IV coinsurance. infusion pumps,speech-generating devices,oxygen Family:A Subscriber and all of their Dependents. equipment,nebulizers,or hospital beds ordered by a provider for use in the home. Grievance:A type of complaint you make about our Emergency Medical Condition:A medical or mental plan,providers,or pharmacies,including a complaint health condition manifesting itself by acute symptoms of concerning the quality of your care. This does not sufficient severity(including severe pain)such that a involve coverage or payment disputes. prudent layperson,with an average knowledge of health Group: The entity with which Health Plan has entered and medicine,could reasonably expect the absence of into the Agreement that includes this EOC. immediate medical attention to result in any of the Health Plan:Kaiser Foundation Health Plan,Inc.,a following: California nonprofit corporation.This EOC sometimes • Serious jeopardy to the health of the individual or,in refers to Health Plan as"we"or"us." the case of a pregnant woman,the health of the woman or her unborn child Home Region:The Region where you enrolled(either the Northern California Region or the Southern • Serious impairment to bodily functions California Region). • Serious dysfunction of any bodily organ or part Income Related Monthly Adjustment Amount A mental health condition is an emergency medical (IRMAA):If your modified adjusted gross income as condition when it meets the requirements of the reported on your IRS tax return from two years ago is paragraph above,or when the condition manifests itself above a certain amount,you'll pay the standard premium by acute symptoms of sufficient severity such that either amount and an Income Related Monthly Adjustment of the following is true: Amount,also known as IRMAA.IRMAA is an extra • The person is an immediate danger to themselves or charge added to your premium.Less than 5%of people to others with Medicare are affected, so most people will not pay a higher premium. • The person is immediately unable to provide for,or use,food,shelter,or clothing,due to the mental Initial Coverage Stage:This is the stage before your disorder out-of-pocket costs for 2025 have reached$2,000. Emergency Services: Covered Services that are(1) Initial Enrollment Period:When you are first eligible rendered by a provider qualified to furnish Emergency for Medicare,the period of time when you can sign up Services;and(2)needed to treat,evaluate,or Stabilize an for Medicare Part B.If you're eligible for Medicare Emergency Medical Condition such as: when you turn 65,your Initial Enrollment Period is the 7-month period that begins 3 months before the month • A medical screening exam that is within the you turn 65,includes the month you turn 65,and ends 3 capability of the Emergency Department of a hospital, months after the month you turn 65. including ancillary services(such as imaging and laboratory Services)routinely available to the Kaiser Permanente:Kaiser Foundation Hospitals(a Emergency Department to evaluate the Emergency California nonprofit corporation),Health Plan,and the Medical Condition Medical Group. • Within the capabilities of the staff and facilities Manufacturer Discount Program—A program under available at the hospital,Medically Necessary which drug manufacturers pay a portion of the plan's full examination and treatment required to Stabilize the cost for covered Part D brand-name drugs and biologics. patient(once your condition is Stabilized, Services Discounts are based on agreements between the federal you receive are Post Stabilization Care and not government and drug manufacturers. Emergency Services) Medical Group: The Permanente Medical Group,Inc.,a EOC: This Evidence of Coverage document,including for-profit professional corporation. any amendments,which describes the health care Medically Necessary: A Service is Medically Necessary coverage of"Kaiser Pennanente Senior Advantage if it is medically appropriate and required to prevent, Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 5 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. diagnose,or treat your condition or clinical symptoms in (such as nurse practitioners,physician assistants, accord with generally accepted professional standards of optometrists,podiatrists,and audiologists). practice that are consistent with a standard of care in the Non—Plan Hospital:A hospital other than a Plan medical community. Hospital. Medicare:The federal health insurance program for Non—Plan Pharmacy:A pharmacy other than a Plan people 65 years of age or older,some people under age Pharmacy.These pharmacies are also called"out-of- 65 with certain disabilities,and people with End-Stage network pharmacies." Renal Disease(generally those with permanent kidney failure who need dialysis or a kidney transplant). Non—Plan Physician: A physician other than a Plan Medicare Advantage Organization:A public or private Physician. entity organized and licensed by a state as a risk-bearing Non—Plan Provider:A provider other than a Plan entity that has a contract with the Centers for Medicare Provider. &Medicaid Services to provide Services covered by Medicare,except for hospice care covered by Original Non Psychiatrist:A psychiatrist who is not a Plan Medicare.Kaiser Foundation Health Plan,Inc.,is a Physician. cian. Medicare Advantage Organization. Non—Plan Skilled Nursing Facility:A Skilled Nursing Medicare Advantage Plan: Sometimes called Medicare Facility other than a Plan Skilled Nursing Facility. Part C.A plan offered by a private company that Organization Determination:A decision our plan contracts with Medicare to provide you with all your makes about whether items or services are covered or Medicare Part A and Part B benefits.A Medicare how much you have to pay for covered items or Services. Advantage Plan can be(i)an HMO,(ii)a PPO,(iii)a Organization determinations are called coverage Private Fee-for-Service(PFFS)plan,or(iv)a Medicare decisions in this EOC. Medical Savings Account(MSA)plan.Besides choosing from these types of plans,a Medicare Advantage HMO Original Medicare("Traditional Medicare"or"Fee- or PPO plan can also be a Special Needs Plan(SNP).In for-Service Medicare"): Original Medicare is offered most cases,Medicare Advantage Plans also offer by the government,and not a private health plan like Medicare Part D(prescription drug coverage). These Medicare Advantage Plans and prescription drug plans. Under Original Medicare,Medicare services are covered plans are called Medicare Advantage Plans with P by paying doctors,hospitals,and other health care Prescription Drug Coverage.A person enrolled in a Medicare Part D plan has Medicare Part D by virtue of providers payment amounts established by Congress. his or her enrollment in the Part D plan. This EOC is for You can see any doctor,hospital,or other health care a Medicare Part D plan. provider that accepts Medicare.You must pay the deductible.Medicare pays its share of the Medicare- Medicare Health Plan:A Medicare Health Plan is approved amount,and you pay your share. Original offered by a private company that contracts with Medicare has two parts:Part A(Hospital Insurance)and Medicare to provide Part A and Part B benefits to people Part B(Medical Insurance)and is available everywhere with Medicare who enroll in the plan.This term includes in the United States. all Medicare Advantage plans,Medicare Cost plans, Out-of-Area Urgent Care:Medically Necessary Demonstration/Pilot Programs,and Programs of All- Services to prevent serious deterioration of your health inclusive Care for the Elderly(PACE). resulting from an unforeseen illness or an unforeseen Medigap(Medicare Supplement Insurance)Policy: injury if all of the following are true: Medicare supplement insurance sold by private insurance . You are temporarily outside our Service Area companies to fill gaps in the Original Medicare plan coverage.Medigap policies only work with the Original • A reasonable person would have believed that your Medicare plan. (A Medicare Advantage Plan is not a health would seriously deteriorate if you delayed Medigap policy.) treatment until you returned to our Service Area Member:A person who is eligible and enrolled under Physician Specialist Visits: Consultations,evaluations, this EOC,and for whom we have received applicable and treatment by physician specialists,including Premiums. This EOC sometimes refers to a Member as personal Plan Physicians who are not Primary Care "YOU." Physicians. Non-Physician Specialist Visits: Consultations, Plan Deductible: The amount you must pay under this evaluations,and treatment by non-physician specialists EOC in the calendar year for certain Services before we will cover those Services at the applicable Copayment or Coinsurance in that calendar year.Refer to the"Benefits Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 6 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. and Your Cost Share"section to learn whether your physician who contracts to provide Services to Members coverage includes a Plan Deductible,the Services that (but not including physicians who contract only to are subject to the Plan Deductible,and the Plan provide referral Services). Deductible amount. Plan Provider:A Plan Hospital,a Plan Physician,the Plan Facility:Any facility listed in the Provider Medical Group,a Plan Pharmacy,or any other health Directory on our website at ko.org/facilities.Plan care provider that Health Plan designates as a Plan Facilities include Plan Hospitals,Plan Medical Offices, Provider. and other facilities that we designate in the directory. Plan Skilled Nursing Facility:A Skilled Nursing The directory is updated periodically.The availability of Facility approved by Health Plan. Plan Facilities may change.If you have questions,please call Member Services. Post-Stabilization Care:Medically Necessary Services Plan Hospital:Any hospital listed in the Provider related to your Emergency Medical Condition that you Directory on our website at ko.org/facilities.In the receive in a hospital(including the Emergency directory,some Plan Hospitals are listed as Kaiser Department)after your treating physician determines that Permanente Medical Centers.The directory is updated this condition is clinically stable.You are considered periodically. The availability of Plan Hospitals may clinically stable when your treating physician believes, change.If you have questions,please call Member within a reasonable medical probability and in Services. accordance with recognized medical standards that you are safe for discharge or transfer and that your condition Plan Medical Office:Any medical office listed in the is not expected to get materially worse during or as a Provider Directory on our website at ko.org/facilities. In result of the discharge or transfer. the directory,Kaiser Permanente Medical Centers may Premiums:The periodic amounts for your membership include Plan Medical Offices. The directory is updated under this EOC. periodically. The availability of Plan Medical Offices may change. If you have questions,please call Member Preventive Services: Covered Services that prevent or Services. detect illness and do one or more of the following: Plan Optical Sales Office:An optical sales office • Protect against disease and disability or further owned and operated by Kaiser Permanente or another progression of a disease optical sales office that we designate.Refer to the . Detect disease in its earliest stages before noticeable Provider Directory on our website at ko.org/facilities for symptoms develop locations of Plan Optical Sales Offices.In the directory, Plan Optical Sales Offices may be called"Vision Primary Care Physicians: Generalists in internal Essentials."The directory is updated periodically. The medicine,pediatrics,and family practice,and specialists availability of Plan Optical Sales Offices may change.If in obstetrics/gynecology whom the Medical Group you have questions,please call Member Services. designates as Primary Care Physicians.Refer to the Provider Directory on our website at ko.org for a list of Plan Optometrist:An optometrist who is a Plan physicians that are available as Primary Care Physicians. Provider. The directory is updated periodically.The availability of Plan Out-of-Pocket Maximum: The total amount of Primary Care Physicians may change.If you have Cost Share you must pay under this EOC in the calendar questions,please call Member Services. year for certain covered Services that you receive in the Primary Care Visits:Evaluations and treatment same calendar year.Refer to the`Benefits and Your Cost provided by Primary Care Physicians and primary care Share"section to find your Plan Out-of-Pocket Plan Providers who are not physicians(such as nurse Maximum amount and to learn which Services apply to practitioners). the Plan Out-of-Pocket Maximum. Provider Directory:A directory of Plan Physicians and Plan Pharmacy:A pharmacy owned and operated by Plan Facilities in your Home Region.This directory is Kaiser Permanente or another pharmacy that we available on our website at ko.org/directory. To obtain designate.Refer to the Provider Directory on our website a printed copy,call Member Services.The directory is at ko.org/facilities for locations of Plan Pharmacies.The updated periodically.The availability of Plan Physicians directory is updated periodically. The availability of Plan and Plan Facilities may change.If you have questions, Pharmacies may change.If you have questions,please please call Member Services. call Member Services. Real-Time Benefit Tool:A portal or computer Plan Physician:Any licensed physician who is an application in which enrollees can look up complete, employee of the Medical Group,or any licensed accurate,timely,clinically appropriate,enrollee-specific Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 7 Member Service:toll free 1-800-443-081 S(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. formulary and benefit information.This includes cost- • The following ZIP codes in Amador County are sharing amounts,alternative formulary medications that inside our Northern California Service Area: 95640, may be used for the same health condition as a given 95669 drug,and coverage restrictions(prior authorization,step • All ZIP codes in Contra Costa County are inside our therapy,quantity limits)that apply to alternative Northern California Service Area: 94505-07,94509, medications. 94511,94513-14,94516-31,94547-49,94551, Region:A Kaiser Foundation Health Plan organization 94553,94556,94561,94563-65,94569-70,94572, or allied plan that conducts a direct-service health care 94575,94582-83,94595-98,94706-08,94801-08, program.Regions may change on January 1 of each year 94820,94850 and are currently the District of Columbia and parts of . The following ZIP codes in El Dorado County are Northern California, Southern California,Colorado, inside our Northern California Service Area: 95613- Georgia,Hawaii,Maryland,Oregon,Virginia,and 14,95619,95623,95633-35,95651,95664,95667, Washington.For the current list of Region locations, 95672,95682,95762 please visit our website at ky.org or call Member Services. • The following ZIP codes in Fresno County are inside our Northern California Service Area: 93242,93602, Serious Emotional Disturbance of a Child Under Age 93606-07,93609,93611-13,93616,93618-19, 18:A condition identified as a"mental disorder"in the 93624-27,93630-31,93646,93648-52,93654, most recent edition of the Diagnostic and Statistical 93656-57,93660,93662,93667-68,93675,93701- Manual of Mental Disorders,other than a primary 12,93714-18,93720-30,93737,93740-41,93744- substance use disorder or developmental disorder,that 45,93747,93750,93755,93760-61,93764-65, results in behavior inappropriate to the child's age 93771-79,93786,93790-94,93844,93888 according to expected developmental norms,if the child also meets at least one of the following three criteria: • The following ZIP codes in Kings County are inside our Northern California Service Area: 93230,93232, • As a result of the mental disorder,(1)the child has 93242,93631,93656 substantial impairment in at least two of the following areas: self-care,school functioning,family • The following ZIP codes in Madera County are inside relationships,or ability to function in the community; our Northern California Service Area: 93601-02, and(2)either(a)the child is at risk of removal from 93654,93614,93623,93626,93636-39,93643-45, the home or has already been removed from the 93653,93669,93720 home,or(b)the mental disorder and impairments • All ZIP codes in Marin County are inside our have been present for more than six months or are Northern California Service Area: 94901,94903-04, likely to continue for more than one year without 94912-15,94920,94924-25,94929-30,94933, treatment 94937-42,94945-50,94952,94956-57,94960, • The child displays psychotic features,or risk of 94963-66,94970-71,94973-74,94976-79 suicide or violence due to a mental disorder • The following ZIP codes in Mariposa County are • The child meets special education eligibility inside our Northern California Service Area: 93 60 1, requirements under Section 5600.3(a)(2)(C)of the 93623,93653 Welfare and Institutions Code • All ZIP codes in Napa County are inside our Northern Service Area: The geographic area approved by the California Service Area: 94503,94508,94515, Centers for Medicare&Medicaid Services within which 94558-59,94562,94567,94573-74,94576,94581, an eligible person may enroll in Senior Advantage.Note: 94599,95476 Subject to approval by the Centers for Medicare& • The following ZIP codes in Placer County are inside Medicaid Services,we may reduce or expand our Service our Northern California Service Area: 95602-04, Area effective any January 1.ZIP codes are subject to 95610,95626,95648,95650,95658,95661,95663, change by the U.S.Postal Service.The ZIP codes below 95668,95677-78,95681,95703,95722,95736, for each county are in our Service Area: 95746-47,95765 • All ZIP codes in Alameda County are inside our • All ZIP codes in Sacramento County are inside our Northern California Service Area: 94501-02,94505, Northern California Service Area: 94203-09,94211, 94514,94536-46,94550-52,94555,94557,94560, 94229-30,94232,94234-37,94239-40,94244-45, 94566,94568,94577-80,94586-88,94601-15, 94247-50,94252,94254,94256-59,94261-63, 94617-21,94622-24,94649,94659-62,94666, 94267-69,94271,94273-74,94277-80,94282-85, 94701-10,94712,94720,95377,95391 94287-91,94293-98,94571,95608-11,95615, 95621,95624,95626,95628,95630,95632,95638- Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 8 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. 39,95641,95652,95655,95660,95662,95670-71, • The following ZIP codes in Tulare County are inside 95673,95678,95680,95683,95690,95693,95741- our Northern California Service Area: 93238,93261, 42,95757-59,95763,95811-38,95840-43,95851- 93618,93631,93646,93654,93666,93673 53,95860,95864-67,95894,95899 • The following ZIP codes in Yolo County are inside • All ZIP codes in San Francisco County are inside our our Northern California Service Area: 95605,95607, Northern California Service Area: 94102-05,94107- 95612,95615-18,95620,95645,95691,95694-95, 12,94114-34,94137,94139-47,94151,94158-61, 95697-98,95776, 95798-99 94163-64,94172,94177,94188 • The following ZIP codes in Yuba County are inside • All ZIP codes in San Joaquin County are inside our our Northern California Service Area: 95692,95903, Northern California Service Area: 94514,95201-15, 95961 95219-20,95227, 95230-31,95234,95236-37, 95240�2,95253,95258,95267,95269,95296-97, For each ZIP code listed for a county,our Service Area 95304,95320,95330,95336-37,95361,95366, includes only the part of that ZIP code that is in that 95376-78,95385,95391,95632,95686,95690 county.When a ZIP code spans more than one county, the part of that ZIP code that is in another county is not • All ZIP codes in San Mateo County are inside our inside our Service Area unless that other county is listed Northern California Service Area: 94002,94005, above and that ZIP code is also listed for that other 94010-11,94014-21,94025-28,94030,94037-38, county.If you have a question about whether a ZIP code 94044,94060-66,94070,94074,94080,94083, is in our Service Area,please call Member Services. 94128,94303,94401-04,94497 Also,the ZIP codes listed above may include ZIP codes • The following ZIP codes in Santa Clara County are for Post Office boxes and commercial rental mailboxes. inside our Northern California Service Area: 94022- A Post Office box or rental mailbox cannot be used to 24,94035,94039-43,94085-89,94301-06,94309, determine whether you meet the residence eligibility 94550,95002,95008-09,95011,95013-15,95020- requirements for Senior Advantage.Your permanent 21,95026,95030-33,95035-38,95042,95044, residence address must be used to determine your Senior 95046,95050-56,95070-71,95076,95101,95103, Advantage eligibility. 95106,95108-13,95115-36,95138-41,95148, Services:Health care services or items("health care" 95150-61,95164, 95170,95172-73,95190-94, includes both physical health care and mental health 95196 care)and services to treat Serious Emotional Disturbance • All ZIP codes in Santa Cruz County are inside our of a Child Under Age 18 or Severe Mental Illness. Northern California Service Area: 95001,95003, Severe Mental Illness: The following mental disorders: 95005-07,95010, 95017-19,95033,95041,95060- schizophrenia,schizoaffective disorder,bipolar disorder 67,95073,95076-77 (manic-depressive illness),major depressive disorders, • All ZIP codes in Solano County are inside our panic disorder,obsessive-compulsive disorder,pervasive Northern California Service Area: 94503,94510, developmental disorder or autism,anorexia nervosa,or 94512,94533-35,94571,94585,94589-92,95616, bulimia nervosa. 95618,95620,95625,95687-88,95690,95694, Skilled Nursing Facility:A facility that provides 95696 inpatient skilled nursing care,rehabilitation services,or • The following ZIP codes in Sonoma County are other related health services and is licensed by the state inside our Northern California Service Area: 94515, of California.The facility's primary business must be the 94922-23,94926-28,94931,94951-55,94972, provision of 24-hour-a-day licensed skilled nursing care. 94975,94999,95401-07,95409,95416,95419, The term"Skilled Nursing Facility"does not include 95421,95425,95430-31,95433,95436,95439, convalescent nursing homes,rest facilities,or facilities 95441-42,95444, 95446,95448,95450,95452, for the aged,if those facilities furnish primarily custodial 95462,95465,95471-73,95476,95486-87,95492 care,including training in routines of daily living.A • All ZIP codes in Stanislaus County are inside our "Skilled Nursing Facility"may also be a unit or section Northern California Service Area: 95230,95304, within another facility(for example,a hospital)as long 95307,95313,95316,95319,95322-23,95326, as it continues to meet this definition. 95328-29,95350-58,95360-61,95363,95367-68, Spouse: The person to whom the Subscriber is legally 95380-82, 95385-87,95397 married under applicable law.For the purposes of this • The following ZIP codes in Sutter County are inside EOC,the term"Spouse"includes the Subscriber's our Northern California Service Area: 95626,95645, domestic partner."Domestic partners"are two people 95659,95668,95674,95676,95692,95836-37 who are registered and legally recognized as domestic partners by California(if your Group allows enrollment Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 9 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. of domestic partners not legally recognized as domestic be expected to pay to your Group,please check with partners by California,"Spouse"also includes the your Group's benefits administrator. Subscriber's domestic partner who meets your Group's eligibility requirements for domestic partners). Medicare Premiums Stabilize: To provide the medical treatment of the Emergency Medical Condition that is necessary to Medicare Part D premium due to income assure,within reasonable medical probability,that no Some members may be required to pay an extra charge, material deterioration of the condition is likely to result known as the Part D Income Related Monthly from or occur during the transfer of the person from the Adjustment Amount,also known as IRMAA.The extra facility.With respect to a pregnant person who is having charge is figured out using your modified adjusted gross contractions,when there is inadequate time to safely income as reported on your IRS tax return from two transfer them to another hospital before delivery(or the years ago.If this amount is above a certain amount, transfer may pose a threat to the health or safety of the you'll pay the standard premium amount and the pregnant person or unborn child),"Stabilize"means to additional IRMAA.For more information on the extra deliver(including the placenta). amount you may have to pay based on your income,visit Subscriber:A Member who is eligible for membership hti)s://www.medicare.2ov. on their own behalf and not by virtue of Dependent If you have to pay an extra amount, Social Security,not status and who meets the eligibility requirements as a your Medicare plan,will send you a letter telling you Subscriber(for Subscriber eligibility requirements,see what that extra amount will be. The extra amount will be "Who Is Eligible"in the"Premiums,Eligibility,and withheld from your Social Security,Railroad Retirement Enrollment"section). Board,or Office of Personnel Management benefit Surrogacy Arrangement:An arrangement in which an check,no matter how you usually pay your plan individual agrees to become pregnant and to surrender premium,unless your monthly benefit isn't enough to the baby(or babies)to another person or persons who cover the extra amount owed.If your benefit check isn't intend to raise the child(or children).The person may be enough to cover the extra amount,you will get a bill impregnated in any manner including,but not limited to, from Medicare.You must pay the extra amount to the artificial insemination,intrauterine insemination,in vitro government.If you do not pay the extra amount,you fertilization,or through the surgical implantation of a will be disenrolled from the plan and lose fertilized egg of another person.For the purposes of this prescription drug coverage. EOC,"Surrogacy Arrangements"includes all types of surrogacy arrangements,including traditional surrogacy If you disagree about paying an extra amount,you can arrangements and gestational surrogacy arrangements. ask Social Security to review the decision.To find out more about how to do this,contact Social Security at Telehealth Visits:Interactive video visits and scheduled 1-800-772-1213(TTY users call 1-800-325-0778). telephone visits between you and your provider. Urgent Care:Medically Necessary Services for a Medicare Part D late enrollment penalty condition that requires prompt medical attention but is Some members are required to pay a Part D late not an Emergency Medical Condition. enrollment penalty. The Part D late enrollment penalty is an additional premium that must be paid for Part D coverage if at any time after your initial enrollment Premiums, Eligibility, and period is over,there is a period of 63 days or more in a row when you did not have Part D or other creditable Enrollment prescription drug coverage."Creditable prescription drug coverage"is coverage that meets Medicare's minimum standards since it is expected to pay,on average,at least Premiums as much as Medicare's standard prescription drug coverage.The cost of the late enrollment penalty Please contact your Group for information about your depends on how long you went without Part D or other plan Premiums.You must also continue to pay Medicare creditable prescription drug coverage.You will have to your monthly Medicare premium. pay this penalty for as long as you have Part D coverage. The Part D late enrollment penalty is added to your plan If you do not have Medicare Part A,you may be eligible premium.Your Group or Health Plan will inform you if to purchase Medicare Part A from Social Security.Please the penalty applies to you. contact Social Security for more information.If you get Medicare Part A,this may reduce the amount you would Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 10 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. You will not have to pay it if: Copayments.This"Extra Help"also counts toward your out-of-pocket costs. • You receive"Extra Help"from Medicare to pay for your prescription drugs People with limited income and resources may qualify • You have gone less than 63 days in a row without for"Extra Help."If you automatically qualify for"Extra creditable coverage Help,"Medicare will mail you a letter.You will not have to apply.If you do not automatically qualify,you may be • You have had creditable drug coverage through able to get"Extra Help"to pay for your prescription drug another source such as a former employer,union, premiums and costs.To see if you qualify for getting TRICARE,or Veterans Health Administration(VA). "Extra Help,"call: Your insurer or your human resources department will tell you each year if your drug coverage is • 1-800-MEDICARE(1-800-633-4227)(TTY users creditable coverage. This information may be sent to call 1-877-486-2048),24 hours a day,seven days a you in a letter or included in a newsletter from the week; plan.Keep this information because you may need it • The Social Security Office at 1-800-772-1213(TTY if you join a Medicare drug plan later users call 1-800-325-0778),8 a.m.to 7 p.m.,Monday ♦ any notice must state that you had"creditable" through Friday;or prescription drug coverage that is expected to pay . Your state Medicaid office(see the"Important Phone as much as Medicare's standard prescription drug Numbers and Resources"section for contact plan pays information) ♦ the following are not creditable prescription drug coverage:prescription drug discount cards,free If you qualify for"Extra Help,"we will send you an clinics,and drug discount websites Evidence of Coverage Rider for People Who Get Extra Medicare determines the amount of the penalty.There Help Paying for Prescription Drugs(also known as the are three important things to note about this monthly Part Low Income Subsidy Rider or the LIS Rider),that D late enrollment penalty: explains your costs as a Member of our plan.If the amount of your"Extra Help"changes during the year, • First,the penalty may change each year because the we will also mail you an updated Evidence of Coverage average monthly premium can change each year Rider for People Who Get Extra Help Paying for • Second,you will continue to pay a penalty every Prescription Drugs. month for as long as you are enrolled in a plan that has Medicare Part D drug benefits,even if you Who Is Eligible change plans • Third,if you are under 65 and currently receiving To enroll and to continue enrollment,you must meet all of the eligibility requirements described in this Who Is Medicare benefits,the Part D late enrollment penalty Eligible"section,including your Group's eligibility will reset when you turn 65.After age 65,your Part D requirements and your Home Region Service Area late enrollment penalty will be based only on the months that you don't have coverage after your initial eligibility requirements. enrollment period for aging into Medicare Group eligibility requirements If you disagree about your Part D late enrollment You must meet your Group's eligibility requirements. penalty,you or your representative can ask for a Your Group is required to inform Subscribers of its review. Generally,you must request this review within eligibility requirements. 60 days from the date on the first letter you receive stating you have to pay a late enrollment penalty. Senior Advantage eligibility requirements However,if you were paying a penalty before joining our plan,you may not have another chance to request a • You must have Medicare Part B review of that late enrollment penalty. • You must be a United States citizen or lawfully present in the United States Medicare's "Extra Help" Program • Your Medicare coverage must be primary and your Medicare provides"Extra Help"to pay prescription drug Group's health care plan must be secondary costs for people who have limited income and resources. • You may not be enrolled in another Medicare Health Resources include your savings and stocks,but not your Plan or Medicare prescription drug plan home or car.If you qualify,you get help paying for any Medicare drug plan's monthly premium and prescription Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 11 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Note:If you are enrolled in a Medicare plan and lose • Prescription drugs from Non—Plan Pharmacies as Medicare eligibility,you may be able to enroll under described under"Outpatient Prescription Drugs, your Group's non-Medicare plan if that is permitted by Supplies,and Supplements"in the"Benefits and your Group(please ask your Group for details). Your Cost Share"section • Routine Services associated with Medicare-approved Service Area eligibility requirements clinical trials as described under"Services Associated with Clinical Trials"in the"Benefits and Your Cost You must live in our Service Area,unless you have been Share"section continuously enrolled in Senior Advantage since December 31, 1998,and lived outside our Service Area If you are not eligible to continue enrollment because during that entire time.In which case,you may continue you move to the service area of another Region,please your membership unless you move and are still outside contact your Group to learn about your Group health care your Home Region Service Area.The"Definitions" options.You may be able to enroll in the service area of section describes our Service Area and how it may another Region if there is an agreement between your change. Group and that Region,but the plan,including coverage, premiums,and eligibility requirements,might not be the Moving outside your Home Region Service Area. same as under this EOC. If you permanently move outside your Home Region Service Area,or you are temporarily absent from your For more information about the service areas of the other Home Region Service Area for a period of more than six Regions,please call Member Services. months in a row,you must notify us and you cannot continue your Senior Advantage membership under this Eligibility as a Subscriber EOC. You may be eligible to enroll and continue enrollment as Send your notice to: a Subscriber if you are: • An employee of your Group Kaiser Foundation Health Plan,Inc. . A proprietor or partner of your Group California Service Center P.O.Box 232400 • Otherwise entitled to coverage under a trust San Diego,CA 92193-2400 agreement,retirement benefit program,or employment contract(unless the Internal Revenue It is in your best interest to notify us as soon as possible Service considers you self-employed) because until your Senior Advantage coverage is officially terminated by the Centers for Medicare& Eligibility as a Dependent Medicaid Services,you will not be covered by us or Enrolling as a Dependent Original Medicare for any care you receive from Non— Dependent eligibility is subject to your Group's Plan Providers,except as described in the sections listed eligibility requirements,which are not described in this below for the following Services: EOC.You can obtain your Group's eligibility • Authorized referrals as described under"Getting a requirements directly from your Group.If you are a Referral"in the"How to Obtain Services"section Subscriber under this EOC: • Covered Services received outside of your Home • Your Spouse Region Service Area as described under"Receiving • Your or your Spouse's Dependent children,who meet Care Outside of Your Home Region Service Area"in the requirements described under"Age limit of the"How to Obtain Services"section Dependent children,"if they are any of the following: • Emergency ambulance Services as described under ♦ biological children "Ambulance Services"in the"Benefits and Your Cost ♦ stepchildren Share"section • Emergency Services,Post-Stabilization Care,and ♦ adopted children Out-of-Area Urgent Care as described in the ♦ children placed with you for adoption "Emergency Services and Urgent Care"section ♦ foster children if you or your Spouse have the • Out-of--area dialysis care as described under"Dialysis legal authority to direct their care Care"in the"Benefits and Your Cost Share"section ♦ children for whom you or your Spouse is the court-appointed guardian(or was when the child reached age 18) Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 12 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Children whose parent is a Dependent child under date coverage will end due to reaching the age limit. your family coverage(including adopted children and The Dependent's membership will terminate as children placed with your Dependent child for described in our notice unless the Subscriber provides adoption or foster care)if they meet all of the us documentation of the Dependent's incapacity and following requirements: dependency within 60 days of receipt of our notice ♦ they are not married and do not have a domestic and we determine that the Dependent is eligible as a partner(for the purposes of this requirement only, disabled dependent.If the Subscriber provides us this "domestic partner"means someone who is documentation in the specified time period and we do registered and legally recognized as a domestic not make a determination about eligibility before the partner by California) termination date,coverage will continue until we make a determination.If we determine that the ♦ they meet the requirements described under"Age Dependent does not meet the eligibility requirements limit of Dependent children" as a disabled dependent,we will notify the Subscriber ♦ they receive all of their support and maintenance that the Dependent is not eligible and let the from you or your Spouse Subscriber know the membership termination date. ♦ they permanently reside with you or your Spouse If we determine that the Dependent is eligible as a disabled dependent,there will be no lapse in Age limit of Dependent children coverage.Also,starting two years after the date that Children must be under age 26 as of the effective date of the Dependent reached the age limit,the Subscriber this EOC to enroll as a Dependent under your plan. must provide us documentation of the Dependent's incapacity and dependency annually within 60 days Dependent children are eligible to remain on the plan after we request it so that we can determine if the through the end of the month in which they reach the age Dependent continues to be eligible as a disabled limit. dependent • If the child is not a Member because you are changing Dependent children of the Subscriber or Spouse coverage,you must give us proof,within 60 days (including adopted children and children placed with you after we request it,of the child's incapacity and for adoption,but not including children placed with you dependency as well as proof of the child's coverage for foster care)who reach the age limit may continue under your prior coverage.In the future,you must coverage under this EOC if all of the following provide proof of the child's continued incapacity and conditions are met: dependency within 60 days after you receive our • They meet all requirements to be a Dependent except request,but not more frequently than annually for the age limit Dependents not eligible to enroll under a Senior • Your Group permits enrollment of Dependents Advantage plan.If you have dependents who do not • They are incapable of self-sustaining employment have Medicare Part B coverage or for some other reason because of a physically-or mentally-disabling injury, are not eligible to enroll under this EOC,you may be illness,or condition that occurred before they reached able to enroll them as your dependents under a non- the age limit for Dependents Medicare plan offered by your Group.Please contact • They receive 50 percent or more of their support and your Group for details,including eligibility and benefit maintenance from you or your Spouse information,and to request a copy of the non-Medicare plan document. • If requested,you give us proof of their incapacity and dependency within 60 days after receiving our request (see"Disabled Dependent certification"below in this How to Enroll and When Coverage "Eligibility as a Dependent"section) Begins Disabled Dependent certification Your Group is required to inform you when you are Proof may be required for a Dependent to be eligible to eligible to enroll and what your effective date of continue coverage as a disabled Dependent.If we request coverage is.If you are eligible to enroll as described it,the Subscriber must provide us documentation of the under"Who Is Eligible"in this"Premiums,Eligibility, dependent's incapacity and dependency as follows: and Enrollment"section,enrollment is permitted as described below and membership begins at the beginning • If the child is a Member,we will send the Subscriber (12:00 a.m.)of the effective date of coverage indicated a notice of the Dependent's membership termination below,except that: due to loss of eligibility at least 90 days before the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 13 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Your Group may have additional requirements,which Group open enrollment allow enrollment in other situations You may enroll as a Subscriber(along with any eligible • The effective date of your Senior Advantage coverage Dependents),and existing Subscribers may add eligible under this EOC must be confirmed by the Centers for Dependents,by submitting a Health Plan—approved Medicare&Medicaid Services,as described under enrollment application,and a Senior Advantage Election "Effective date of Senior Advantage coverage"in this Form for each person to your Group during your Group's "How to Enroll and When Coverage Begins"section open enrollment period.Your Group will let you know when the open enrollment period begins and ends and the If you are a Subscriber under this EOC and you have effective date of coverage,which is subject to dependents who do not have Medicare Part B coverage or confirmation by the Centers for Medicare&Medicaid for some other reason are not eligible to enroll under this Services. EOC,you may be able to enroll them as your dependents under a non-Medicare plan offered by your Group.Please Special enrollment contact your Group for details,including eligibility and If you do not enroll when you are first eligible and later benefit information,and to request a copy of the non- want to enroll,you can enroll only during open Medicare plan document. enrollment unless one of the following is true: • You become eligible because you experience a If you are eligible to be a Dependent under this EOC but the qualifying event(sometimes called a"triggering subscriber in your family is enrolled under a non-Medicare event")as described in this"Special enrollment" plan offered by your Group,the subscriber must follow the section rules applicable to Subscribers who are enrolling • You did not enroll in any coverage offered by your Dependents in this"How to Enroll and When Coverage Group when you were first eligible and your Group Begins"section. does not give us a written statement that verifies you Effective date of Senior Advantage coverage signed a document that explained restrictions about enrolling in the future. Subject to confirmation by the After we receive your completed Senior Advantage Centers for Medicare&Medicaid Services,the Election Form,we will submit your enrollment request to effective date of an enrollment resulting from this the Centers for Medicare&Medicaid Services for provision is no later than the first day of the month confirmation and send you a notice indicating the following the date your Group receives a Health proposed effective date of your Senior Advantage Plan—approved enrollment or change of enrollment coverage under this EOC. application,and a Senior Advantage Election Form for each person,from the Subscriber If the Centers for Medicare&Medicaid Services confirms your Senior Advantage enrollment and Special enrollment due to new Dependents effective date,we will send you a notice that confirms You may enroll as a Subscriber(along with eligible your enrollment and effective date.If the Centers for Dependents),and existing Subscribers may add eligible Medicare&Medicaid Services tells us that you do not Dependents,within 30 days after marriage,establishment have Medicare Part B coverage,we will notify you that of domestic partnership,birth,adoption,placement for you will be disenrolled from Senior Advantage. adoption,or placement for foster care by submitting to New employees your Group a Health Plan—approved enrollment application,and a Senior Advantage Election Form for When your Group informs you that you are eligible to each person. enroll as a Subscriber,you may enroll yourself and any eligible Dependents by submitting a Health Plan— Subject to confirmation by the Centers for Medicare& approved enrollment application,and a Senior Medicaid Services,the effective date of an enrollment Advantage Election Form for each person,to your Group resulting from marriage or establishment of domestic within 31 days. partnership is no later than the first day of the month following the date your Group receives an enrollment Effective date of Senior Advantage coverage.The application,and a Senior Advantage Election Form for effective date of Senior Advantage coverage for new each person,from the Subscriber. Subject to employees and their eligible family Dependents or newly confirmation by the Centers for Medicare&Medicaid acquired Dependents,is determined by your Group, Services,enrollments of newly acquired Dependent subject to confirmation by the Centers for Medicare& children are effective as follows: Medicaid Services. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 14 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Enrollments due to birth are effective on the date of change of enrollment application,and Senior Advantage birth Election Form for each person,from the Subscriber. • Enrollments due to adoption are effective on the date of adoption Special enrollment due to court or administrative order.Within 31 days after the date of a court or • Enrollments due to placement for adoption or foster administrative order requiring a Subscriber to provide care are effective on the date you or your Spouse have health care coverage for a Spouse or child who meets the newly assumed a legal right to control health care eligibility requirements as a Dependent,the Subscriber may add the Spouse or child as a Dependent by Special enrollment due to loss of other coverage.You submitting to your Group a Health Plan—approved may enroll as a Subscriber(along with any eligible enrollment or change of enrollment application,and a Dependents),and existing Subscribers may add eligible Senior Advantage Election Form for each person. Dependents,if all of the following are true: • The Subscriber or at least one of the Dependents had Subject to confirmation by the Centers for Medicare& other coverage when they previously declined all Medicaid Services,the effective date of coverage coverage through your Group resulting from a court or administrative order is the first of the month following the date we receive the • The loss of the other coverage is due to one of the enrollment request,unless your Group specifies a following: different effective date(if your Group specifies a ♦ exhaustion of COBRA coverage different effective date,the effective date cannot be ♦ termination of employer contributions for non- earlier than the date of the order). COBRA coverage ♦ loss of eligibility for non-COBRA coverage,but Special enrollment due to eligibility for premium not termination for cause or termination from an assistance.You may enroll as a Subscriber(along with individual(nongroup)plan for nonpayment.For eligible Dependents),and existing Subscribers may add example,this loss of eligibility may be due to legal eligible Dependents,if you or a dependent become separation or divorce,moving out of the plan's eligible for premium assistance through the Medi-Cal service area,reaching the age limit for dependent program.Premium assistance is when the Medi-Cal children,or the subscriber's death,termination of program pays all or part of premiums for employer group employment,or reduction in hours of employment coverage for a Medi-Cal beneficiary. To request ♦ loss of eligibility(but not termination for cause) enrollment in your Group's health care coverage,the for coverage through Covered California, Subscriber must submit a Health Plan—approved Medicaid coverage(known as Medi-Cal in enrollment or change of enrollment application,and a California),Children's Health Insurance Program Senior Advantage Election Form for each person,to your coverage,or Medi-Cal Access Program coverage Group within 60 days after you or a dependent become eligible for premium assistance.Please contact the ♦ reaching a lifetime maximum on all benefits California Department of Health Care Services to find out if premium assistance is available and the eligibility Note:If you are enrolling yourself as a Subscriber along requirements. with at least one eligible Dependent,only one of you must meet the requirements stated above. Special enrollment due to reemployment after military service.If you terminated your health care To request enrollment,the Subscriber must submit a coverage because you were called to active duty in the Health Plan—approved enrollment or change of military service,you may be able to reenroll in your enrollment application,and a Senior Advantage Election Group's health plan if required by state or federal law. Form for each person,to your Group within 30 days after Please ask your Group for more information. loss of other coverage,except that the timeframe for submitting the application is 60 days if you are requesting enrollment due to loss of eligibility for coverage through Covered California,Medicaid, How to Obtain Services Children's Health Insurance Program,or Medi-Cal Access Program coverage. Subject to confirmation by As a Member,you are selecting our medical care the Centers for Medicare&Medicaid Services,the program to provide your health care.You must receive effective date of an enrollment resulting from loss of all covered care from Plan Providers inside our Service other coverage is no later than the first day of the month following the date your Group receives an enrollment or Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 15 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Area,except as described in the sections listed below for Our Advice Nurses the following Services: • Authorized referrals as described under"Getting a We know that sometimes it's difficult to know what type Referral"in this"How to Obtain Services"section of care you need.That's why we have telephone advice nurses available to assist you.Our advice nurses are • Covered Services received outside of your Home registered nurses specially trained to help assess medical Region Service Area as described under"Receiving symptoms and provide advice over the phone,when Care Outside of Your Home Region Service Area"in medically appropriate.Whether you are calling for this"How to Obtain Services"section advice or to make an appointment,you can speak to an • Emergency ambulance Services as described under advice nurse.They can often answer questions about a "Ambulance Services"in the"Benefits and Your Cost minor concern,tell you what to do if a Plan Medical Share"section Office is closed,or advise you about what to do next, including making a same-day Urgent Care appointment • Emergency Services,Post-Stabilization Care,and for you if it's medically appropriate.To reach an advice Out-of--Area Urgent Care as described in the nurse,refer to our Provider Directory or call Member "Emergency Services and Urgent Care"section Services. • Out-of-area dialysis care as described under"Dialysis Care"in the"Benefits and Your Cost Share"section • Prescription drugs from Non—Plan Pharmacies as Your Personal Plan Physician described under"Outpatient Prescription Drugs, Personal Plan Physicians provide primary care and play Supplies,and Supplements"in the"Benefits and an important role in coordinating care,including hospital Your Cost Share"section stays and referrals to specialists. • Routine Services associated with Medicare-approved clinical trials as described under"Services Associated We encourage you to choose a personal Plan Physician. with Clinical Trials"in the"Benefits and Your Cost You may choose any available personal Plan Physician. Share"section Parents may choose a pediatrician as the personal Plan Physician for their child. Most personal Plan Physicians Our medical care program gives you access to all of the are Primary Care Physicians(generalists in internal covered Services you may need,such as routine care medicine,pediatrics,or family practice,or specialists in with your own personal Plan Physician,hospital obstetrics/gynecology whom the Medical Group Services,laboratory and pharmacy Services,Emergency designates as Primary Care Physicians). Some specialists Services,Urgent Care,and other benefits described in who are not designated as Primary Care Physicians but this EOC. who also provide primary care may be available as personal Plan Physicians.For example,some specialists in internal medicine and obstetrics/gynecology who are Routine Care not designated as Primary Care Physicians may be available as personal Plan Physicians.However,if you To request a non-urgent appointment,you can call your choose a specialist who is not designated as a Primary local Plan Facility or request the appointment online.For Care Physician as your personal Plan Physician,the Cost appointment phone numbers,refer to our Provider Share for a Physician Specialist Visit will apply to all Directory or call Member Services.To request an visits with the specialist except for Preventive Services appointment online,go to our website at kp•org. listed in the"Benefits and Your Cost Share"section. Urgent Care To learn how to select or change to a different personal Plan Physician,visit our website at kp•org,or call An Urgent Care need is one that requires prompt medical Member Services.Refer to our Provider Directory for a attention but is not an Emergency Medical Condition. list of physicians that are available as Primary Care If you think you may need Urgent Care,call the Physicians.The directory is updated periodically.The appropriate appointment or advice phone number at a availability of Primary Care Physicians may change.If Plan Facility.For phone numbers,refer to our Provider you have questions,please call Member Services.You Directory or call Member Services. can change your personal Plan Physician at any time for any reason. For information about Out-of-Area Urgent Care,refer to "Urgent Care"in the"Emergency Services and Urgent Care"section. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 16 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Getting a Referral Utilization Management("UM")is a process that determines whether a Service recommended by your Referrals to Plan Providers treating provider is Medically Necessary for you.Prior A Plan Physician must refer you before you can receive authorization is a UM process that determines whether care from specialists,such as specialists in surgery, the requested services are Medically Necessary before orthopedics,cardiology,oncology,dermatology,and care is provided. If it is Medically Necessary,then you physical,occupational,and speech therapies.However, will receive authorization to obtain that care in a you do not need a referral or prior authorization to clinically appropriate place consistent with the terms of receive most care from any of the following Plan your health coverage.Decisions regarding requests for Providers: authorization will be made only by licensed physicians • Your personal Plan Physician or other appropriately licensed medical professionals. • Generalists in internal medicine,pediatrics,and For the complete list of Services that require prior family practice authorization,and the criteria that are used to make • Specialists in optometry,mental health Services, authorization decisions,please visit our website at substance use disorder treatment,and ky.orE/UM or call Member Services to request a printed obstetrics/gynecology copy.Refer to"Post-Stabilization Care"under "Emergency Services"in the"Emergency Services and A Plan Physician must refer you before you can get care Urgent Care"section for authorization requirements that from a specialist in urology except that you do not need a apply to Post-Stabilization Care from Non—Plan referral to receive Services related to sexual or Providers. reproductive health,such as a vasectomy. Additional information about prior authorization for Although a referral or prior authorization is not required durable medical equipment,ostomy,urological,and to receive most care from these providers,a referral may specialized wound care supplies.The prior be required in the following situations: authorization process for durable medical equipment, ostomy,urological,and specialized wound care supplies • The provider may have to get prior authorization for includes the use of formulary guidelines. These certain Services in accord with"Medical Group guidelines were developed by a multidisciplinary clinical authorization procedure for certain referrals"in this and operational work group with review and input from "Getting a Referral"section Plan Physicians and medical professionals with clinical • The provider may have to refer you to a specialist expertise.The formulary guidelines are periodically who has a clinical background related to your illness updated to keep pace with changes in medical or condition technology,Medicare guidelines,and clinical practice. Standing referrals If your Plan Physician prescribes one of these items,they If a Plan Physician refers you to a specialist,the referral will submit a written referral in accord with the UM will be for a specific treatment plan.Your treatment plan process described in this"Medical Group authorization may include a standing referral if ongoing care from the procedure for certain referrals"section. If the formulary specialist is prescribed.For example,if you have a life- guidelines do not specify that the prescribed item is threatening,degenerative,or disabling condition,you can appropriate for your medical condition,the referral will get a standing referral to a specialist if ongoing care from be submitted to the Medical Group's designee Plan the specialist is required. Physician,who will make an authorization decision as described under"Medical Group's decision time frames" Medical Group authorization procedure for in this"Medical Group authorization procedure for certain referrals certain referrals"section. The following are examples of Services that require prior authorization by the Medical Group for the Services to Medical Group's decision time frames.The applicable be covered("prior authorization"means that the Medical Medical Group designee will make the authorization Group must approve the Services in advance): decision within the time frame appropriate for your • Durable medical equipment condition,but no later than five business days after receiving all of the information(including additional • Ostomy and urological supplies examination and test results)reasonably necessary to • Services not available from Plan Providers make the decision,except that decisions about urgent Services will be made no later than 72 hours after receipt • Transplants of the information reasonably necessary to make the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 17 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. decision.If the Medical Group needs more time to make reimbursement,refer to the Travel and Lodging Program the decision because it doesn't have information Description.The Travel and Lodging Program reasonably necessary to make the decision,or because it Description is available online at ku.org/suecialty- has requested consultation by a particular specialist,you care/travel-reimbursements or by calling Member and your treating physician will be informed about the Services. additional information,testing,or specialist that is needed,and the date that the Medical Group expects to make a decision. Second Opinions Your treating physician will be informed of the decision If you want a second opinion,you can ask Member within 24 hours after the decision is made.If the Services Services to help you arrange one with a Plan Physician are authorized,your physician will be informed of the who is an appropriately qualified medical professional scope of the authorized Services.If the Medical Group for your condition. If there isn't a Plan Physician who is does not authorize all of the Services,Health Plan will an appropriately qualified medical professional for your send you a written decision and explanation within two condition,Member Services will help you arrange a business days after the decision is made.Any written consultation with a Non—Plan Physician for a second criteria that the Medical Group uses to make the decision opinion.For purposes of this"Second Opinions" to authorize,modify,delay,or deny the request for provision,an"appropriately qualified medical authorization will be made available to you upon request. professional"is a physician who is acting within their scope of practice and who possesses a clinical If the Medical Group does not authorize all of the background,including training and expertise,related to Services requested and you want to appeal the decision, the illness or condition associated with the request for a you can file a grievance as described in the"Coverage second medical opinion. Decisions,Appeals,and Complaints"section. Here are some examples of when a second opinion may For these referral Services,you pay the Cost Share be provided or authorized: required for Services provided by a Plan Provider as • Your Plan Physician has recommended a procedure described in this EOC. and you are unsure about whether the procedure is reasonable or necessary • You question a diagnosis or plan of care for a Travel and Lodging for Certain Services condition that threatens substantial impairment or loss of life,limb,or bodily functions The following are examples of when we will arrange or . The clinical indications are not clear or are complex provide reimbursement for certain travel and lodging expenses in accord with our Travel and Lodging and confusing Program Description: • A diagnosis is in doubt due to conflicting test results • If Medical Group refers you to a provider that is more • The Plan Physician is unable to diagnose the than 50 miles from where you live for certain condition specialty Services such as bariatric surgery,complex . The treatment plan in progress is not improving your thoracic surgery,transplant nephrectomy,or inpatient medical condition within an appropriate period of chemotherapy for leukemia and lymphoma time,given the diagnosis and plan of care • If Medical Group refers you to a provider that is • You have concerns about the diagnosis or plan of care outside your Home Region Service Area for certain specialty Services such as a transplant or transgender An authorization or denial of your request for a second surgery opinion will be provided in an expeditious manner,as • If you are outside of California and you need an appropriate for your condition.If your request for a abortion on an emergency or urgent basis,and the second opinion is denied,you will be notified in writing abortion can't be obtained in a timely manner due to a of the reasons for the denial and of your right to file a near total or total ban on health care providers' ability grievance as described in the"Coverage Decisions, to provide such Services Appeals,and Complaints"section. For the complete list of specialty Services for which we For these referral Services,you pay the Cost Share will arrange or provide reimbursement for travel and required for Services provided by a Plan Provider as lodging expenses,the amount of reimbursement, described in this EOC. limitations and exclusions,and how to request Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 18 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Contracts with Plan Providers For the Services of a terminated provider,you pay the Cost Share required for Services provided by a Plan How Plan Providers are paid Provider as described in this EOC. Health Plan and Plan Providers are independent contractors.Plan Providers are paid in a number of ways, More information.For more information about this such as salary,capitation,per diem rates,case rates,fee provision,or to request the Services,please call Member for service,and incentive payments. To learn more about Services. how Plan Physicians are paid to provide or arrange medical and hospital Services for Members,please visit our website at kp.org or call Member Services. Receiving Care Outside of Your Home Region Service Area Financial liability Our contracts with Plan Providers provide that you are For information about your coverage when you are away not liable for any amounts we owe.However,you may from home,visit our website at kp.org/travel.You can have to pay the full price of noncovered Services you also call the Away from Home Travel Line at obtain from Plan Providers or Non—Plan Providers. 1-951-268-3900,24 hours a day,seven days a week (closed holidays). When you are referred to a Plan Provider for covered Services,you pay the Cost Share required for Services Receiving care in another Kaiser Permanente from that provider as described in this EOC. service area If you are visiting in another Kaiser Permanente service Termination of a Plan Provider's contract and area,you may receive certain covered Services from completion of Services designated providers in that other Kaiser Permanente If our contract with any Plan Provider terminates while service area,subject to exclusions,limitations,prior you are under the care of that provider,we will retain authorization or approval requirements,and reductions. financial responsibility for the covered Services you For more information about receiving covered Services receive from that provider until we make arrangements in another Kaiser Permanente service area,including for the Services to be provided by another Plan Provider provider and facility locations,please visit ky.org/travel and notify you of the arrangements. or call our Away from Home Travel Line at 1-951-268- 3900,24 hours a day,seven days a week(closed Completion of Services.If you are undergoing holidays). treatment for specific conditions from a Plan Physician (or certain other providers)when the contract with him Receiving care outside of any Kaiser or her ends(for reasons other than medical disciplinary Permanente service area cause,criminal activity,or the provider's voluntary If you are traveling outside of any Kaiser Permanente termination),you may be eligible to continue receiving service area,we cover Services as described in the covered care from the terminated provider for your "Emergency Services and Urgent Care"section about condition. The conditions that are subject to this Emergency Services,Post-Stabilization Care,and Out- continuation of care provision are: of-Area Urgent Care and the"Benefits and Your Cost Share"section about out-of-area dialysis care. • Certain conditions that are either acute,or serious and chronic.We may cover these Services for up to 90 days,or longer,if necessary for a safe transfer of care Your ID Card to a Plan Physician or other contracting provider as determined by the Medical Group Each Member's Kaiser Permanente ID card has a • A high-risk pregnancy or a pregnancy in its second or medical record number on it,which you will need when third trimester.We may cover these Services through you call for advice,make an appointment,or go to a postpartum care related to the delivery,or longer provider for covered care.When you get care,please if Medically Necessary for a safe transfer of care to a bring your Kaiser Permanente ID card and a photo ID. Plan Physician as determined by the Medical Group Your medical record number is used to identify your medical records and membership information.Your medical record number should never change.Please call The Services must be otherwise covered under this EOC. Member Services if we ever inadvertently issue you Also,the terminated provider must agree in writing to more than one medical record number or if you need to our contractual terms and conditions and comply with replace your Kaiser Permanente ID card. them for Services to be covered by us. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 19 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Your ID card is for identification only.To receive Plan Facilities covered Services,you must be a current Member. Anyone who is not a Member will be billed as a non- Plan Medical Offices and Plan Hospitals are listed in the Member for any Services they receive.If you let Provider Directory for your Home Region.The directory someone else use your ID card,we may keep your ID describes the types of covered Services that are available card and terminate your membership as described under from each Plan Facility,because some facilities provide "Termination for Cause"in the"Termination of only specific types of covered Services.This directory is Membership"section. available on our website at kp.or2/facilities.To obtain a Your Medicare card printed copy,call Member Services.The directory is updated periodically.The availability of Plan Facilities Do NOT use your red,white,and blue Medicare card for may change.If you have questions,please call Member covered medical Services while you are a Member of this Services. plan.If you use your Medicare card instead of your Senior Advantage membership card,you may have to At most of our Plan Facilities,you can usually receive all pay the full cost of medical services yourself.Keep your of the covered Services you need,including specialty Medicare card in a safe place.You may be asked to show care,pharmacy,and lab work.You are not restricted to a it if you need hospice services or participate in routine particular Plan Facility,and we encourage you to use the research studies. facility that will be most convenient for you: • All Plan Hospitals provide inpatient Services and are Getting Assistance open 24 hours a day, seven days a week We want you to be satisfied with the health care you • Emergency Services are available from Plan Hospital receive from Kaiser Permanente.If you have any Emergency Departments(for Emergency Department questions or concerns,please discuss them with your locations,refer to our Provider Directory or call personal Plan Physician or with other Plan Providers Member Services) who are treating you.They are committed to your • Same-day Urgent Care appointments are available at satisfaction and want to help you with your questions. many locations(for Urgent Care locations,refer to our Provider Directory or call Member Services) Member Services • Many Plan Medical Offices have evening and Member Services representatives can answer any weekend appointments questions you have about your benefits,available Services,and the facilities where you can receive care. • Many Plan Facilities have a Member Services office For example,they can explain the following: (for locations,refer to our Provider Directory or call Member Services) • Your Health Plan benefits • Plan Pharmacies are located at most Plan Medical • How to make your first medical appointment Offices(refer to our Kaiser Permanente Pharmacy • What to do if you move Directory for pharmacy locations) • How to replace your Kaiser Permanente ID card Provider Directory Many Plan Facilities have an office staffed with representatives who can provide assistance if you need The Provider Directory lists our Plan Providers.It is help obtaining Services.At different locations,these subject to change and periodically updated. If you don't offices may be called Member Services,Patient have our Provider Directory,you can get a copy by Assistance,or Customer Service.In addition,Member calling Member Services or by visiting our website at Services representatives are available to assist you seven kp.ore/directory. days a week from 8 a.m.to 8 p.m.toll free at 1-800-443- 0815 or 711 (TTY for the deaf,hard of hearing,or speech impaired).For your convenience,you can also Pharmacy Directory contact us through our website at kp.ora. The Kaiser Permanente Pharmacy Directory lists the Cost Share estimates locations of Plan Pharmacies,which are also called "network pharmacies."The pharmacy directory provides For information about estimates,see"Getting an additional information about obtaining prescription estimate of your Cost Share"under"Your Cost Share"in drugs.It is subject to change and periodically updated. the"Benefits and Your Cost Share"section. If you don't have the Kaiser Permanente Pharmacy Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 20 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Directory,you can get a copy by calling Member Your Cost Share Services or by visiting our website at kp.org/directory. Your Cost Share for covered Emergency Services and Post-Stabilization Care is described in the`Benefits and Your Cost Share"section.Your Cost Share is the same Emergency Services and Urgent whether you receive the Services from a Plan Provider or a Non—Plan Provider.For example: Care • If you receive Emergency Services in the Emergency Department of a Non—Plan Hospital,you pay the Cost Emer lency Services Share for an Emergency Department visit as described under"Outpatient Care" If you have an Emergency Medical Condition,call 911 • If we gave prior authorization for inpatient Post- (where available)or go to the nearest Emergency Stabilization Care in a Non—Plan Hospital,you pay Department.You do not need prior authorization for the Cost Share for hospital inpatient care as described Emergency Services.When you have an Emergency under"Hospital Inpatient Care" Medical Condition,we cover Emergency Services you receive from Plan Providers or Non—Plan Providers anywhere in the world. Urgent Care Emergency Services are available from Plan Hospital Inside your Home Region Service Area Emergency Departments 24 hours a day, seven days a An Urgent Care need is one that requires prompt medical week. attention but is not an Emergency Medical Condition. If you think you may need Urgent Care,call the Post-Stabilization Care appropriate appointment or advice phone number at a Post-Stabilization Care is Medically Necessary Services Plan Facility.For appointment and advice phone related to your Emergency Medical Condition that you numbers,refer to our Provider Directory or call Member receive in a hospital(including the Emergency Services. Department)after your treating physician determines that your condition is Stabilized. In the event of unusual circumstances that delay or render impractical the provision of Services under this To request prior authorization,the Non—Plan Provider EOC(such as a major disaster,epidemic,war,riot,and must call 1-800-225-8883 or the notification phone civil insurrection),we cover Urgent Care inside our number on your Kaiser Permanente ID card before you Service Area from a Non—Plan Provider. receive the care.We will discuss your condition with the Non—Plan Provider.If we determine that you require Out-of-Area Urgent Care Post-Stabilization Care and that this care is part of your If you need Urgent Care due to an unforeseen illness or covered benefits,we will authorize your care from the unforeseen injury,we cover Medically Necessary Non—Plan Provider or arrange to have a Plan Provider(or Services to prevent serious deterioration of your health other designated provider)provide the care with the from a Non—Plan Provider if all of the following are true: treating physician's concurrence.If we decide to have a . You receive the Services from Non—Plan Providers Plan Hospital,Plan Skilled Nursing Facility,or while you are temporarily outside our Service Area designated Non—Plan Provider provide your care,we may authorize special transportation services that are • A reasonable person would have believed that your medically required to get you to the provider.This may health would seriously deteriorate if you delayed include transportation that is otherwise not covered. treatment until you returned to our Service Area Be sure to ask the Non—Plan Provider to tell you what You do not need prior authorization for Out-of-Area care(including any transportation)we have authorized Urgent Care.We cover Out-of-Area Urgent Care you because we will not cover unauthorized Post- receive from Non—Plan Providers if the Services would Stabilization Care or related transportation provided by have been covered under this EOC if you had received Non—Plan Providers.If you receive care from a Non— them from Plan Providers. Plan Provider that we have not authorized,you may have to pay the full cost of that care if you are notified by the We do not cover follow-up care from Non—Plan Non—Plan Provider or us about your potential liability. Providers after you no longer need Urgent Care.To obtain follow-up care from a Plan Provider,call the appointment or advice phone number at a Plan Facility. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 21 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. For phone numbers,refer to our Provider Directory or Benefits and Your Cost Share call Member Services. This section describes the Services that are covered Your Cost Share under this EOC. Your Cost Share for covered Urgent Care is the Cost Services are covered under this EOC as specifically Share required for Services provided by Plan Providers described in this EOC. Services that are not specifically as described in this EOC.For example: described in this EOC are not covered,except as required • If you receive an Urgent Care evaluation as part of by federal law. Services are subject to exclusions and covered Out-of-Area Urgent Care from a Non—Plan limitations described in the"Exclusions,Limitations, Provider,you pay the Cost Share for Urgent Care Coordination of Benefits,and Reductions"section. consultations,evaluations,and treatment as described Except as otherwise described in this EOC,all of the under"Outpatient Care" following conditions must be satisfied: • If the Out-of-Area Urgent Care you receive includes • You are a Member on the date that you receive the an X-ray,you pay the Cost Share for an X-ray as Services described under"Outpatient Imaging,Laboratory,and • The Services are Medically Necessary Other Diagnostic and Treatment Services"in addition to the Cost Share for the Urgent Care evaluation • The Services are one of the following: ♦ Preventive Services Note:If you receive Urgent Care in an Emergency ♦ health care items and services for diagnosis, Department,you pay the Cost Share for an Emergency assessment,or treatment Department visit as described under"Outpatient Care." ♦ health education covered under"Health Education"in this`Benefits and Your Cost Share" Payment and Reimbursement section ♦ other health care items and services If you receive Emergency Services,Post-Stabilization ♦ other services to treat Serious Emotional Care,or Urgent Care from a Non—Plan Provider as Disturbance of a Child Under Age 18 or Severe described in this"Emergency Services and Urgent Care" Mental Illness section,or emergency ambulance Services described under"Ambulance Services"in the`Benefits and Your • The Services are provided,prescribed,authorized,or Cost Share"section,ask the Non—Plan Provider to directed by a Plan Physician except for: submit a claim to us within 60 days or as soon as ♦ covered Services received outside of your Home possible,but no later than 15 months after receiving the Region Service Area,as described under care(or up to 27 months according to Medicare rules,in "Receiving Care Outside of Your Home Region some cases). If the provider refuses to bill us,send us the Service Area"in the"How to Obtain Services" unpaid bill with a claim form.Also,if you receive section Services from a Plan Provider that are prescribed by a ♦ drugs prescribed by dentists,as described under Non—Plan Provider as part of covered Emergency "Outpatient Prescription Drugs, Supplies,and Services,Post-Stabilization Care,and Urgent Care(for Supplements"in this"Benefits and Your Cost example,drugs),you may be required to pay for the Share"section Services and file a claim.To request payment or ♦ emergency ambulance Services,as described reimbursement,you must file a claim as described in the under"Ambulance Services"in this"Benefits and "Requests for Payment"section. Your Cost Share"section We will reduce any payment we make to you or the ♦ Emergency Services,Post-Stabilization Care,and Non—Plan Provider by the applicable Cost Share.Also, Out-of-Area Urgent Care,as described in the in accord with applicable law,we will reduce our "Emergency Services and Urgent Care"section payment by any amounts paid or payable(or that in the ♦ eyeglasses and contact lenses prescribed by Non— absence of this plan would have been payable)for the Plan Providers,as described under"Vision Services under any insurance policy,or any other Services"in this`Benefits and Your Cost Share" contract or coverage,or any government program except section Medicaid. ♦ out-of-area dialysis care,as described under "Dialysis Care"in this"Benefits and Your Cost Share"section Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 22 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. ♦ routine Services associated with Medicare- Services that are subject to the Plan Deductible,your approved clinical trials,as described under Cost Share for those Services will be Charges until you "Services Associated with Clinical Trials"in this reach the Plan Deductible. "Benefits and Your Cost Share"section • You receive the Services from Plan Providers inside General rules, examples, and exceptions our Service Area,except for: Your Cost Share for covered Services will be the Cost ♦ authorized referrals,as described under"Getting a Share in effect on the date you receive the Services, Referral"in the"How to Obtain Services"section except as follows: ♦ covered Services received outside of your Home • If you are receiving covered hospital inpatient Region Service Area,as described under Services on the effective date of this EOC,you pay "Receiving Care Outside of Your Home Region the Cost Share in effect on your admission date until Service Area"in the"How to Obtain Services" you are discharged if the Services were covered under section your prior Health Plan evidence of coverage and there ♦ emergency ambulance Services,as described has been no break in coverage.However,if the Services were not covered under your prior Health under"Ambulance Services"in this"Benefits and Plan evidence of coverage,or if there has been a Your Cost Share"section break in coverage,you pay the Cost Share in effect on ♦ Emergency Services,Post-Stabilization Care,and the date you receive the Services Out-of-Area Urgent Care,as described in the • For items ordered in advance "Emergency Services and Urgent Care"section ,you pay the Cost Share in effect on the order date(although we will not cover ♦ out-of-area dialysis care,as described under the item unless you still have coverage for it on the "Dialysis Care"in this"Benefits and Your Cost date you receive it)and you may be required to pay Share"section the Cost Share when the item is ordered.For ♦ prescription drugs from Non—Plan Pharmacies,as outpatient prescription drugs,the order date is the described under"Outpatient Prescription Drugs, date that the pharmacy processes the order after Supplies,and Supplements"in this"Benefits and receiving all of the information they need to fill the Your Cost Share"section prescription ♦ routine Services associated with Medicare- approved clinical trials,as described under Payment toward your Cost Share(and when you may "Services Associated with Clinical Trials"in this be billed) "Benefits and Your Cost Share"section In most cases,your provider will ask you to make a • The Medical Group has given prior authorization for payment toward your Cost Share at the time you receive the Services,if required,as described under"Medical Services.If you receive more than one type of Services Group authorization procedure for certain referrals" (such as primary care treatment and laboratory tests),you in the"How to Obtain Services"section may be required to pay separate Cost Share for each of those Services.Keep in mind that your payment toward Please also refer to: your Cost Share may cover only a portion of your total Cost Share for the Services you receive,and you will be • The"Emergency Services and Urgent Care"section billed for any additional amounts that are due.The for information about how to obtain covered following are examples of when you may be asked to Emergency Services,Post-Stabilization Care,and pay(or you may be billed for)Cost Share amounts in Out-of-Area Urgent Care addition to the amount you pay at check-in: • Our Provider Directory for the types of covered • You receive non-preventive Services during a Services that are available from each Plan Facility, preventive visit.For example,you go in for a routine because some facilities provide only specific types of physical exam,and at check-in you pay your Cost covered Services Share for the preventive exam(your Cost Share may be"no charge").However,during your preventive Your Cost Share exam your provider finds a problem with your health and orders non-preventive Services to diagnose your Your Cost Share is the amount you are required to pay problem(such as laboratory tests).You may be asked for covered Services.The Cost Share for covered to pay(or you will be billed for)your Cost Share for Services is listed in this EOC.For example,your Cost these additional non-preventive diagnostic Services Share may be a Copayment or Coinsurance.If your • You receive diagnostic Services during a treatment coverage includes a Plan Deductible and you receive visit.For example,you go in for treatment of an Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 23 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. existing health condition,and at check-in you pay receive care.You are not responsible for any amounts your Cost Share for a treatment visit.However, beyond your Cost Share for the covered Services you during the visit your provider finds a new problem receive at Plan Facilities or at contracted facilities where with your health and performs or orders diagnostic we have authorized you to receive care.However,if the Services(such as laboratory tests).You may be asked provider does not agree to bill us,you may have to pay to pay(or you will be billed for)your Cost Share for for the Services and file a claim for reimbursement.For these additional diagnostic Services information on how to file a claim,please see the • You receive treatment Services during a diagnostic "Requests for Payment"section. visit.For example,you go in for a diagnostic exam, and at check-in you pay your Cost Share fora Primary Care Visits,Non-Physician Specialist Visits, diagnostic exam.However,during the diagnostic and Physician Specialist Visits.The Cost Share for a exam your provider confirms a problem with your Primary Care Visit applies to evaluations and treatment health and performs treatment Services(such as an provided by generalists in internal medicine,pediatrics, outpatient procedure).You may be asked to pay(or or family practice,and by specialists in you will be billed for)your Cost Share for these obstetrics/gynecology whom the Medical Group additional treatment Services designates as Primary Care Physicians. Some physician specialists provide primary care in addition to specialty • You receive Services from a second provider during care but are not designated as Primary Care Physicians. your visit.For example,you go in for a diagnostic If you receive Services from one of these specialists,the exam,and at check-in you pay your Cost Share for a Cost Share for a Physician Specialist Visit will apply to diagnostic exam.However,during the diagnostic all consultations,evaluations,and treatment provided by exam your provider requests a consultation with a the specialist except for routine preventive counseling specialist.You may be asked to pay(or you will be and exams listed under"Preventive Services"in this billed for)your Cost Share for the consultation with "Benefits and Your Cost Share"section.For example, the specialist if your personal Plan Physician is a specialist in internal medicine or obstetrics/gynecology who is not a Primary In some cases,your provider will not ask you to make a Care Physician,you will pay the Cost Share for a payment at the time you receive Services,and you will Physician Specialist Visit for all consultations, be billed for your Cost Share(for example,some evaluations,and treatment by the specialist except Laboratory Departments are not able to collect Cost routine preventive counseling and exams listed under Shares). "Preventive Services"in this"Benefits and Your Cost Share"section.The Non-Physician Specialist Visit Cost When we send you a bill,it will list Charges for the Share applies to consultations,evaluations,and treatment Services you received,payments and credits applied to provided by non-physician specialists(such as nurse your account,and any amounts you still owe.Your practitioners,physician assistants,optometrists, current bill may not always reflect your most recent podiatrists,and audiologists). Charges and payments.Any Charges and payments that are not on the current bill will appear on a future bill. Noncovered Services.If you receive Services that are Sometimes,you may see a payment but not the related not covered under this EOC,you may have to pay the Charges for Services. That could be because your full price of those Services.Payments you make for payment was recorded before the Charges for the noncovered Services do not apply to any deductible or Services were processed.If so,the Charges will appear out-of-pocket maximum. on a future bill.Also,you may receive more than one bill for a single outpatient visit or inpatient stay.For Getting an estimate of your Cost Share example,you may receive a bill for physician services If you have questions about the Cost Share for specific and a separate bill for hospital services.If you don't see Services that you expect to receive or that your provider all the Charges for Services on one bill,they will appear orders during a visit or procedure,please visit our on a future bill.If we determine that you overpaid and website at ky.org to use our cost estimate tool or call are due a refund,then we will send a refund to you Member Services. within four weeks after we make that determination. If you have questions about a bill,please call the phone • If you have a Plan Deductible and would like an number on the bill. estimate for Services that are subject to the Plan Deductible,please call 1-800-390-3507(TTY users In some cases,a Non—Plan Provider may be involved in call 711)Monday through Friday,6 a.m.to 5 p.m. the provision of covered Services at a Plan Facility or a contracted facility where we have authorized you to Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 24 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • For all other Cost Share estimates,please call 1-800- Copayments or Coinsurance even if you have already 443-0815,8 a.m.to 8 p.m.,seven days a week(TTY reached the out-of-pocket maximum.In addition: users should call 711) • If your plan includes supplemental chiropractic or acupuncture Services described in an amendment to Cost Share estimates are based on your benefits and the this EOC,those Services do not apply toward the Services you expect to receive.They are a prediction of maximum cost and not a guarantee of the final cost of Services. Your final cost may be higher or lower than the estimate • If your plan includes an Allowance for specific since not everything about your care can be known in Services(such as eyeglasses,contact lenses,or hearing aids),any amounts you pay that exceed the advance. Allowance do not apply toward the maximum Copayments and Coinsurance The Copayment or Coinsurance you must pay for each Outpatient Care covered Service,after you meet any applicable deductible,is described in this EOC. We cover the following outpatient care subject to the Cost Share indicated: Note:If Charges for Services are less than the Copayment or Coinsurance described in this EOC,you Office visits will pay the lesser amount. • Primary Care Visits and Non-Physician Specialist Plan Out-of-Pocket Maximum Visits that are not described elsewhere in this EOC: a $25 Copayment per visit There is a limit to the total amount of Cost Share you • Physician Specialist Visits that are not described must pay under this EOC in the calendar year for y p covered Services that you receive in the same calendar elsewhere in this EOC: a$25 Copayment per visit year.The Services that apply to the Plan Out-of-Pocket • Outpatient visits that are available as group Maximum are described under the"Payments that count appointments that are not described elsewhere in this toward the Plan Out-of-Pocket Maximum"section EOC: a$12 Copayment per visit below.The limit is: • House calls by a Plan Physician(or a Plan Provider • $1,000 per calendar year for any one Member who is a registered nurse)inside our Service Area when care can best be provided in your home as For Services subject to the Plan Out-of-Pocket determined by a Plan Physician: Maximum,you will not pay any more Cost Share during ♦ Primary Care Visits and Non-Physician Specialist the remainder of the calendar year,but every other Visits: a$25 Copayment per visit Member in your Family must continue to pay Cost Share during the remainder of the calendar year until either he ♦ physician Specialist Visits: a$25 Copayment per visit or she reaches the$1,000 maximum for any one Member. • Routine physical exams that are medically appropriate preventive care in accord with generally Payments that count toward the Plan Out-of-Pocket accepted professional standards of practice: Maximum.Any amounts you pay for the following ac charge Services apply toward the out-of-pocket maximum: • Family planning counseling,or internally implanted • Covered in-network Medicare Part A and Part B time-release contraceptives or intrauterine devices Services (IUDs)and office visits related to their administration • Medicare Part B drugs(all other drugs do not apply) and management: a$25 Copayment per visit • Residential treatment program Services covered in the • After confirmation of pregnancy,the normal series of "Substance Use Disorder Treatment"and"Mental regularly scheduled preventive prenatal care exams Health Services"sections and the first postpartum follow-up consultation and Copayments and Coinsurance you pay for Services that exam: a$5 Copayment per visit are not described above,do not apply to the out-of- • Voluntary termination of pregnancy and related pocket maximum.For these Services,you must pay Services: no charge • Physical,occupational,and speech therapy in accord with Medicare guidelines: a$25 Copayment per visit Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 25 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Group and individual physical therapy prescribed by a are admitted for observation but are not admitted as an Plan Provider to prevent falls: no charge inpatient. • Physical,occupational,and speech therapy provided in an organized,multidisciplinary rehabilitation day- Outpatient surgeries and procedures treatment program in accord with Medicare • Outpatient surgery and outpatient procedures when guidelines: a$25 Copayment per day provided in an outpatient or ambulatory surgery • Manual manipulation of the spine to correct center or in a hospital operating room,or if it is subluxation,in accord with Medicare guidelines,is provided in any setting and a licensed staff member covered when provided by a Plan Provider or a monitors your vital signs as you regain sensation after chiropractor when referred by a Plan Provider: a receiving drugs to reduce sensation or to minimize $20 Copayment per visit. (For the list of discomfort: a$25 Copayment per procedure participating ASH Plans providers,please refer to • Any other outpatient surgery that does not require a your Provider Directory) licensed staff member to monitor your vital signs as described above: a$25 Copayment per procedure Acupuncture Services • Any other outpatient procedures that do not require a • Acupuncture for chronic low back pain up to 12 visits licensed staff member to monitor your vital signs as in 90 days,in accord with Medicare guidelines: a described above: the Cost Share that would $25 Copayment per visit. Chronic low back pain is otherwise apply for the procedure in this"Benefits defined as follows: and Your Cost Share"section(for example,radiology ♦ lasting 12 weeks or longer procedures that do not require a licensed staff member to monitor your vital signs as described ♦ non-specific,in that it has no identifiable systemic above are covered under"Outpatient Imaging, cause(i.e.not associated with metastatic, Laboratory,and Other Diagnostic and Treatment inflammatory,infectious,disease,etc) Services") ♦ not associated with surgery or pregnancy • Pre-and post-operative visits: • An additional eight sessions will be covered for those ♦ Primary Care Visits and Non-Physician Specialist patients demonstrating an improvement.No more Visits: a$25 Copayment per visit than 20 acupuncture treatments may be administered annually.Treatment must be discontinued if the ♦ Physician Specialist Visits: a$25 Copayment per patient is not improving or is regressing visit • Acupuncture not covered by Medicare(typically Administered drugs and products provided only for the treatment of nausea or as part of Administered drugs and products are medications and a comprehensive pain management program for the products that require administration or observation by treatment of chronic pain): a$25 Copayment per medical personnel.We cover these items when visit prescribed by a Plan Provider,in accord with our drug Emergency Services and Urgent Care formulary guidelines,and they are administered to you in a Plan Facility or during home visits. • Urgent Care consultations,evaluations,and treatment: a$25 Copayment per visit We cover the following Services and their administration • Emergency Department visits: a$75 Copayment per in a Plan Facility at the Cost Share indicated: visit • Whole blood,red blood cells,plasma,and platelets: no charge If you are admitted from the Emergency Department. • Allergy antigens(including administration): a If you are admitted to the hospital as an inpatient for $3 Copayment per visit covered Services(either within 24 hours for the same condition or after an observation stay),then the Services • Cancer chemotherapy drugs and adjuncts:no charge you received in the Emergency Department and • Drugs and products that are administered via observation stay,if applicable,will be considered part of intravenous therapy or injection that are not for your inpatient hospital stay. For the Cost Share for cancer chemotherapy,including blood factor products inpatient care,refer to"Hospital Inpatient Services"in and biological products("biologics")derived from this"Benefits and Your Cost Share"section.However, tissue,cells,or blood: no charge the Emergency Department Cost Share does apply if you . Tuberculosis skin tests: no charge Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 26 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • All other administered drugs and products: no charge Hospital Inpatient Services We cover drugs and products administered to you during We cover the following inpatient Services in a Plan a home visit at no charge. Hospital,when the Services are generally and customarily provided by acute care general hospitals Certain administered drugs are Preventive Services. inside our Service Area: Refer to"Preventive Services"for information on • Room and board,including a private room immunizations. if Medically Necessary Note:Vaccines covered by Medicare Part D are not • Specialized care and critical care units covered under this"Outpatient Care"section(instead, • General and special nursing care refer to"Outpatient Prescription Drugs, Supplies,and . Operating and recovery rooms Supplements"in this"Benefits and Your Cost Share" section). • Services of Plan Physicians,including consultation and treatment by specialists For the following Services, refer to these • Anesthesia sections o Drugs prescribed in accord with our drug formulary • Bariatric Surgery guidelines(for discharge drugs prescribed when you are released from the hospital,refer to"Outpatient • Dental Services Prescription Drugs, Supplies,and Supplements"in • Dialysis Care this"Benefits and Your Cost Share"section) • Durable Medical Equipment("DME")for Home Use • Radioactive materials used for therapeutic purposes • Fertility Services • Durable medical equipment and medical supplies • Health Education • Imaging,laboratory,and other diagnostic and • Hearing Services treatment Services,including MRI,CT,and PET scans • Home-Delivered Meals • Whole blood,red blood cells,plasma,platelets,and • Home Health Care their administration • Hospice Care o Obstetrical care and delivery(including cesarean • Mental Health Services section).Note:If you are discharged within 48 hours • Ostomy,Urological,and Specialized Wound Care after delivery(or within 96 hours if delivery is by Supplies cesarean section),your Plan Physician may order a follow-up visit for you and your newborn to take • Outpatient Imaging,Laboratory,and Other place within 48 hours after discharge(for visits after Diagnostic and Treatment Services you are released from the hospital,please refer to • Outpatient Prescription Drugs,Supplies,and "Outpatient Care"in this`Benefits and Your Cost Supplements Share"section) • Preventive Services • Physical,occupational,and speech therapy(including treatment in an organized,multidisciplinary • Prosthetic and Orthotic Devices rehabilitation program)in accord with Medicare • Reconstructive Surgery guidelines • Services Associated with Clinical Trials • Respiratory therapy • Substance Use Disorder Treatment • Medical social services and discharge planning • Transplant Services Your Cost Share.We cover hospital inpatient Services • Transportation Services at a$250 Copayment per admission. • Vision Services For the following Services, refer to these sections • Bariatric surgical procedures(refer to"Bariatric Surgery") Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 27 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Dental procedures(refer to"Dental Services") Nonemergency • Dialysis care(refer to"Dialysis Care") Inside our Service Area,we cover nonemergency ambulance Services in accord with Medicare guidelines • Fertility Services related to diagnosis and treatment of if a Plan Physician determines that your condition infertility,artificial insemination,or assisted requires the use of Services that only a licensed reproductive technology(refer to"Fertility Services") ambulance can provide and that the use of other means • Hospice care(refer to"Hospice Care") of transportation would endanger your health. These • Mental health Services(refer to"Mental Health Services are covered only when the vehicle transports Services") you to and from qualifying locations as defined by Medicare guidelines. • Prosthetics and orthotics(refer to"Prosthetic and Orthotic Devices") Your Cost Share • Reconstructive surgery Services(refer to You pay the following for covered ambulance Services: "Reconstructive Surgery") . Emergency ambulance Services: a$100 Copayment • Religious Nonmedical Health Care Institution per trip Services(refer to"Religious Nonmedical Health Care . Nonemergency Services: a$100 Copayment per Institution") trip • Services in connection with a clinical trial(refer to "Services in Connection with a Clinical Trial") Ambulance Services exclusions • Skilled inpatient Services in a Plan Skilled Nursing • Transportation by car,taxi,bus,gurney van, Facility(refer to"Skilled Nursing Facility Care") wheelchair van,and any other type of transportation • Substance use disorder treatment Services(refer to (other than a licensed ambulance),even if it is the "Substance Use Disorder Treatment") only way to travel to a Plan Provider,except as otherwise covered under"Transportation Services"in • Transplant Services(refer to"Transplant Services") this section Ambulance Services Bariatric Surgery Emergency We cover hospital inpatient Services related to bariatric We cover Services of a licensed ambulance anywhere in surgical procedures(including room and board,imaging, the world without prior authorization(including laboratory,other diagnostic and treatment Services,and transportation through the 911 emergency response Plan Physician Services)when performed to treat obesity system where available)in the following situations: by modification of the gastrointestinal tract to reduce • You reasonably believed that the medical condition nutrient intake and absorption,if all of the following was an Emergency Medical Condition which required requirements are met: ambulance Services • You complete the Medical Group—approved pre- • Your treating physician determines that you must be surgical educational preparatory program regarding transported to another facility because your lifestyle changes necessary for long term bariatric Emergency Medical Condition is not Stabilized and surgery success the care you need is not available at the treating • A Plan Physician who is a specialist in bariatric care facility determines that the surgery is Medically Necessary If you receive emergency ambulance Services that are Your Cost Share.For covered Services related to not ordered by a Plan Provider,you are not responsible bariatric surgical procedures that you receive,you will for any amounts beyond your Cost Share for covered pay the Cost Share you would pay if the Services were emergency ambulance Services.However,if the provider not related to a bariatric surgical procedure.For does not agree to bill us,you may have to pay for the example,see"Hospital Inpatient Services"in this Services and file a claim for reimbursement.For "Benefits and Your Cost Share"section for the Cost information on how to file a claim,please see the Share that applies for hospital inpatient Services. "Requests for Payment"section. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 28 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. For the following Services, refer to these Your Cost Share sections You pay the following for dental Services covered under • Outpatient prescription drugs(refer to"Outpatient this"Dental Services"section: Prescription Drugs, Supplies,and Supplements") • Non-Physician Specialist Visits with dentists for • Outpatient administered drugs(refer to"Outpatient Services covered under this"Dental Services" Care") section: a$25 Copayment per visit • Physician Specialist Visits for Services covered under this"Dental Services"section: a$25 Copayment per Dental Services visit Dental Services for radiation treatment • Outpatient surgery and outpatient procedures when We cover services in accord with Medicare guidelines, provided in an outpatient or ambulatory surgery including dental evaluation,X-rays,fluoride treatment, center or in a hospital operating room,or if it is and extractions necessary to prepare your jaw for provided in any setting and a licensed staff member radiation therapy of cancer in your head or neck if a Plan monitors your vital signs as you regain sensation after Physician provides the Services or if the Medical Group receiving drugs to reduce sensation or to minimize authorizes a referral to a dentist for those Services(as discomfort: a$25 Copayment per procedure described in"Medical Group authorization procedure for • Any other outpatient surgery that does not require a certain referrals"under"Getting a Referral"in the"How licensed staff member to monitor your vital signs as to Obtain Services"section). described above: a$25 Copayment per procedure Dental Services for transplants • Any other outpatient procedures that do not require a licensed staff member to monitor your vital signs as We cover dental services that are Medically Necessary to described above: the Cost Share that would free the mouth from infection in order to prepare fora otherwise apply for the procedure in this"Benefits transplant covered under"Transplant Services"in this and Your Cost Share"section(for example,radiology "Benefits and Your Cost Share"section,if a Plan procedures that do not require a licensed staff Physician provides the Services or if the Medical Group member to monitor your vital signs as described authorizes a referral to a dentist for those Services(as above are covered under"Outpatient Imaging, described in"Medical Group authorization procedure for Laboratory,and Other Diagnostic and Treatment certain referrals"under"Getting a Referral"in the"How Services") to Obtain Services"section). • Hospital inpatient Services(including room and Dental anesthesia board,drugs,imaging,laboratory,other diagnostic For dental procedures at a Plan Facility,we provide and treatment Services,and Plan Physician Services): general anesthesia and the facility's Services associated a$250 Copayment per admission with the anesthesia if all of the following are true: For the following Services, refer to these • You are under age 7,or you are developmentally sections disabled,or your health is compromised • Office visits not described in this"Dental Services" • Your clinical status or underlying medical condition section(refer to"Outpatient Care") requires that the dental procedure be provided in a hospital or outpatient surgery center • Outpatient imaging,laboratory,and other diagnostic and treatment Services(refer to"Outpatient Imaging, • The dental procedure would not ordinarily require Laboratory,and Other Diagnostic and Treatment general anesthesia Services") We do not cover any other Services related to the dental • Outpatient prescription drugs(refer to"Outpatient procedure,such as the dentist's Services,unless the Prescription Drugs, Supplies,and Supplements") Service is covered in accord with Medicare guidelines or for transplant services. Dialysis Care We cover acute and chronic dialysis Services if all of the following requirements are met: • You satisfy all medical criteria developed by the Medical Group Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 29 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • The facility is certified by Medicare • Outpatient laboratory(refer to"Outpatient Imaging, • A Plan Physician provides a written referral for your Laboratory,and Other Diagnostic and Treatment dialysis treatment except for out-of-area dialysis care Services") • Outpatient prescription drugs(refer to"Outpatient We also cover hemodialysis and peritoneal home dialysis Prescription Drugs, Supplies,and Supplements") (including equipment,training,and medical supplies). • Outpatient administered drugs(refer to"Outpatient Coverage is limited to the standard item of equipment or Care") supplies that adequately meets your medical needs.We . Telehealth Visits(refer to"Telehealth Visits") decide whether to rent or purchase the equipment and supplies,and we select the vendor.You must return the equipment and any unused supplies to us or pay us the Dialysis care exclusions fair market price of the equipment and any unused • Comfort,convenience,or luxury equipment,supplies supply when we are no longer covering them. and features Out-of-area dialysis care • Nonmedical items,such as generators or accessories We cover dialysis(kidney) Services that you get at a to make home dialysis equipment portable for travel Medicare-certified dialysis facility when you are temporarily outside our Service Area.If possible,before Durable Medical Equipment ("DME") for you leave the Service Area,please let us know where Home Use you are going so we can help arrange for you to have maintenance dialysis while outside our Service Area. DME coverage rules DME for home use is an item that meets the following The procedure for obtaining reimbursement for out-of- criteria: area dialysis care is described in the"Requests for • The item is intended for repeated use Payment"section. • The item is primarily and customarily used to serve a Your Cost Share.You pay the following for these medical purpose covered Services related to dialysis: o The item is generally useful only to an individual • Equipment and supplies for home hemodialysis and with an illness or injury home peritoneal dialysis: no charge . The item is appropriate for use in the home(or • One routine outpatient visit per month with the another location used as your home as defined by multidisciplinary nephrology team for a consultation, Medicare) evaluation,or treatment: no charge • The item is expected to last at least 3 years • Hemodialysis and peritoneal dialysis treatment: no charge For a DME item to be covered,all of the following • Hospital inpatient Services(including room and requirements must be met: board,drugs,imaging,laboratory,and other • Your EOC includes coverage for the requested DME diagnostic and treatment Services,and Plan Physician item Services): a$250 Copayment per admission • A Plan Physician has prescribed the DME item for For the following Services, refer to these your medical condition sections • The item has been approved for you through the Plan's prior authorization process,as described in • Durable medical equipment for home use(refer to "Medical Group authorization procedure for certain "Durable Medical Equipment("DME")for Home referrals"under"Getting a Referral"in the"How to Use") Obtain Services"section • Hospital inpatient Services(refer to"Hospital • The Services are provided inside our Service Area Inpatient Services") • Office visits not described in this"Dialysis Care" Coverage is limited to the standard item of equipment section(refer to"Outpatient Care") that adequately meets your medical needs.We decide • Kidney disease education(refer to"Health whether to rent or purchase the equipment,and we select Education") the vendor. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 30 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. DME for diabetes ("DME")for Home Use"section are met,we cover the We cover the following diabetes testing supplies and following other DME items(including repair or equipment and insulin-administration devices if all of the replacement of covered equipment): requirements described under"DME coverage rules"in • Bed accessories for a hospital bed when bed this"Durable Medical Equipment("DME")for Home extension is required Use"section are met: • Heel or elbow protectors to prevent or minimize • Glucose monitors for diabetes testing and their advanced pressure relief equipment use supplies(such as glucose monitor test strips,lancets, • Iontophoresis device to treat hyperhidrosis when and lancet devices) antiperspirants are contraindicated and the • Insulin pumps and supplies to operate the pump hyperhidrosis has created medical complications(for example,skin infection)or preventing daily living Your Cost Share.You pay the following for covered activities DME for diabetes(including repair or replacement of • Nontherapeutic continuous glucose monitoring covered equipment): devices and related supplies • Glucose monitors for diabetes testing and their • Peak flow meters supplies(such as glucose monitor test strips,lancets, and lancet devices): no charge • Resuscitation bag if tracheostomy patient has • Insulin pumps and supplies to operate the pump: significant secretion management problems,needing 20 percent Coinsurance lavage and suction technique aided by deep breathing via resuscitation bag Base DME Items Your Cost Share.You pay the following for other We cover Base DME Items(including repair or covered DME items: 20 percent Coinsurance,except replacement of covered equipment)if all of the peak flow meters are covered at: no charge. requirements described under"DME coverage rules"in this"Durable Medical Equipment("DME")for Home Outside our Service Area Use"section are met. "Base DME Items"means the following items: We do not cover most DME for home use outside our Service Area.However,if you live outside our Service • Glucose monitors for diabetes blood testing and their Area,we cover the following DME(subject to the Cost supplies(such as blood glucose monitor test strips, Share and all other coverage requirements that apply to lancets,and lancet devices) DME for home use inside our Service Area)when the • Bone stimulator item is dispensed at a Plan Facility: • Canes(standard curved handle or quad)and • Blood glucose monitors for diabetes blood testing and replacement supplies their supplies(such as blood glucose monitor test Cervical traction(over door) strips,lancets,and lancet devices)from a Plan • Pharmacy • Crutches(standard or forearm)and replacement • Canes(standard curved handle) supplies • Dry pressure pad for a mattress • Crutches(standard) • Nebulizers and their supplies for the treatment of • Infusion pumps(such as insulin pumps)and supplies pediatric asthma to operate the pump IV pole • Peak flow meters from a Plan Pharmacy • • Nebulizer and supplies For the following Services, refer to these • Phototherapy blankets for treatment of jaundice in sections newborns • Dialysis equipment and supplies required for home hemodialysis and home peritoneal dialysis(refer to Your Cost Share.You pay the following for covered "Dialysis Care") Base DME Items: 20 percent Coinsurance. • Diabetes urine testing supplies and insulin- Other covered DME items administration devices other than insulin pumps(refer to"Outpatient Prescription Drugs, Supplies,and If all of the requirements described under"DME Supplements") coverage rules"in this"Durable Medical Equipment Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 31 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Durable medical equipment related to the terminal You pay the following for covered infertility Services: illness for Members who are receiving covered • Office visits: a$25 Copayment per visit hospice care(refer to"Hospice Care") • Most outpatient surgery and outpatient procedures • Insulin and any other drugs administered with an when provided in an outpatient or ambulatory surgery infusion pump(refer to"Outpatient Prescription center or in a hospital operating room,or provided in Drugs,Supplies,and Supplements") any setting where a licensed staff member monitors your vital signs as you regain sensation after DME for home use exclusions receiving drugs to reduce sensation or to minimize • Comfort,convenience,or luxury equipment or discomfort: a$25 Copayment per procedure features • Any other outpatient surgery that does not require a • Dental appliances licensed staff member to monitor your vital signs as • Items not intended for maintaining normal activities described above: a$25 Copayment per procedure of daily living,such as exercise equipment(including • Outpatient imaging: no charge devices intended to provide additional support for • Outpatient laboratory: no charge recreational or sports activities) • Outpatient administered drugs: no charge • Hygiene equipment • Hospital inpatient Services(including room and • Nonmedical items,such as sauna baths or elevators board,imaging,laboratory,and other diagnostic and • Modifications to your home or car,unless covered in treatment Services,and Plan Physician Services):a accord with Medicare guidelines $250 Copayment per admission • Devices for testing blood or other body substances (except diabetes glucose monitors and their supplies) Note:Administered drugs and products are medications and products that require administration or observation • Electronic monitors of the heart or lungs except infant by medical personnel.We cover these items when they apnea monitors are prescribed by a Plan Provider,in accord with our • Repair or replacement of equipment due to misuse drug formulary guidelines,and they are administered to you in a Plan Facility. Fertility Services For the following Services, refer to these sections "Fertility Services"means treatments and procedures to • Outpatient drugs,supplies,and supplements(refer to help you become pregnant. "Outpatient Prescription Drugs, Supplies,and Before starting or continuing a course of fertility Supplements") Services,you may be required to pay initial and • Diagnostic Services provided by Plan Providers who subsequent deposits toward your Cost Share for some or are not physicians,such as EKGs and EEGs(refer to all of the entire course of Services,along with any past- "Outpatient Imaging,Laboratory,and Other due fertility-related Cost Share.Any unused portion of Diagnostic and Treatment Services") your deposit will be returned to you.When a deposit is not required,you must pay the Cost Share for the Fertility Services exclusions procedure,along with any past-due fertility-related Cost • Reversal of surgical sterilization originally performed Share,before you can schedule a fertility procedure. for family planning purposes Diagnosis and treatment of infertility • Semen and eggs(and Services related to their For purposes of this"Diagnosis and treatment of procurement and storage) infertility"section,"infertility"means not being able to • Assisted reproductive technology Services,such as get pregnant or carry a pregnancy to a live birth after a ovum transplants,gamete intrafallopian transfer year or more of regular sexual relations without (GIFT),in vitro fertilization(IVF),and zygote contraception or having a medical or other demonstrated intrafallopian transfer(ZIFT) condition that is recognized by a Plan Physician as a cause of infertility.We cover the following: • Services for the diagnosis and treatment of infertility • Artificial insemination Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 32 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Fitness benefit (One Pass TM) Health Education A fitness benefit is provided through the One Pass We cover a variety of health education counseling, program to help members take control of their health and programs,and materials that your personal Plan feel their best.The One Pass program includes: Physician or other Plan Providers provide during a visit • Gyms and Fitness Locations:You receive a covered under another part of this EOC. membership with access to a wide variety of in- network gyms through the core and premium We also cover a variety of health education counseling, networks.Fitness locations include national,local, programs,and materials to help you take an active role in and community fitness centers and boutique studios. protecting and improving your health,including You can use any in-network location,and you may programs for tobacco cessation,stress management,and use multiple participating fitness locations during the chronic conditions(such as diabetes and asthma).Kaiser Permanente also offers health education counseling, same month programs,and materials that are not covered,and you • Online Fitness:You have access to live,digital fitness may be required to pay a fee. classes and on-demand workouts through the One Pass member website or mobile app For more information about our health education • Fitness and Social Activities:You also have access to counseling,programs,and materials,please contact a groups,clubs,and social events through the One Pass Health Education Department or Member Services or go member website to our website at ky.org. • Home Fitness Kits:If you prefer to work out at home, you can select a home fitness kit for Strength,Yoga, Note: Our Health Education Department offers a comprehensive self-management workshop to help or Dance members learn the best choices in exercise,diet, • Brain Health:Access to online brain health cognitive monitoring,and medications to manage and control training programs diabetes.Members may also choose to receive diabetes self-management training from a program outside our For more information about participating gyms and plan that is recognized by the American Diabetes fitness locations,the program's benefits,or to set up your Association(ADA)and approved by Medicare.Also,our online account,please visit www.YourOnePass.com or Health Education Department offers education to teach call 1-877-614-0618(TTY 711),Monday through kidney care and help members make informed decisions Friday,6 a.m.to 7 p.m. about their care. One Pass®is a registered trademark of Optum,Inc. in Your Cost Share.You pay the following for these the U.S. and other jurisdictions and is a voluntary covered Services: program.The One Pass program and amenities vary by plan,area,and location.The information provided under • Covered health education programs,which may this program is for general informational purposes only include programs provided online and counseling and is not intended to be nor should be construed as over the phone: no charge medical advice. One Pass is not responsible for the • Other covered individual counseling when the office services or information provided by third parties. visit is solely for health education: a$25 Copayment Individuals should consult an appropriate health care per visit professional before beginning any exercise program o Health education provided during an outpatient and/or to determine what may be right for them. consultation or evaluation covered in another part of this EOC: no additional Cost Share beyond the Your Cost Share:You pay the following: no charge. Cost Share required in that other part of this EOC Fitness benefit exclusions • Covered health education materials: no charge • Additional services(such as personal training,fee- based group fitness classes,expanded access hours,or Hearing Services additional classes outside of the standard membership offering) We cover the following: • Hearing exams with an audiologist to determine the need for hearing correction: a$25 Copayment per visit Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 33 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Physician Specialist Visits to diagnose and treat of discharge.You can contact Member Services if hearing problems: a$25 Copayment per visit you have any questions about your meals coverage • In addition to meals for general health,there are Hearing aids menus to support specific conditions and diets We cover the following Services related to hearing aids: • A$1,000 Allowance for each ear toward the purchase Your Cost Share.We cover home-delivered meals at price of a hearing aid(including fitting,counseling, no charge. adjustment,cleaning,and inspection during the 3-year warranty)every 36 months when prescribed by a Plan Home-delivered meals exclusions Physician or by a Plan Provider who is an audiologist. We will not cover meals if more than 30 days have We will cover hearing aids for both ears only if both passed since your discharge(except in limited aids are required to provide significant improvement circumstances)or if you are discharged as follows: that is not obtainable with only one hearing aid.We . To another facility that provides meals(for example, will not provide the Allowance if we have provided inpatient rehabilitation) an Allowance toward(or otherwise covered)a hearing aid within the previous 36 months.Also,the • From a Non-Plan Hospital or Skilled Nursing Allowance can only be used at the initial point of sale. Facility,Hospital Observation,Outpatient Surgery,or If you do not use all of your Allowance at the initial Emergency Department point of sale,you cannot use it later • To a home outside of California We select the provider or vendor that will furnish the covered hearing aids.Coverage is limited to the types Home Health Care and models of hearing aids furnished by the provider or "Home health care"means Services provided in the vendor. home by nurses,medical social workers,home health For the following Services, refer to these aides,and physical,occupational,and speech therapists. sections We cover part-time or intermittent home health care in accord with Medicare guidelines.Home health care • Services related to the ear or hearing other than those services are covered up to the number of visits and described in this section, such as outpatient care to length of time that are determined to be medically treat an ear infection or outpatient prescription drugs, necessary under the Member's home health treatment supplies,and supplements(refer to the applicable plan and no more than the limits established under heading in this"Benefits and Your Cost Share" Medicare guidelines,only if all of the following are true: section) o You are substantially confined to your home • Cochlear implants and osseointegrated hearing devices(refer to"Prosthetic and Orthotic Devices") • Your condition requires the Services of a nurse, physical therapist,or speech therapist or continued Hearing Services exclusions need for an occupational therapist(home health aide Services are not covered unless you are also getting • Internally implanted hearing aids covered home health care from a nurse,physical • Replacement parts and batteries,repair of hearing therapist,occupational therapist,or speech therapist aids,and replacement of lost or broken hearing aids that only a licensed provider can provide) (the manufacturer warranty may cover some of these) • A Plan Physician determines that it is feasible to maintain effective supervision and control of your care in your home and that the Services can be safely Home-Delivered Meals and effectively provided in your home Immediately following discharge from a Plan Hospital or • The Services are provided inside our Service Area Skilled Nursing Facility as an inpatient,we cover up to three meals per day in a consecutive four-week period, Your Cost Share.We cover home health care Services once per calendar year as follows: at no charge. • When you are discharged from a Plan Hospital or Skilled Nursing Facility,the meal delivery vendor For the following Services, refer to these will contact you to review your meal options and sections arrange meal delivery to your home in California.In • Dialysis care(refer to"Dialysis Care") most cases,the meals must be initiated within 30 days Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 34 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Durable medical equipment(refer to"Durable • The following equipment necessary to ensure that you Medical Equipment("DME")for Home Use") are monitored appropriately in your home:blood • Ostomy,urological,and specialized wound care pressure cuff/monitor,pulse oximeter,scale,and supplies(refer to"Ostomy,Urological,and thermometer Specialized Wound Care Supplies") • Mobile imaging and tests such as X-rays,labs,and • Outpatient drugs,supplies,and supplements(refer to EKGs "Outpatient Prescription Drugs, Supplies,and • The following safety items: shower stools,raised Supplements") toilet seats,grabbers,long handle shoehorn,and sock • Outpatient physical,occupational,and speech therapy aid visits(refer to"Outpatient Care") • Up to 21 meals per week while you are receiving • Prosthetic and orthotic devices(refer to"Prosthetic acute care in the home and Orthotic Devices") In addition,for Medicare-covered services and items Home health care exclusions listed below,the Cost-Sharing indicated elsewhere in this EOC does not apply when the Services and items are • Care in the home if the home is not a safe and prescribed as part of your home treatment plan: effective treatment setting • Durable medical equipment • Medical supplies Home Medical Care Not Covered by Non-emergent ambulance transportation to and from Medicare for Members Who Live in network facilities when scheduled ambulance Certain Counties (Advanced Care at transport is Medically Necessary Home) • Physician assistant and nurse practitioner house calls We cover inedical care in your home that is not or office visits otherwise covered by Medicare when found medically • The following Services at a Plan Facility if the appropriate by a physician based on your health status to Services are part of your home treatment plan: provide you with an alternative to receiving acute care in ♦ Network Emergency Department visits associated a hospital and post-acute care Services in the home to with this benefit support your recovery. Services in the home must be: ♦ Physical,speech,or occupational therapy office • Prescribed by a network hospitalist who has visits determined that based on your health status,treatment ♦ X-rays,labs,ultrasounds,and EKGs plan,and home setting that you can be treated safely and effectively in the home The cost-sharing indicated elsewhere in this EOC will • Elected by you because you prefer to receive the care apply to all other Services and items that are not part of described in your treatment plan in your home your home treatment plan(for example,DME unrelated to your home treatment plan)or are part of your home Our network provider will provide the following services treatment plan,but are not provided in your home except and items in your home in accord with your treatment as listed above.Note:For prescription drug Cost-Sharing plan for as long as they are prescribed by a network information,refer to the"Outpatient Prescription Drugs, hospitalist: Supplies,and Supplements"section. • Home visits by RNs,physical therapists,occupational therapists,speech therapists,respiratory therapists, Hospice Care nutritionist,home health aides,and other healthcare professionals in accord with the home care treatment Hospice care is a specialized form of interdisciplinary plan and the provider's scope of practice and license health care designed to provide palliative care and to • Communication devices to allow you to contact the alleviate the physical,emotional,and spiritual Advanced Care at Home command center 24 hours a discomforts of a Member experiencing the last phases of day,7 days a week.This includes needed life due to a terminal illness.It also provides support to communication technology to support reliable the primary caregiver and the Member's family.A communication,and an PERS alert device to contact Member who chooses hospice care is choosing to receive the command center if you are unable to get to a palliative care for pain and other symptoms associated phone with the terminal illness,but not to receive care to try to Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 35 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. cure the terminal illness.You may change your decision For drugs that may be covered by our plan's Part D to receive hospice care benefits at any time. benefit:If these drugs are unrelated to your terminal hospice condition,you pay cost-sharing.If they are If you have Medicare Part A,you are eligible for the related to your terminal hospice condition,then you pay hospice benefit when your doctor and the hospice Original Medicare cost-sharing.Drugs are never covered medical director have given you a terminal prognosis by both hospice and our plan at the same time.For more certifying that you're terminally ill and have six months information,please see"What if you're in a Medicare- or less to live if your illness runs its normal course.You certified hospice"in the"Outpatient Prescription Drugs, may receive care from any Medicare-certified hospice Supplies,and Supplements"section. program. Our plan is obligated to help you find Medicare-certified hospice programs in our plan's Note:If you need non-hospice care(care that is not Service Area,including those the MA organization owns, related to your terminal prognosis),you should contact controls,or has a financial interest in.Your hospice us to arrange the services. doctor can be a Plan Provider or a Non—Plan Provider. Covered Services include: For more information about Original Medicare hospice • Drugs for symptom control and pain relief coverage,visit https://www.medicare.2ov,and under "Search Tools,"choose"Find a Medicare Publication"to • Short-term respite care view or download the publication"Medicare Hospice • Home care Benefits."Or call 1-800-MEDICARE(1-800-633-4227) (TTY users call 1-877-486-2048),24 hours a day,seven When you are admitted to a hospice you have the right to days a week. remain in your plan;if you chose to remain in your plan, you must continue to pay plan premiums. Special note if you do not have Medicare Part A We cover the hospice Services listed below at no charge For hospice services and for services that are covered only if all of the following requirements are met: by Medicare Part A or B and are related to your o You are not entitled to Medicare Part A terminal prognosis: Original Medicare(rather than our plan)will a our hospice provider for our hospice • A Plan Physician has diagnosed you with a terminal p ) pay y p p y p expectancy life ext that our i t d determines a services and any Part A and Part B services related to illness an y p y is 12 your terminal condition.While you are in the hospice months or less program,your hospice provider will bill Original • The Services are provided inside our Service Area(or Medicare for the services that Original Medicare pays inside California but within 15 miles or 30 minutes for.You will be billed Original Medicare cost-sharing. from our Service Area if you live outside our Service Area,and you have been a Senior Advantage Member For services that are covered by Medicare Part A or continuously since before January 1, 1999,at the B and are not related to your terminal prognosis: same home address) If you need nonemergency,non—urgently needed o The Services are provided by a licensed hospice services that are covered under Medicare Part A or B and agency that is a Plan Provider that are not related to your terminal condition,your cost for these services depends on whether you use a Plan • A Plan Physician determines that the Services are Provider and follow plan rules(such as if there is a necessary for the palliation and management of your requirement to obtain prior authorization): terminal illness and related conditions • If you obtain the covered services from a Plan If all of the above requirements are met,we cover the Provider and follow plan rules for obtaining service, following hospice Services,if necessary for your hospice you only pay the Plan Cost Share amount care: • If you obtain the covered services from a Non—Plan o Plan Physician Services Provider,you pay the cost sharing under Fee-for- Service Medicare(Original Medicare) • Skilled nursing care,including assessment, evaluation,and case management of nursing needs, For services that are covered by our plan but are not treatment for pain and symptom control,provision of covered by Medicare Part A or B:We will continue to emotional support to you and your family,and cover Plan-covered Services that are not covered under instruction to caregivers Part A or B whether or not they are related to your terminal condition.You pay your Plan Cost Share amount for these Services. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 36 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Physical,occupational,and speech therapy for "Mental Disorders"include the following conditions: purposes of symptom control or to enable you to • Severe Mental Illness of a person of any age maintain activities of daily living • Serious Emotional Disturbance of a Child Under Age • Respiratory therapy 18 • Medical social services • Home health aide and homemaker services In addition to the Services described in this Mental Health Services section,we also cover other Services • Palliative drugs prescribed for pain control and that are Medically Necessary to treat Serious Emotional symptom management of the terminal illness for up to Disturbance of a Child Under Age 18 or Severe Mental a 100-day supply in accord with our drug formulary Illness,if the Medical Group authorizes a written referral guidelines.You must obtain these drugs from a Plan (as described in"Medical Group authorization procedure Pharmacy.Certain drugs are limited to a maximum for certain referrals"under"Getting a Referral"in the 30-day supply in any 30-day period(your Plan "How to Obtain Services"section). Pharmacy can tell you if a drug you take is one of these drugs) Outpatient mental health Services • Durable medical equipment We cover the following Services when provided by Plan • Respite care when necessary to relieve your Physicians or other Plan Providers who are licensed caregivers.Respite care is occasional short-term health care professionals acting within the scope of their inpatient Services limited to no more than five license: consecutive days at a time • Individual and group mental health evaluation and • Counseling and bereavement services treatment • Psychological testing when necessary to evaluate a • Dietary counseling Mental Disorder We also cover the following hospice Services only • Outpatient Services for the purpose of monitoring during periods of crisis when they are Medically drug therapy Necessary to achieve palliation or management of acute medical symptoms: Intensive psychiatric treatment programs • Nursing care on a continuous basis for as much as 24 We cover intensive psychiatric treatment programs at a hours a day as necessary to maintain you at home Plan Facility,such as: • Short-term inpatient Services required at a level that • Partial hospitalization cannot be provided at home • Multidisciplinary treatment in an intensive outpatient or day-treatment program Mental Health Services • Psychiatric observation for an acute psychiatric crisis We cover Services specified in this"Mental Health Your Cost Share.You pay the following for these Services"section only when the Services are for the covered Services: diagnosis or treatment of Mental Disorders.A"Mental • Individual mental health evaluation and treatment: a Disorder"is a mental health condition identified as a $25 Copayment per visit "mental disorder"in the Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition, Text • Group mental health treatment: a$12 Copayment Revision,as amended in the most recently issued edition, per visit (`DSM")that results in clinically significant distress or • Partial hospitalization: no charge impairment of mental,emotional,or behavioral functioning.We do not cover services for conditions that • Other intensive psychiatric treatment programs: the DSM identifies as something other than a"mental no charge disorder."For example,the DSM identifies relational Residential treatment problems as something other than a"mental disorder,"so we do not cover services(such as couples counseling or Inside our Service Area,we cover the following Services family counseling)for relational problems. when the Services are provided in a licensed residential treatment facility that provides 24-hour individualized mental health treatment,the Services are generally and customarily provided by a mental health residential treatment program in a licensed residential treatment Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 37 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. facility,and the Services are above the level of custodial • Toxicology testing care: . Intake activities • Individual and group mental health evaluation and . Periodic assessments treatment Medical services • Medicare Part B clinically administered drugs • • Medication monitoring Your Cost Share:You pay the following for these • Room and board covered Services: no charge. • Drugs prescribed by a Plan Provider as part of your plan of care in the residential treatment facility in Ostomy, Urological, and Specialized accord with our drug formulary guidelines if they are Wound Care Supplies administered to you in the facility by medical personnel(for discharge drugs prescribed when you We cover ostomy,urological,and specialized wound are released from the residential treatment facility, care supplies if the following requirements are met: refer to"Outpatient Prescription Drugs, Supplies,and . A Plan Physician has prescribed ostomy,urological, Supplements"in this"Benefits and Your Cost Share" section) and specialized wound care supplies for your medical condition • Discharge planning • The item has been approved for you through the Your Cost Share.We cover residential mental health Plan's prior authorization process,as described in "Medical Group authorization procedure for certain treatment Services at no charge. referrals"under"Getting a Referral"in the"How to Inpatient psychiatric hospitalization Obtain Services"section We cover care for acute psychiatric conditions in a • The Services are provided inside our Service Area Medicare-certified psychiatric hospital. Coverage is limited to the standard item of equipment Your Cost Share.We cover inpatient psychiatric that adequately meets your medical needs.We decide hospital Services at a$250 Copayment per admission. whether to rent or purchase the equipment,and we select the vendor. For the following Services, refer to these sections Your Cost Share:You pay the following for covered ostomy,urological,and specialized wound care supplies: • Outpatient drugs,supplies,and supplements(refer to 20 percent Coinsurance. "Outpatient Prescription Drugs, Supplies,and Supplements") Ostomy, urological, and specialized wound care • Outpatient laboratory and sleep studies(refer to supplies exclusions "Outpatient Imaging,Laboratory,and Other • Comfort,convenience,or luxury equipment or Diagnostic and Treatment Services") features • Telehealth Visits(refer to"Telehealth Visits") Outpatient Imaging, Laboratory, and Opioid Treatment Program Services Other Diagnostic and Treatment Members with opioid use disorder(OUD)can receive Services coverage of Services to treat OUD through an Opioid We cover the following Services at the Cost Share Treatment Program(OTP)which includes the following indicated only when part of care covered under other Services: headings in this"Benefits and Your Cost Share"section. • U.S.Food and Drug Administration(FDA)approved The Services must be prescribed by a Plan Provider: opioid agonist and antagonist medication-assisted . Complex imaging(other than preventive)such as CT treatment(MAT)medications and the dispensing and scans,MRIs,and PET scans: no charge administration of MAT medications(if applicable) • Basic imaging Services,such as diagnostic and • Substance use disorder counseling therapeutic X-rays,mammograms,and ultrasounds: • Individual and group therapy no charge Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 38 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Nuclear medicine: no charge Outpatient Imaging, Laboratory, and Other • Routine preventive retinal photography screenings: Diagnostic and Treatment Services exclusions no charge • Ultraviolet light therapy comfort,convenience,or • Routine laboratory tests to monitor the effectiveness luxury equipment or features of dialysis:no charge • Repair or replacement of ultraviolet light therapy • Hemoglobin(Alc)testing for diabetes,Low-Density equipment due to misuse Lipoprotein(LDL)testing for heart disease, International Normalized Ratio(INR)for persons Outpatient Prescription Drugs, Supplies, with liver disease or certain blood disorders,and glucose quantitative blood tests not covered at$0 and Supplements under Original Medicare: no charge We cover outpatient drugs,supplies,and supplements • All other laboratory tests(including tests for specific specified in this"Outpatient Prescription Drugs, genetic disorders for which genetic counseling is Supplies,and Supplements"section,in accord with our available): no charge drug formulary guidelines,subject to any applicable • Diagnostic Services provided by Plan Providers who exclusions or limitations under this EOC.We cover are not physicians(such as EKGs,EEGs,and sleep items described in this section when prescribed as studies): no charge follows: • Radiation therapy: no charge • Items prescribed by Plan Providers,within the scope of their licensure and practice • Ultraviolet light therapy treatments,including . Items prescribed by the following Non—Plan ultraviolet light therapy equipment for home use,if (1)the equipment has been approved for you through Providers unless a Plan Physician determines that the the Plan's prior authorization process,as described in item is not Medically Necessary or the drug is for a "Medical Group authorization procedure for certain sexual dysfunction disorder: referrals"under"Getting a Referral"in the"How to ♦ dentists if the drug is for dental care Obtain Services"section and(2)the equipment is ♦ Non—Plan Physicians if the Medical Group provided inside your Home Region Service Area. authorizes a written referral to the Non—Plan (Coverage for ultraviolet light therapy equipment is Physician(in accord with"Medical Group limited to the standard item of equipment that authorization procedure for certain referrals" adequately meets your medical needs.We decide under"Getting a Referral'in the"How to Obtain whether to rent or purchase the equipment,and we Services"section)and the drug, supply,or select the vendor.You must return the equipment to supplement is covered as part of that referral us or pay us the fair market price of the equipment ♦ Non—Plan Physicians if the prescription was when we are no longer covering it.): no charge obtained as part of covered Emergency Services, For the following Services, refer to these Post-Stabilization Care,or Out-of-Area Urgent sections Care described in the"Emergency Services and Urgent Care"section(if you fill the prescription at • Outpatient imaging and laboratory Services that are a Plan Pharmacy,you may have to pay Charges Preventive Services,such as routine mammograms, for the item and file a claim for reimbursement as bone density scans,and laboratory screening tests described in the"Requests for Payment"section) (refer to"Preventive Services") • The item meets the requirements of our applicable • Outpatient procedures that include imaging and drug formulary guidelines diagnostic Services(refer to "Outpatient surgeries and • You obtain the item at a Plan Pharmacy or through procedures") our mail-order service,except as otherwise described • Services related to diagnosis and treatment of under"Certain items from Non—Plan Pharmacies"in infertility,artificial insemination,or assisted this"Outpatient Prescription Drugs, Supplies,and reproductive technology("ART")Services(refer to Supplements"section.Refer to our Kaiser "Fertility Services") Permanente Pharmacy Directory for the locations of Plan Pharmacies in your area.Plan Pharmacies can change without notice and if a pharmacy is no longer a Plan Pharmacy,you must obtain covered items from another Plan Pharmacy,except as otherwise described under"Certain items from Non—Plan Pharmacies"in Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 39 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. this"Outpatient Prescription Drugs, Supplies,and covered Part D prescription drugs.We will cover Supplements"section prescriptions that are filled at a Non—Plan • Your prescriber must either accept Medicare or file Pharmacy according to our Medicare Part D documentation with the Centers for Medicare& formulary guidelines Medicaid Services showing that he or she is qualified ♦ if you are unable to obtain a covered drug in a to write prescriptions,or your Part D claim will be timely manner inside your Home Region Service denied.You should ask your prescribers the next time Area because there is no Plan Pharmacy within a you call or visit if they meet this condition.If not, reasonable driving distance that provides 24-hour please be aware it takes time for your prescriber to service.We may not cover your prescription if a submit the necessary paperwork to be processed reasonable person could have purchased the drug at a Plan Pharmacy during normal business hours In addition to our plan's Part D and medical benefits ♦ if you are trying to fill a prescription for a drug coverage,if you have Medicare Part A,your drugs may that is not regularly stocked at an accessible Plan be covered by Original Medicare if you are in Medicare Pharmacy or available through our mail-order hospice.For more information,please see"What pharmacy(including high-cost drugs) if you're in a Medicare-certified hospice"in this ♦ if you are not able to get your prescriptions from a "Outpatient Prescription Drugs, Supplies,and Plan Pharmacy during a disaster Supplements"section. In these situations,please check first with Member Obtaining refills by mail Services to see if there is a Plan Pharmacy nearby. Most refills are available through our mail-order service, You may be required to pay the difference between what but there are some restrictions.A Plan Pharmacy,our you pay for the drug at the Non—Plan Pharmacy and the Kaiser Permanente Pharmacy Directory,or our cost that we would cover at Plan Pharmacy. website at ky.org/refill can give you more information about obtaining refills through our mail-order service. Payment and reimbursement.If you go to a Non—Plan Please check with your local Plan Pharmacy if you have Pharmacy for the reasons listed,you may have to pay the a question about whether your prescription can be full cost(rather than paying just your Copayment or mailed.Items available through our mail-order service Coinsurance)when you fill your prescription.You may are subject to change at any time without notice. ask us to reimburse you for our share of the cost by submitting a request for reimbursement as described in Certain items from Non—Plan Pharmacies the"Requests for Payment"section.If we pay for the Generally,we cover drugs filled at a Non—Plan drugs you obtained from a Non—Plan Pharmacy,you may Pharmacy only when you are not able to use a Plan still pay more for your drugs than what you would have Pharmacy.If you cannot use a Plan Pharmacy,here are paid if you had gone to a Plan Pharmacy because you the circumstances when we would cover prescriptions may be responsible for paying the difference between filled at a Non—Plan Pharmacy. Plan Pharmacy Charges and the price that the Non—Plan • The drug is related to covered Emergency Services, Pharmacy charged you. Post-Stabilization Care,or Out-of-Area Urgent Care described in the"Emergency Services and Urgent What if you're in a Medicare-certified hospice Care"section.Note:Prescription drugs prescribed If you have Medicare Part A,drugs are never covered by and provided outside of the United States and its both hospice and our plan at the same time.If you are territories as part of covered Emergency Services or enrolled in Medicare hospice and require an anti-nausea, Urgent Care are covered up to a 30-day supply in a laxative,pain medication,or antianxiety drug that is not 30-day period.These drugs are covered under your covered by your hospice because it is unrelated to your medical benefits,and are not covered under Medicare terminal illness and related conditions,our plan must Part D.Therefore,payments for these drugs do not receive notification from either the prescriber or your count toward reaching the Part D Catastrophic hospice provider that the drug is unrelated before our Coverage Stage plan can cover the drug. To prevent delays in receiving • For Medicare Part D covered drugs,the following are any unrelated drugs that should be covered by our plan, additional situations when a Part D drug may be you can ask your hospice provider or prescriber to make covered: sure we have the notification that the drug is unrelated before you ask a pharmacy to fill your prescription. ♦ if you are traveling outside your Home Region Service Area,but in the United States and its In the event you either revoke your hospice election or territories,and you become ill or run out of your are discharged from hospice,our plan should cover all Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 40 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. your drugs.To prevent any delays at a pharmacy when • The following insulin-administration devices at a your Medicare hospice benefit ends,you should bring $10 Copayment for up to a 30-day supply:needles, documentation to the pharmacy to verify your revocation syringes,alcohol swabs,and gauze or discharge.For more information about Medicare Part D coverage and what you pay,please see"Medicare Catastrophic Coverage Stage Part D drugs"in this"Outpatient Prescription Drugs, You enter the Catastrophic Coverage Stage when your Supplies,and Supplements"section. out-of-pocket costs have reached the$2,000 limit for the calendar year. Once you are in the Catastrophic Medicare Part D drugs Coverage Stage,you will stay in this payment stage until Medicare Part D covers most outpatient prescription the end of the calendar year.During this payment stage, drugs if they are sold in the United States and approved you pay nothing for your covered Part D drugs. for sale by the federal Food and Drug Administration. Our Part D formulary includes drugs that can be covered Note:Each year,effective on January 1,the Centers for under Medicare Part D according to Medicare Medicare&Medicaid Services may change coverage requirements and certain insulin administration devices thresholds that apply for the calendar year.We will (needles,syringes,alcohol swabs,and gauze).Refer to notify you in advance of any change to your coverage. our"Medicare Part D drug formulary(2025 Comprehensive Formulary)"in this"Outpatient These payments are included in your out-of-pocket Prescription Drugs, Supplies,and Supplements"section costs.Your out-of-pocket costs include the payments for more information about this formulary. listed below(as long as they are for Part D covered drugs,and you followed the rules for drug coverage that Initial Coverage Stage are explained in this section): During the Initial Coverage Stage,we pay our share of • The amount you pay for drugs when you are in the the cost of your covered prescription drugs,and you pay Initial Coverage Stage your Cost Share.Your Cost Share will vary depending on the drug and where you fill your prescription. • Any payments you made during this calendar year as Sometimes the cost of the drug is lower than your Cost a member of a different Medicare prescription drug Share.In these cases,you pay the lower price for the plan before you joined our plan drug instead of your Cost Share. It matters who pays: Cost Share for Medicare Part D drugs.You will pay • If you make these payments yourself,they are the following Cost Share for covered Medicare Part D included in your out-of-pocket costs drugs in this stage: • These payments are also included in your out-of- • Generic drugs: pocket costs if they are made on your behalf by ♦ a$10 Copayment for up to a 30-day supply,a certain other individuals or organizations.This $20 Copayment for a 31-to 60-day supply,or a includes payments for your drugs made by a friend or $30 Copayment for a 61-to 100-day supply at a relative,by most charities,by AIDS drug assistance Plan Pharmacy programs,employer or union health plans, ♦ a$10 Copayment for up to a 30-day supply or a TRICARE,or by the Indian Health Service.Payments $20 Copayment for a 31-to 100-day supply made by Medicare's"Extra Help"Program are also through our mail-order service included • Brand-name and specialty drugs: These payments are not included in your out-of- ♦ a$25 Copayment for up to a 30-day supply,a pocket costs.Your out-of-pocket costs do not include $50 Copayment for a 31-to 60-day supply,or a any of these types of payments: $75 Copayment for a 61-to 100-day supply at a o The amount you contribute,if any,toward your Plan Pharmacy group Is Premium ♦ a$25 Copayment for up to a 30-day supply or a $50 Copayment for a 31-to 100-day supply • Drugs you buy outside the United States and its through our mail-order service territories • Injectable Part D vaccines: no charge • Drugs that are not covered by our plan • Emergency contraceptive pills: no charge • Drugs you get at an out-of-network pharmacy that do not meet our plan's requirements for out-of-network coverage Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 41 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Non—Part D drugs,including prescription drugs amount when you get your prescription at a Plan covered by Part A or Part B and other drugs excluded Pharmacy,our plan has a process for you to either from coverage by Medicare request assistance in obtaining evidence of your proper • Payments for your drugs that are made by the Cost Share level,or,if you already have the evidence,to Veterans Health Administration(VA) provide this evidence to us. • Payments for your drugs made by a third-party with a If you aren't sure what evidence to provide us,please legal obligation to pay for prescription costs(for contact a Plan Pharmacy or Member Services.The example,Workers' Compensation) evidence is often a letter from either your state Medicaid • Payments made by drug manufacturers under the or Social Security office that confirms you are qualified Manufacturer Discount Program for"Extra Help."The evidence may also be state-issued documentation with your eligibility information Reminder: If any other organization such as the ones associated with Home and Community-Based Services. described above pays part or all of your out-of-pocket costs for Part D drugs,you are required to tell our plan You or your appointed representative may need to by calling Member Services. provide the evidence to a Plan Pharmacy when obtaining covered Part D prescriptions so that we may charge you Keeping track of Medicare Part D drugs.The Part D the appropriate Cost Share amount until the Centers for Explanation of Benefits is a document you will get for Medicare&Medicaid Services(CMS)updates its each month you use your Part D prescription drug records to reflect your current status.Once CMS updates coverage.The Part D Explanation of Benefits will tell its records,you will no longer need to present the you the total amount you,or others on your behalf,have evidence to the Plan Pharmacy. Please provide your spent on your prescription drugs and the total amount we evidence in one of the following ways so we can forward have paid for your prescription drugs.A Part D it to CMS for updating: Explanation of Benefits is also available upon request • Write to Kaiser Permanente at: from Member Services. California Service Center Attn:Best Available Evidence Medicare's "Extra Help" Program P.O.Box 232400 Medicare provides"Extra Help"to pay prescription drug San Diego,CA 92193-2400 costs for people who have limited income and resources. . Fax it to 1-877-528-8579 Resources include your savings and stocks,but not your home or car.If you qualify,you get help paying for any • Take it to a Plan Pharmacy or your local Member Medicare drug plan's monthly premium and prescription Services office at a Plan Facility Copayments.This"Extra Help"also counts toward your out-of-pocket costs. When we receive the evidence showing your Cost Share level,we will update our system so that you can pay the If you automatically qualify for"Extra Help"Medicare correct Cost Share when you get your next prescription will mail you a letter.You will not have to apply.If you at our Plan Pharmacy. If you overpay your Cost Share, do not automatically qualify you may be able to get we will reimburse you.Either we will forward a check to "Extra Help"to pay for your prescription drug premiums you in the amount of your overpayment,or we will offset and costs. To see if you qualify for getting"Extra Help," future Cost Share.If our Plan Pharmacy hasn't collected call: a Cost Share from you and is carrying your Cost Share as a debt owed by you,we may make the payment directly • 1-800-MEDICARE(1-800-633-4227)(TTY users to our Plan Pharmacy.If a state paid on your behalf,we call 1-877-486-2048),24 hours a day,seven days a may make payment directly to the state.Please call week; Member Services if you have questions. • The Social Security Office at 1-800-772-1213 (TTY users call 1-800-325-0778),between 8 a.m. and 7 If you qualify for"Extra Help,"we will send you an p.m.,Monday through Friday;or Evidence of Coverage Rider for People Who Get • Your state Medicaid office. See the"Important Phone "Extra Help"Paying for Prescription Drugs(also Numbers and Resources"section for contact known as the Low Income Subsidy Rider or the LIS information Rider),which tells you about your Part D drug coverage. If you don't have this insert,please call Member If you believe you have qualified for"Extra Help"and Services and ask for the LIS Rider. you believe that you are paying an incorrect Cost Share Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 42 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. The AIDS Drug Assistance Program (ADAP) Medicare Part D drug formulary(2025 The AIDS Drug Assistance Program(ADAP)helps Comprehensive Formulary) ADAP-eligible individuals living with HIV/AIDS have Our plan has a 2025 Comprehensive Formulary.In this access to life-saving HIV medications.Medicare Part D EOC,we call it the Drug List for short. prescription drugs that are also on the ADAP formulary qualify for prescription cost-sharing assistance through The drugs on this list are selected by our plan with the the California AIDS Drug Assistance Program. help of a team of doctors and pharmacists.The list meets Medicare's requirements and has been approved by Note:To be eligible for the ADAP operating in your Medicare. state,individuals must meet certain criteria,including proof of state residence and HIV status,low income as The drugs on our Drug List are only those covered under defined by the state,and uninsured/under-insured status. Medicare Part D. If you change plans,please notify your local ADAP enrollment worker so you can continue to receive We will generally cover a drug on our plan's Drug List assistance.For information on eligibility criteria,covered as long as you follow the other coverage rules explained drugs,or how to enroll in the program,please call the in this section and the drug is used for a medically ADAP call center at 1-844-421-7050 between 8 a.m. and accepted indication.A medically accepted indication is a 5 p.m.(excluding holidays). use of the drug that is either: Medicare Prescription Payment Plan • Approved by the Food and Drug Administration for the diagnosis or condition for which it is being The Medicare Prescription Payment Plan is a new prescribed,or payment option that works with your current drug coverage,and it can help you manage your drug costs by • Supported by certain references, such as the spreading them across monthly payments that vary American Hospital Formulary Service Drug throughout the year(January—December). This Information and the Micromedex DRUGDEX payment option might help you manage your Information System expenses,but it doesn't save you money or lower your drug costs. `Extra Help"from Medicare and help from Our Drug List includes brand-name drugs,generic drugs, your State Pharmaceutical Assistance Program(SPAP) and biological products(which may include biosimilars). and AIDS Drug Assistance Program(ADAP),for those A brand-name drug is a prescription drug that is sold who qualify,is more advantageous than participation in under a trademarked name owned by the drug the Medicare Prescription Payment Plan.All members manufacturer.Biological products are drugs that are are eligible to participate in this payment option, more complex than typical drugs.On the Drug List, regardless of income level,and all Medicare drug plans when we refer to drugs,this could mean a drug or a and Medicare health plans with drug coverage must offer biological product. this payment option. Contact us or visit Medicare.gov to find out if this payment option is right for you. A generic drug is a prescription drug that has the same active ingredients as the brand-name drug.Biological If you're participating in the Medicare Prescription products have alternatives that are called biosimilars. Payment Plan,each month you'll pay your plan premium Generally,generics and biosimilars work just as well as (if you have one)and you'll get a bill from your health or the brand-name drug or original biological product and drug plan for your prescription drugs(instead of paying usually cost less.There are generic drug substitutes the pharmacy).Your monthly bill is based on what you available for many brand-name drugs and biosimilar owe for any prescriptions you get,plus your previous alternatives for some original biological products. Some month's balance,divided by the number of months left in biosimilars are interchangeable biosimilars and, the year. depending on state law,may be substituted for the original biological product at the pharmacy without The"Important Phone Numbers and Resources"section needing a new prescription,just like generic drugs can be tells more about the Medicare Prescription Payment substituted for brand-name drugs. Plan.If you disagree with the amount billed as part of this payment option,you can follow the steps described Preferred generic and generic drugs listed in the in the"Coverage Decisions.Appeals,and Complaints" formulary will be subject to the generic drug Copayment section to make a complaint or appeal. or Coinsurance listed under"Cost Share for Medicare Part D drugs"in this"Outpatient Prescription Drugs, Supplies,and Supplements"section.Preferred and Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 43 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. nonpreferred brand-name drugs and specialty tier drugs • You may ask your Plan Physician if you can switch to listed in the formulary will be subject to the brand-name another drug that is covered by us Copayment or Coinsurance listed under"Cost Share for • You or your Plan Physician may ask us to make an Medicare Part D drugs"in this"Outpatient Prescription exception(a type of coverage determination)to cover Drugs,Supplies,and Supplements"section.Please note your Medicare Part D drug. See the"Coverage that sometimes a drug may appear more than once on our Decisions,Complaints,and Appeals"section for 2025 Comprehensive Formulary.This is because more information on how to request an exception different restrictions or cost-sharing may apply based on factors such as the strength,amount,or form of the drug prescribed by your health care provider(for instance, 10 Transition policy.If you recently joined our plan,you mg versus 100 mg;one per day versus two per day; may be able to get a temporary supply of a Medicare tablet versus liquid). Part D drug you were previously taking that may not be on our formulary or has other restrictions,during the first You can get updated information about the drugs our 90 days of your membership.Current members may also be affected by changes in our formulary from one year to plan covers by visiting our website at kp.org/seniorrx. the next.Members should talk to their Plan Physicians to You may also call Member Services to find out if your decide if they should switch to a different drug that we drug is on the formulary or to request an updated copy of cover or request a Part D formulary exception in order to our formulary. get coverage for the drug.Refer to our formulary or our website,kp.org/seniorrx,for more information about We may make certain changes to our formulary during our Part D transition coverage. the year. Changes in the formulary may affect which drugs are covered and how much you will pay when Medicare Part D exclusions(non—Part D drugs).If filling your prescription. The kinds of formulary changes you get drugs that are excluded,you must pay for them we may make include: yourself.If you appeal and the requested drug is found • Adding or removing drugs from the formulary not to be excluded under Part D,we will pay for or cover • Adding prior authorizations or other restrictions on a it.For information about appealing a decision,go to drug "Coverage Decisions,Appeals,and Complaints." If a drug is not covered by Medicare Part D,any amounts If we remove drugs from the formulary or add prior you pay for that drug will not count toward reaching the authorizations or restrictions on a drug,and you are Catastrophic Coverage Stage. taking the drug affected by the change,you will be permitted to continue receiving that drug at the same Here are three general rules about drugs that Medicare level of Cost Share for the remainder of the calendar drug plans will not cover under Part D: year.However,if a brand-name drug is replaced with a • Our plan's Part D drug coverage cannot cover a drug new generic drug,or our formulary is changed as a result that would be covered under Medicare Part A or of new information on a drug's safety or effectiveness, Part B you may be affected by this change.We will notify you • Our Plan cannot cover a drug purchased outside the of the change at least 30 days before the date that the United States or its territories change becomes effective or provide you with at least a month's supply at the Plan Pharmacy.This will give you • Our plan cannot cover off-label use of a drug when an opportunity to work with your physician to switch to a the use is not supported by certain references,such as different drug that we cover or request an exception. (If a the American Hospital Formulary Service Drug drug is removed from our formulary because the drug Information and the Micromedex DRUGDEX has been recalled,we will not give 30 days'notice before Information System. Off-label use is any use of the removing the drug from the formulary.Instead,we will drug other than those indicated on a drug's label as remove the drug immediately and notify members taking approved by the Food and Drug Administration the drug about the change as soon as possible.) In addition,by law,the following categories of drugs are If your drug isn't listed on your copy of our formulary, not covered by Medicare drug plans: you should first check the formulary on our website, • Nonprescription drugs(also called over-the-counter which we update when there is a change.In addition,you drugs) may call Member Services to be sure it isn't covered. If Member Services confirms that we don't cover your • Drugs when used to promote fertility drug,you have two options: • Drugs when used for the relief of cough or cold symptoms Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 44 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Drugs when used for cosmetic purposes or to promote • Clotting factors you give yourself by injection if you hair growth have hemophilia • Prescription vitamins and mineral products,except • Transplant/Immunosuppressive drugs,if Medicare prenatal vitamins and fluoride preparations paid for your organ transplant(or a group plan was • Drugs when used for the treatment of sexual or required to pay before Medicare paid for it).You erectile dysfunction must have Part A at the time of the covered transplant,and you must have Part B at the time you • Drugs when used for treatment of anorexia,weight get immunosuppressive drugs.Keep in mind, loss,or weight gain Medicare drug coverage(Part D)covers • Outpatient drugs for which the manufacturer seeks to immunosuppressive drugs if Part B doesn't cover require that associated tests or monitoring services be them purchased exclusively from the manufacturer as a • Certain oral anti-cancer drugs: Medicare covers some condition of sale oral cancer drugs you take by mouth if the same drug is available in injectable form or the drug is a prodrug Note:In addition to the coverage provided under this (an oral form of a drug that,when ingested,breaks Medicare Part D plan,you also have coverage for non— down into the same active ingredient found in the Part D drugs described under"Home infusion therapy," injectable drug)of the injectable drug.As new oral "Outpatient drugs covered by Medicare Part B,""Certain cancer drugs become available,Part B may cover intravenous drugs,supplies,and supplements,"and them.If Part B doesn't cover them,Part D does "Outpatient drugs,supplies,and supplements not • Intravenous Immune Globulin for the home treatment covered by Medicare"in this"Outpatient Prescription Drugs,Supplies,and Supplements"section.If a drug is of primary immune deficiency diseases not covered under Medicare Part D,refer to those • Drugs that usually aren't self-administered by the headings for information about your non—Part D drug patient and are injected or infused while you are coverage. getting physician,hospital outpatient,or ambulatory surgical center services Other prescription drug coverage.If you have o Insulin furnished through an item of durable medical additional health care or drug coverage from another equipment(such as a Medically Necessary insulin plan,you must provide that information to our plan. The pump) information you provide helps us calculate how much you and others have paid for your prescription drugs.In • Injectable osteoporosis drugs,if you are homebound, addition,if you lose or gain additional health care or have a bone fracture that a doctor certifies was related prescription drug coverage,please call Member Services post-menopausal osteoporosis,and cannot self- prescription to update your membership records. administer the drug • Some Antigens:Medicare covers antigens if a doctor Home infusion therapy prepares them and a properly instructed person(who We cover home infusion supplies and drugs at no charge could be you,the patient)gives them under if all of the following are true: appropriate supervision • Your prescription drug is on our Medicare Part D • Oral anti-nausea drugs:Medicare covers oral anti- formulary nausea drugs you use as part of an anti-cancer • We approved your prescription drug for home chemotherapeutic regimen if they're administered infusion therapy before,at,or within 48 hours of chemotherapy or are used as a full therapeutic replacement for an • Your prescription is written by a Plan Provider and intravenous anti-nausea drug filled at a Plan home-infusion pharmacy • Certain oral End-Stage Renal Disease(ESRD)drugs Outpatient drugs covered by Medicare Part B if the same drug is available in injectable form and the Part B ESRD benefit covers it In addition to Medicare Part D drugs,we also cover outpatient prescription drugs that are covered by • Calcimimetic medications under the ESRD payment Medicare Part B.The following are the types of drugs system,including the intravenous medication that Medicare Part B covers: ParsabivO,and the oral medication Sensipar® • Drugs you take using durable medical equipment • Certain drugs for home dialysis,including heparin, (such as nebulizers)that were prescribed by a Plan the antidote for heparin,when Medically Necessary, Physician and topical anesthetics Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 45 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Erythropoiesis-stimulating agents:Medicare covers prescription by law if they are listed on our drug erythropoietin by injection if you have End-Stage formulary applicable to non—Part D items and Renal Disease(ESRD)or you need this drug to treat prescribed by a Plan Physician anemia related to certain other conditions(such as • Diaphragms,cervical caps,contraceptive rings,and Procrit®,Retacrit®,Epoetin Alfa,Aranesp®,or contraceptive patches Darbepoetin Alfa) • Disposable needles and syringes needed for injecting • The Alzheimer's drug,Leqembi®(generic name covered drugs and supplements lecanemab),which is administered intravenously.In addition to medication costs,you may need additional • Inhaler spacers needed to inhale covered drugs scans and tests before and/or during treatment that o Ketone test strips and sugar or acetone test tablets or could add to your overall costs.Talk to your doctor tapes for diabetes urine testing about what scans and tests you may need as part of o FDA-approved medications for tobacco cessation, your treatment including over-the-counter medications when • Parenteral and enteral nutrition(intravenous and tube prescribed by a Plan Physician feeding) Your Cost Share for outpatient drugs,supplies,and Your Cost Share for Medicare Part B drugs.You pay supplements not covered by Medicare.Your Cost the following for Medicare Part B drugs: Share for these items is as follows: • Generic drugs: • Generic items(that are not described elsewhere in this ♦ a$10 Copayment for up to a 30-day supply,a EOC)at a Plan Pharmacy: a$10 Copayment for up $20 Copayment for a 31-to 60-day supply,or a to a 30-day supply,a$20 Copayment for a 31-to $30 Copayment for a 61-to 100-day supply at a 60-day supply,or a$30 Copayment for a 61-to Plan Pharmacy 100-day supply ♦ a$10 Copayment for up to a 30-day supply or a • Generic items(that are not described elsewhere in this $20 Copayment for a 31-to 100-day supply EOC)through our mail-order service: a through our mail-order service $10 Copayment for up to a 30-day supply or a • Brand-name drugs,specialty drugs,and compounded $20 Copayment for a 31-to 100-day supply products: • Brand-name items,specialty drugs,and compounded ♦ a$25 Copayment for up to a 30-day supply,a products(that are not described elsewhere in this $50 Copayment for a 31-to 60-day supply,or a EOC)at a Plan Pharmacy: a$25 Copayment for up $75 Copayment for a 61-to 100-day supply at a to a 30-day supply,a$50 Copayment for a 31-to Plan Pharmacy 60-day supply,or a$75 Copayment for a 61-to ♦ a$25 Copayment for up to a 30-day supply or a 100-day supply $50 Copayment for a 31-to 100-day supply • Brand-name items,specialty drugs,and compounded through our mail-order service products(that are not described elsewhere in this EOC)through our mail-order service: a Certain intravenous drugs, supplies, and $25 Copayment for up to a 30-day supply or a supplements $50 Copayment for a 31-to 100-day supply We cover certain self-administered intravenous drugs, • Generic drugs prescribed for the treatment of sexual fluids,additives,and nutrients that require specific types dysfunction disorders:25 percent Coinsurance for of parenteral-infusion(such as an intravenous or up to a 100-day supply intraspinal-infusion)at no charge for up to a 30-day . Brand drugs prescribed for the treatment of sexual supply.In addition,we cover the supplies and equipment required for the administration of these drugs at dysfunction disorders:25 percent Coinsurance for up to a 100-day supply no charge. • Generic drugs prescribed for the treatment of Outpatient drugs, supplies, and supplements infertility: a$10 Copayment for up to a 30-day not covered by Medicare supply,a$20 Copayment for a 31-to 60-day If a drug,supply,or supplement is not covered by supply,or a$30 Copayment for a 61-to 100-day Medicare Part B or D,we cover the following additional supply items in accord with our non—Part D drug formulary: • Brand drugs prescribed for the treatment of infertility: • Drugs for which a prescription is required by law.We a$25 Copayment for up to a 30-day supply,a also cover certain drugs that do not require a Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 46 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. $50 Copayment for a 31-to 60-day supply,or a prescription is required by law and a Plan Physician $75 Copayment for a 61-to 100-day supply continues to prescribe the drug for the same condition • Amino acid—modified products used to treat and for a use approved by the federal Food and Drug congenital errors of amino acid metabolism(such as Administration. phenylketonuria):no charge for up to a 30-day supply About specialty drugs. Specialty drugs are high-cost drugs that are on our specialty drug list.If your Plan • Elemental dietary enteral formula when used as a Physician prescribes more than a 30-day supply for an primary therapy for regional enteritis:no charge for outpatient drug,you may be able to obtain more than a up to a 30-day supply 30-day supply at one time,up to the day supply limit for • Ketone test strips and sugar or acetone test tablets or that drug.However,most specialty drugs are limited to a tapes for diabetes urine testing: no charge for up to a 30-day supply in any 30-day period.Your Plan 100-day supply Pharmacy can tell you if a drug you take is one of these • Tobacco cessation drugs: no charge.For over-the- drags. counter medications,we cover up to two 100-day supplies per calendar year Manufacturer coupon program.For outpatient prescription drugs or items that are covered under the Note:If Charges for the drug,supply,or supplement are "Outpatient drugs,supplies,and supplements not less than the Copayment or Coinsurance,you will pay covered by Medicare"section above and obtained at a the lesser amount. Plan Pharmacy,you may be able to use approved manufacturer coupons as payment for the Cost Share that you owe,as allowed under Health Plan's coupon Non—Part D drug formulary.The non—Part D drug program.You will owe any additional amount if the formulary includes a list of drugs that our Pharmacy and coupon does not cover the entire amount of your Cost Therapeutics Committee has approved for our Members. Share for your prescription. Certain health plan Our Pharmacy and Therapeutics Committee,which is coverages are not eligible for coupons.You can get more primarily composed of Plan Physicians and pharmacists, information regarding the Kaiser Permanente coupon selects drugs for the drug formulary based on several program rules and limitations at ku.org/rxcoupons. factors,including safety and effectiveness as determined from a review of medical literature.The drug formulary Drug utilization review is updated monthly based on new information or new drugs that become available.To find out which drugs are We conduct drug utilization reviews to make sure that on the formulary for your plan,please refer to the you are getting safe and appropriate care.These reviews California Commercial HMO formulary on our website are especially important if you have more than one at kp.org/formulary. The formulary also discloses doctor who prescribes your medications.We conduct requirements or limitations that apply to specific drugs, drug utilization reviews each time you fill a prescription such as whether there is a limit on the amount of the drug and on a regular basis by reviewing our records.During these reviews,we look for medication problems such as: that can be dispensed and whether the drug must be obtained at certain specialty pharmacies.If you would • Possible medication errors like to request a copy of this drug formulary,please call • Duplicate drugs that are unnecessary because you are Member Services.Note:The presence of a drug on the taking another similar drug to treat the same medical drug formulary does not necessarily mean that it will be condition prescribed for a particular medical condition. • Drugs that are inappropriate because of your age or Drug formulary guidelines allow you to obtain a non- gender formulary prescription drug(those not listed on our drug • Possible harmful interactions between drugs you are formulary for your condition)if it would otherwise be taking covered by your plan,as described above,and it is • Drug allergies Medically Necessary.If you disagree with a Health Plan determination that a non-formulary prescription drug is • Drug dosage errors not covered,you may file a grievance as described in the • Unsafe amounts of opioid pain medications "Coverage Decisions,Appeals,and Complaints"section. If we identify a medication problem during our drug Continuity drugs.If this EOC is amended to exclude a utilization review,we will work with your doctor to drug that we have been covering and providing to you correct the problem. under this EOC,we will continue to provide the drug if a Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 47 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Drug management program developed for us by a team of pharmacists and doctors. We have a program that that helps make sure members We use this medication therapy management program to safely use prescription opioids and other frequently help us provide better care for our members.For abused medications.This program is called a Drug example,this program helps us make sure that you are Management Program(DMP).If you use opioid using appropriate drugs to treat your medical conditions medications that you get from several prescribers or and help us identify possible medication errors. pharmacies,or if you had a recent opioid overdoes,we may talk to your prescribers to make sure your use of If you are selected to join a medication therapy opioid medications is appropriate and Medically management program,we will send you information Necessary.Working with your prescribers,if we decide about the specific program,including information about your use of prescription opioid or benzodiazepine how to access the program. medications may not be safe,we may limit how you can get those medications.If we place you in our DMP,the For the following Services, refer to these limitations may be: sections • Requiring you to get all your prescriptions for opioid • Diabetes blood-testing equipment and their supplies, or benzodiazepine medications from a certain and insulin pumps and their supplies(refer to pharmacy(ies) "Durable Medical Equipment for Home Use") • Requiring you to get all your prescriptions for opioid • Drugs covered during a covered stay in a Plan or benzodiazepine medications from a certain Hospital or Skilled Nursing Facility(refer to prescriber "Hospital Inpatient Care"and"Skilled Nursing • Limiting the amount of opioid or benzodiazepine Facility Care") medications we will cover for you • Drugs prescribed for pain control and symptom management of the terminal illness for Members who If we plan on limiting how you may get these are receiving covered hospice care(refer to"Hospice medications or how much you can get,we will send you Care") a letter in advance. The letter will tell you if we will limit o Durable medical equipment used to administer drugs coverage of these drugs for you,or if you'll be required to get the prescriptions for these drugs only from a (refer to"Durable Medical Equipment for Home Use") specific prescriber or pharmacy.You will have an opportunity to tell us which prescribers or pharmacies • Outpatient administered drugs(refer to"Outpatient you prefer to use,and about any other information you Care") think is important for us to know.After you've had the • Vaccines covered by Medicare Part B(refer to opportunity to respond,if we decide to limit your "Preventive Services") coverage for these medications,we will send you another letter confirming the limitation.If you think we made a Outpatient prescription drugs, supplies, and mistake or you disagree with our decision or with the supplements not covered by Medicare limitation,you and your prescriber have the right to limitations appeal. If you appeal,we will review your case and give you a new decision.If we continue to deny any part of • The prescribing physician or dentist determines how your request related to the limitations that apply to your much of a drug,supply,item,or supplement to access to medications,we will automatically send your prescribe.For purposes of day supply coverage limits, case to an independent reviewer outside of our plan. See Plan Physicians determine the amount of an item that the"Coverage Decisions,Appeals,and Complaints" constitutes a Medically Necessary 30-or 100-day section for information about how to ask for an appeal. supply for you.Upon payment of the Cost Share specified in the"Outpatient prescription drugs, You will not be placed in our DMP if you have certain supplies,and supplements,"you will receive the medical conditions,such as cancer-related pain or sickle supply prescribed up to the day supply limit specified cell disease,you are receiving hospice,palliative,or end- in this section or in the drug formulary for your plan of-life care,or you live in a long-term care facility. (see"Non—Part D drug formulary"above).The maximum you may receive at one time of a covered Medication therapy management program item,is either one 30-day supply in a 30-day period or We offer a medication therapy management program at one 100-day supply in a 100-day period. If you wish no additional cost to Members who have multiple to receive more than the covered day supply limit, medical conditions,who are taking many prescription then you must pay Charges for any prescribed drugs,and who have high drug costs.This program was quantities that exceed the day supply limit Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 48 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • For sexual dysfunction drugs,the maximum you may limit doesn't carry forward to the next quarter.(Your receive at one time of episodic drugs prescribed for benefit limit resets on January 1,April 1,July 1,and the treatment of sexual dysfunction disorders is eight October 1). doses in any 30-day period or up to 27 doses in any 100-day period To view our catalog and place an order online,please • The pharmacy may reduce the day supply dispensed visit kmorg/otc/ca.You may place an order over the at the Cost Share specified under"Outpatient phone or request a printed catalog be mailed to you by prescription drugs,supplies,and supplements not calling 1-833-569-2360(TTY 711),7 a.m.to 5 p.m. covered by Medicare"for any drug to a 30-day supply PST,Monday through Friday. in any 30-day period if the pharmacy determines that the item is in limited supply in the market or for Preventive Services specific drugs(your Plan Pharmacy can tell you if a drug you take is one of these drugs) We cover a variety of Preventive Services in accord with Medicare guidelines.The list of Preventive Services is Outpatient prescription drugs, supplies, and subject to change by the Centers for Medicare& supplements not covered by Medicare Medicaid Services.These Preventive Services are subject exclusions to all coverage requirements described in this"Benefits • Any requested packaging(such as dose packaging) and Your Cost Share"section and all provisions in the other than the dispensing pharmacy's standard "Exclusions,Limitations,Coordination of Benefits,and packaging Reductions"section.If you have questions about • Compounded products unless the drug is listed on one Preventive Services,please call Member Services. of our drug formularies or one of the ingredients Note:If you receive any other covered Services that are requires a prescription by law not Preventive Services during or subsequent to a visit • Drugs prescribed to shorten the duration of the that includes Preventive Services on the list,you will pay common cold the applicable Cost Share for those other Services.For • Prescription drugs for which there is an over-the- example,if laboratory tests or imaging Services ordered counter equivalent(the same active ingredient, during a preventive office visit are not Preventive strength,and dosage form as the prescription drug). Services,you will pay the applicable Cost Share for This exclusion does not apply to: those Services. ♦ insulin Your Cost Share.You pay the following for covered ♦ over-the-counter tobacco cessation drugs and Preventive Services: contraceptive drugs • Abdominal aortic aneurysm screening prescribed ♦ an entire class of prescription drugs when one drug during the one-time"Welcome to Medicare" within that class becomes available over-the- preventive visit: no charge counter • Drugs when prescribed solely for the purposes of • Annual Wellness visit: no charge losing weight,except when Medically Necessary for • Bone mass measurement: no charge the treatment of morbid obesity.We may require o Breast cancer screening(mammograms): no charge Members who are prescribed drugs for morbid obesity to be enrolled in a covered comprehensive • Cardiovascular disease risk reduction visit(therapy weight loss program,for a reasonable period of time for cardiovascular disease): no charge prior to or concurrent with receiving the prescription • Cardiovascular disease testing:no charge drug • Cervical and vaginal cancer screening: no charge • Colorectal cancer screening,including flexible Over-the-Counter (OTC) Health and sigmoidoscopies,colonoscopies,and fecal occult Wellness blood tests:no charge • Depression screening: no charge We cover OTC items listed in our OTC catalog for free . Diabetes screening,including fasting glucose tests: home delivery at no charge.You may order OTC items g, g g up to the$70 quarterly benefit limit.Each order must be no charge at least$25.Your order may not exceed your quarterly . Diabetes self-management training: no charge benefit limit.Any unused portion of the quarterly benefit Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 49 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Glaucoma screening: no charge the Cost Share that you would pay for obtaining that • HIV screening: no charge device. • Immunizations(including the vaccine)covered by Base prosthetic and orthotic devices Medicare Part B such as Hepatitis B,influenza, If all of the requirements described under"Prosthetic and pneumococcal,and COVID-19 vaccines that are orthotic coverage rules"in this"Prosthetics and Orthotic administered to you in a Plan Medical Office: Devices"section are met,we cover the items described no charge in this"Base prosthetic and orthotic devices"section. • Lung cancer screening: no charge • Medical nutrition therapy for kidney disease and Internally implanted devices.We cover prosthetic and diabetes: no charge orthotic devices such as pacemakers,intraocular lenses, cochlear implants,osseointegrated hearing devices,and • Medicare diabetes prevention program: no charge hip joints,in accord with Medicare guidelines,if they are • Obesity screening and therapy to promote sustained implanted during a surgery that we are covering under weight loss: no charge another section of this"Benefits and Your Cost Share" • Prostate cancer screening exams,including digital section.We cover these devices at no charge. rectal exams and Prostate Specific Antigens(PSA) External devices.We cover the following external tests: no charge prosthetic and orthotic devices at 20 percent • Screening and counseling to reduce alcohol misuse: Coinsurance: no charge • Prosthetics and orthotics in accord with Medicare • Screening for sexually transmitted infections(STIs) guidelines.These include,but are not limited to, and counseling to prevent STIs: no charge braces,prosthetic shoes,artificial limbs,and • Smoking and tobacco use cessation(counseling to therapeutic footwear for severe diabetes-related foot stop smoking or tobacco use): no charge disease in accord with Medicare guidelines • "Welcome to Medicare"preventive visit:no charge • Prosthetic devices and installation accessories to restore a method of speaking following the removal of all or part of the larynx(this coverage does not Prosthetic and Orthotic Devices include electronic voice-producing machines,which are not prosthetic devices) Prosthetic and orthotic devices coverage rules o After Medically Necessary removal of all or part of a We cover the prosthetic and orthotic devices specified in breast,prosthesis including custom-made prostheses this `Prosthetic and Orthotic Devices section if all of when Medically Necessary the following requirements are met: • The device is in general use,intended for repeated • Podiatric devices(including footwear)to prevent or use,and primarily and customarily used for medical treat diabetes-related complications when prescribed purposes by a Plan Physician or by a Plan Provider who is a podiatrist • The device is the standard device that adequately • Compression burn garments and lymphedema wraps meets your medical needs and garments • You receive the device from the provider or vendor • Enteral formula for Members who require tube that we select feeding in accord with Medicare guidelines • The item has been approved for you through the • Enteral pump and supplies Plan's prior authorization process,as described in "Medical Group authorization procedure for certain • Tracheostomy tube and supplies referrals"under"Getting a Referral"in the"How to • Prostheses to replace all or part of an external facial Obtain Services"section body part that has been removed or impaired as a • The Services are provided inside our Service Area result of disease,injury,or congenital defect Coverage includes fitting and adjustment of these Other covered prosthetic and orthotic devices devices,their repair or replacement,and Services to If all of the requirements described under"Prosthetic and determine whether you need a prosthetic or orthotic orthotic coverage rules"in this"Prosthetics and Orthotic device. If we cover a replacement device,then you pay Devices"section are met,we cover the following items Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 50 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. described in this"Other covered prosthetic and orthotic (including devices intended to provide additional devices"section: support for recreational or sports activities) • Prosthetic devices required to replace all or part of an • Nonconventional intraocular lenses(IOLs)following organ or extremity,in accord with Medicare cataract surgery(for example,presbyopia-correcting guidelines IOLs).You may request and we may provide • Vacuum erection device for sexual dysfunction insertion of presbyopia-correcting IOLs or astigmatism-correcting IOLs following cataract • Certain surgical boots following surgery when surgery in lieu of conventional IOLs.However,you provided during an outpatient visit must pay the difference between Charges for • Orthotic devices required to support or correct a nonconventional IOLs and associated services and defective body part,in accord with Medicare Charges for insertion of conventional IOLs following guidelines cataract surgery Your Cost Share.You pay the following for other covered prosthetic and orthotic devices: 20 percent Reconstructive Surgery Coinsurance.For internally implanted prosthetic and We cover the following reconstructive surgery Services: orthotic devices,you pay the Cost Share for the procedure to implant the device.For example,see • Reconstructive surgery to correct or repair abnormal "Outpatient Care"in this"Benefits and Your Cost structures of the body caused by congenital defects, Share"section for the Cost Share that applies for developmental abnormalities,trauma,infection, outpatient surgery. tumors,or disease,if a Plan Physician determines that it is necessary to improve function,or create a normal For the following Services, refer to these appearance,to the extent possible sections • Following Medically Necessary removal of all or part • Eyeglasses and contact lenses,including contact of a breast,we cover reconstruction of the breast, lenses to treat aniridia or aphakia(refer to"Vision surgery and reconstruction of the other breast to Services") produce a symmetrical appearance,and treatment of physical complications,including lymphedemas • Eyewear following cataract surgery(refer to"Vision Services") Your Cost Share.You pay the following for covered • Hearing aids other than internally implanted devices reconstructive surgery Services: described in this section(refer to"Hearing Services") . Outpatient surgery and outpatient procedures when • Injectable implants(refer to"Administered drugs and provided in an outpatient or ambulatory surgery products"under"Outpatient Care") center or in a hospital operating room,or if it is provided in any setting and a licensed staff member Prosthetic and orthotic devices exclusions monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize • Dental appliances discomfort: a$25 Copayment per procedure • Nonrigid supplies not covered by Medicare,such as . Any other outpatient surgery that does not require a elastic stockings and wigs,except as otherwise licensed staff member to monitor your vital signs as described above in this"Prosthetic and Orthotic described above: a$25 Copayment per procedure Devices"section and the"Ostomy,Urological,and Specialized Wound Care Supplies"section • Any other outpatient procedures that do not require a Comfort,convenience,or luxury equipment or licensed staff member to monitor your vital signs as • features described above: the Cost Share that would otherwise apply for the procedure in this"Benefits • Repair or replacement of device due to misuse and Your Cost Share"section(for example,radiology • Shoes,shoe inserts,arch supports,or any other procedures that do not require a licensed staff footwear,even if custom-made,except footwear member to monitor your vital signs as described described above in this"Prosthetic and Orthotic above are covered under"Outpatient Imaging, Devices"section for diabetes-related complications Laboratory,and Other Diagnostic and Treatment Services") • Prosthetic and orthotic devices not intended for maintaining normal activities of daily living • Hospital inpatient Services(including room and board,drugs,imaging,laboratory,other diagnostic Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 51 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. and treatment Services,and Plan Physician Services): Services Associated with Clinical Trials a$250 Copayment per admission If you participate in a Medicare-approved study,Original For the following Services, refer to these Medicare pays most of the costs for the covered Services sections you receive as part of the study.If you tell us that you • Office visits not described in this"Reconstructive are in a qualified clinical trial,then you are only Surgery"section(refer to"Outpatient Care") responsible for the in-network cost-sharing for the services in that trial.If you paid more,for example,if • Outpatient imaging and laboratory(refer to you already paid the Original Medicare cost-sharing "Outpatient Imaging,Laboratory,and Other amount,we will reimburse the difference between what Diagnostic and Treatment Services") you paid and the in-network cost-sharing.However,you • Outpatient prescription drugs(refer to"Outpatient will need to provide documentation to show us how Prescription Drugs, Supplies,and Supplements") much you paid.When you are in a clinical research study,you may stay enrolled in our plan and continue to • Outpatient administered drugs(refer to"Outpatient get the rest of your care(the care that is not related to the Care") study)through our plan. • Prosthetics and orthotics(refer to"Prosthetic and Orthotic Devices") If you want to participate in any Medicare-approved • Telehealth Visits(refer to"Telehealth Visits") clinical research study,you do not need to tell us or to get approval from us or your Plan Provider.The Reconstructive surgery exclusions providers that deliver your care as part of the clinical research study do not need to be part of our plan's • Surgery that,in the judgment of a Plan Physician network of providers.Although you do not need to get specializing in reconstructive surgery,offers only a our plan's permission to be in a clinical research study, minimal improvement in appearance we encourage you to notify us in advance when you choose to participate in Medicare-qualified clinical trials. Religious Nonmedical Health Care If you participate in a study that Medicare has not Institution Services approved,you will be responsible for paying all costs for Care in aMedicare-certified Religious Nonmedical your participation in the study. Health Care Institution(RNHCI)is covered by our plan under certain conditions.Covered Services in an RNHCI Once you join aMedicare-approved clinical research are limited to nonreligious aspects of care.To be eligible study,Original Medicare covers the routine items and Services you receive as part of the study,including: for covered Services in a RNHCI,you must have a medical condition that would allow you to receive • Room and board for a hospital stay that Medicare inpatient hospital or Skilled Nursing Facility care.You would pay for even if you weren't in a study may get Services furnished in the home,but only items o An operation or other medical procedure if it is part and Services ordinarily furnished by home health of the research study agencies that are not RNHCIs.In addition,you must sign • Treatment of side effects and complications of the a legal document that says you are conscientiously opposed to the acceptance of"nonexcepted"medical new care treatment. ("Excepted"medical treatment is a Service or treatment that you receive involuntarily or that is After Medicare has paid its share of the cost for these required under federal,state,or local law. Services,our plan will pay the difference between the "Nonexcepted"medical treatment is any other Service or cost-sharing in Original Medicare and your Cost Share as treatment.)Your stay in the RNHCI is not covered by us a Member of our plan.This means you will pay the same unless you obtain authorization(approval)in advance amount for the Services you receive as part of the study from us. as you would if you received these Services from our plan.However,you are required to submit Note: Covered Services are subject to the same documentation showing how much cost sharing you limitations and Cost Share required for Services provided paid.Please see the"Requests for Payment"section for by Plan Providers as described in this"Benefits and Your more information for submitting requests for payment. Cost Share"section. You can get more information about joining a clinical research study by visiting the Medicare website to read Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 52 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. or download the publication"Medicare and Clinical ordinarily furnish the equipment(refer to"Medical Research Studies."(The publication is available at Group authorization procedure for certain referrals" httus://www.medicare.2ov.)You can also call under"Getting a Referral"in the"How to Obtain 1-800-MEDICARE(1-800-633-4227),24 hours a day, Services"section) seven days a week.TTY users call 1-877-486-2048. . Imaging and laboratory Services that Skilled Nursing Services associated with clinical trials Facilities ordinarily provide exclusions • Medical social services When you are part of a clinical research study,neither • Whole blood,red blood cells,plasma,platelets,and Medicare nor our plan will pay for any of the following: their administration • The new item or service that the study is testing, • Medical supplies unless Medicare would cover the item or service even o Physical,occupational,and speech therapy in accord if you were not in a study with Medicare guidelines • Items or services provided only to collect data,and • Respiratory therapy not used in your direct health care • Services that are customarily provided by the research Your Cost Share.We cover these Skilled Nursing sponsors free of charge to enrollees in the clinical trial Facility Services at no charge. • Items and services provided solely to determine trial eligibility For the following Services, refer to these sections • Outpatient imaging,laboratory,and other diagnostic Skilled Nursing Facility Care and treatment Services(refer to"Outpatient Imaging, Inside our Service Area,we cover up to 100 days per Laboratory,and Other Diagnostic and Treatment benefit period of skilled inpatient Services in a Plan Services") Skilled Nursing Facility and in accord with Medicare guidelines.The skilled inpatient Services must be Non—Plan Skilled Nursing Facility care customarily provided by a Skilled Nursing Facility,and Generally,you will get your Skilled Nursing Facility above the level of custodial or intermediate care. care from Plan Facilities.However,under certain conditions listed below,you may be able to receive A benefit period begins on the date you are admitted to a covered care from a non—Plan facility,if the facility hospital or Skilled Nursing Facility at a skilled level of accepts our plan's amounts for payment. care(defined in accord with Medicare guidelines).A • A nursing home or continuing care retirement benefit period ends on the date you have not been an community where you were living right before you inpatient in a hospital or Skilled Nursing Facility, went to the hospital(as long as it provides Skilled receiving a skilled level of care,for 60 consecutive days. Nursing Facility care) A new benefit period can begin only after any existing o A Skilled Nursing Facility where your spouse is benefit period ends.A prior three-day stay in an acute living at the time you leave the hospital care hospital is not required.Note: If your Cost Share changes during a benefit period,you will continue to pay the previous Cost Share amount until a new benefit Substance Use Disorder Treatment period begins. We cover Services specified in this"Substance Use We cover the following Services: Disorder Treatment"section only when the Services are • Physician and nursing Services for the preventive,diagnosis,or treatment of Substance Use Disorders.A"Substance Use Disorder"is a • Room and board condition identified as a"substance use disorder"in the • Drugs prescribed by a Plan Physician as part of your most recently issued edition of the Diagnostic and plan of care in the Plan Skilled Nursing Facility in Statistical Manual of Mental Disorders("DSM"). accord with our drug formulary guidelines if they are administered to you in the Plan Skilled Nursing Outpatient substance use disorder treatment Facility by medical personnel We cover the following Services for treatment of • Durable medical equipment in accord with our prior substance use disorders: authorization procedure if Skilled Nursing Facilities • Day-treatment programs Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 53 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Individual and group substance use disorder Your Cost Share.We cover inpatient detoxification counseling by a qualified clinician,including a Services at a$250 Copayment per admission. licensed marriage and family therapist(LMFT) For the following Services, refer to these • Intensive outpatient programs sections • Medical treatment for withdrawal symptoms • Outpatient laboratory(refer to"Outpatient Imaging, Your Cost Share.You pay the following for these Laboratory,and Other Diagnostic and Treatment covered Services: Services") • Outpatient self-administered drugs(refer to • Individual substance use disorder evaluation and "Outpatient Prescription Drugs, Supplies,and treatment: a$25 Copayment per visit Supplements") • Group substance use disorder treatment: a . Telehealth Visits(refer to"Telehealth Visits") $5 Copayment per visit • Intensive outpatient and day-treatment programs: a $5 Copayment per day Telehealth Visits Residential treatment Telehealth Visits between you and your provider are Inside our Service Area,we cover the following Services intended to make it more convenient for you to receive when the Services are provided in a licensed residential covered Services,when a Plan Provider determines it is treatment facility that provides 24-hour individualized medically appropriate for your medical condition.You substance use disorder treatment,the Services are have the option of receiving these services either through generally and customarily provided by a substance use an in-person visit or via telehealth.You may receive disorder residential treatment program in a licensed covered Services via Telehealth Visits,when available residential treatment facility,and the Services are above and if the Services would have been covered under this the level of custodial care: EOC if provided in person.If you choose to receive Services via telehealth,then you must use a Plan • Individual and group substance use disorder Provider that currently offers the service via telehealth. counseling We offer the following telehealth Services: • Medical services • Telehealth Services for monthly End-Stage Renal • Medication monitoring Disease--related visits for home dialysis members in a • Room and board hospital-based or critical access hospital-based renal dialysis center,renal dialysis facility,or the • Drugs prescribed by a Plan Provider as part of your Member's home plan of care in the residential treatment facility in . Telehealth Services to diagnose,evaluate or treat accord with our drug formulary guidelines if they are symptoms of a stroke,regardless of your location administered to you in the facility by medical personnel(for discharge drugs prescribed when you • Telehealth services for members with a substance use are released from the residential treatment facility, disorder or co-occurring mental health disorder, refer to"Outpatient Prescription Drugs, Supplies,and regardless of their location Supplements"in this"Benefits and Your Cost Share" . Telehealth services for diagnosis,evaluation,and section) treatment of mental health disorders if: • Discharge planning ♦ you have an in-person visit within 6 months prior to your first telehealth visit Your Cost Share.We cover residential substance use ♦ you have an in-person visit every 12 months while disorder treatment Services at no charge. receiving these telehealth services Inpatient detoxification ♦ exceptions can be made to the above for certain circumstances We cover hospitalization in a Plan Hospital only for medical management of withdrawal symptoms,including • Telehealth services for mental health visits provided room and board,Plan Physician Services,drugs, by Rural Health Clinics and Federally Qualified dependency recovery Services,education,and Health Centers counseling. • Virtual check-ins(for example,by phone or video chat)with your doctor for 5-10 minutes if: ♦ you're not a new patient,and Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 54 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. ♦ the check-in isn't related to an office visit in the Your Cost Share.For covered transplant Services that past 7 days,and you receive,you will pay the Cost Share you would pay ♦ the check-in doesn't lead to an office visit within if the Services were not related to a transplant.For 24 hours or the soonest available appointment example,see"Hospital Inpatient Services"in this "Benefits and Your Cost Share"section for the Cost • Evaluation of video and/or images you send to your Share that applies for hospital inpatient Services. doctor,and interpretation and follow-up by your doctor within 24 hours if: We provide or pay for donation-related Services for ♦ you're not a new patient,and actual or potential donors(whether or not they are ♦ the evaluation isn't related to an office visit in the Members)in accord with our guidelines for donor past 7 days,and Services at no charge. ♦ the evaluation doesn't lead to an office visit within 24 hours or the soonest available appointment For the following Services, refer to these sections • Consultation your doctor has with other doctors by phone,internet,or electronic health record • Dental Services that are Medically Necessary to prepare for a transplant(refer to"Dental Services") Your Cost Share.You pay the following types for • Outpatient imaging and laboratory(refer to Telehealth Visits with Primary Care Physicians,Non- "Outpatient Imaging,Laboratory,and Other Physician Specialists,and Physician Specialists: Diagnostic and Treatment Services") • Interactive video visits: no charge • Outpatient prescription drugs(refer to"Outpatient • Scheduled telephone visits: no charge Prescription Drugs, Supplies,and Supplements") • Outpatient administered drugs(refer to"Outpatient Transplant Services Care") We cover transplants of organs,tissue,or bone marrow Transportation Services in accord with Medicare guidelines and if the Medical Group provides a written referral for care to a transplant We cover transportation up to 24 one-way trips(50 miles facility as described in"Medical Group authorization per trip)per calendar year,if you meet the following procedure for certain referrals"under"Getting a conditions: Referral"in the"How to Obtain Services"section. o You are traveling to and from a network provider when provided by our designated transportation After the referral to a transplant facility,the following provider.Each stop will count towards one trip applies: • The ride is for Services covered under this EOC • If either the Medical Group or the referral facility determines that you do not satisfy its respective For trips greater than 50 miles,you will need an approval criteria for a transplant,we will only cover Services from a provider indicating medical necessity to travel to you receive before that determination is made a location beyond this limit. • Health Plan,Plan Hospitals,the Medical Group,and Plan Physicians are not responsible for finding, To request non-medical transportation(rideshare, furnishing,or ensuring the availability of an organ, taxi,or private transportation),please call our tissue,or bone marrow donor transportation provider at 1-877-930-1477(TTY 711), Monday through Friday, 5:00 a.m.to 6:00 p.m.You may • In accord with our guidelines for Services for living also create an account with our transportation vendor and transplant donors,we provide certain donation-related schedule rides online at medicaltrip.net or via their Services for a donor,or an individual identified by the mobile app. Medical Group as a potential donor,whether or not the donor is a Member. These Services must be If you need to use non-emergency medical directly related to a covered transplant for you,which transportation(wheelchair van or gurney van) may include certain Services for harvesting the organ, because you physically or medically are not able to get to tissue,or bone marrow and for treatment of your medical appointment by non-medical transportation complications.Please call Member Services for (rideshare,taxi,or private transportation),please call questions about donor Services 1-833-226-6760(TTY 711),Monday through Friday, 9:00 a.m.to 5:00 p.m. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 55 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Call at least three business days before your appointment 1,2025.You can use the Allowances under this"Optical or as soon as you can when you have an urgent Services"section only when you first order an item. appointment.Please have all of the following when you If you use part but not all of an Allowance when you first call: order an item,you cannot use the rest of that Allowance • Your Kaiser Permanente ID card later. • The date and time of your medical appointments Eyeglasses and contact lenses following cataract • The address of where you need to be picked up and surgery the address of where you are going We cover at no charge one pair of eyeglasses or contact • If you will need a return trip lenses(including fitting or dispensing)following each • If someone will be traveling with you(for example,a cataract surgery that includes insertion of an intraocular lens at Plan Medical Offices or Plan Optical Sales parent/legal guardian or caregiver) Offices when prescribed by a physician or optometrist. When multiple cataract surgeries are needed,and you do Your Cost Share: You pay the following for covered not obtain eyeglasses or contact lenses between transportation: no charge. procedures,we will only cover one pair of eyeglasses or contact lenses after any surgery.If the eyewear you For the following Services, refer to this section purchase costs more than what Medicare covers for • Emergency and non-emergency ambulance Services someone who has Original Medicare(also known as (refer to"Ambulance Services") "Fee-for-Service Medicare"),you pay the difference. Transportation Services exclusion Special contact lenses Transportation will not be provided if. We cover the following: • The ride is not for a service covered under this EOC • For aniridia(missing iris),we cover up to two Medically Necessary contact lenses per eye (including fitting and dispensing)in any 12-month Vision Services period when prescribed by a Plan Physician or Plan Optometrist: no charge We cover the following: • In accord with Medicare guidelines,we cover • Routine eye exams with a Plan Optometrist to corrective lenses(including contact lens fitting and determine the need for vision correction(including dispensing)and frames(and replacements)for dilation Services when Medically Necessary)and to Members who are aphakic(for example,who have provide a prescription for eyeglass lenses: a had a cataract removed but do not have an implanted $25 Copayment per visit intraocular lens(IOL)or who have congenital • Physician Specialist Visits to diagnose and treat absence of the lens): no charge injuries or diseases of the eye: a$25 Copayment per • For other specialty contact lenses that will provide a visit significant improvement in your vision not obtainable • Non-Physician Specialist Visits to diagnose and treat with eyeglass lenses,we cover either one pair of injuries or diseases of the eye: a$25 Copayment per contact lenses(including fitting and dispensing)or an visit initial supply of disposable contact lenses(up to six months,including fitting and dispensing)in any 24 Optical Services months at no charge We cover the Services described in this"Optical Services"section when received from Plan Medical Eyeglasses and contact lenses Offices or Plan Optical Sales Offices. We provide a single$175 Allowance toward the purchase price of any or all of the following not more The date we provide an Allowance toward(or otherwise than once every 24 months when a physician or cover)an item described in this"Optical Services" optometrist prescribes an eyeglass lens(for eyeglass section is the date on which you order the item.For lenses and frames)or contact lens(for contact lenses): example,if we last provided an Allowance toward an • Eyeglass lenses when a Plan Provider puts the lenses item you ordered on May 1,2023,and if we provide an into a frame Allowance not more than once every 24 months for that we cover a clear balance lens when only one eye type of item,then we would not provide another needs correction Allowance toward that type of item until on or after May Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 56 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. ♦ we cover tinted lenses when Medically Necessary Exclusions, Limitations, to treat macular degeneration or retinitis Coordination of Benefits, and pigmentosa • Eyeglass frames when a Plan Provider puts two lenses Reductions (at least one of which must have refractive value)into the frame Exclusions • Contact lenses,fitting,and dispensing The items and services listed in this"Exclusions"section We will not provide the Allowance if we have provided are excluded from coverage.These exclusions apply to an Allowance toward(or otherwise covered)eyeglass all Services that would otherwise be covered under this lenses or frames within the previous 24 months. EOC regardless of whether the services are within the scope of a provider's license or certificate.Additional Replacement lenses exclusions that apply only to a particular benefit are If you have a change in prescription of at least.50 listed in the description of that benefit in this EOC. diopter in one or both eyes within 12 months of the These exclusions or limitations do not apply to Services initial point of sale of an eyeglass lens or contact lens that are Medically Necessary to treat Severe Mental that we provided an Allowance toward(or otherwise Illness or Serious Emotional Disturbance of a Child covered)we will provide an Allowance toward the Under Age 18. purchase price of a replacement item of the same type (eyeglass lens,or contact lens,fitting,and dispensing) Certain exams and Services for the eye that had the .50 diopter change. The Routine physical exams and other Services that are not Allowance toward one of these replacement lenses is$30 Medically Necessary,such as when required(1)for for a single vision eyeglass lens or for a contact lens obtaining or maintaining employment or participation in (including fitting and dispensing)and$45 for a employee programs,(2)for insurance,credentialing or multifocal or lenticular eyeglass lens. licensing,(3)for travel,or(4)by court order or for parole or probation. For the following Services, refer to these sections Chiropractic Services • Services related to the eye or vision other than Chiropractic Services and the Services of a chiropractor, Services covered under this"Vision Services" except for manual manipulation of the spine as described section,such as outpatient surgery and outpatient under"Outpatient Care"in the"Benefits and Your Cost prescription drugs,supplies,and supplements refer to Share"section or unless you have coverage for the applicable heading in this"Benefits and Your supplemental chiropractic Services as described in an Cost Share"section) amendment to this EOC. Vision Services exclusions Cosmetic Services Services that are intended primarily to change or • Eyeglass contact lens adornment,such as maintain your appearance,including cosmetic surgery engraving,,faceting,or jeweling (surgery that is performed to alter or reshape normal • Items that do not require a prescription by law(other structures of the body in order to improve appearance), than eyeglass frames),such as eyeglass holders, except that this exclusion does not apply to any of the eyeglass cases,and repair kits following: • Lenses and sunglasses without refractive value, • Services covered under"Reconstructive Surgery"in except as described in this"Vision Services"section the"Benefits and Your Cost Share"section • Low vision devices • The following devices covered under"Prosthetic and • Replacement of lost,broken,or damaged contact Orthotic Devices"in the"Benefits and Your Cost lenses,eyeglass lenses,and frames Share"section:testicular implants implanted as part of a covered reconstructive surgery,breast prostheses needed after removal of all or part of a breast or lumpectomy,and prostheses to replace all or part of an external facial body part Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 57 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Custodial care "Home Health Care,"and"Hospice Care"in the Assistance with activities of daily living(for example: "Benefits and Your Cost Share"section. walking,getting in and out of bed,bathing,dressing, feeding,toileting,and taking medicine). Items and services that are not health care items and services This exclusion does not apply to assistance with For example,we do not cover: activities of daily living that is provided as part of • Teaching manners and etiquette covered hospice for Members who do not have Part A, Skilled Nursing Facility,or hospital inpatient care. • Teaching and support services to develop planning skills such as daily activity planning and project or Dental care task planning Dental care and dental X-rays,such as dental Services • Items and services for the purpose of increasing following accidental injury to teeth,dental appliances, academic knowledge or skills dental implants,orthodontia,and dental Services • Teaching and support services to increase intelligence resulting from medical treatment such as surgery on the jawbone and radiation treatment,except for Services • Academic coaching or tutoring for skills such as covered in accord with Medicare guidelines or under grammar,math,and time management "Dental Services"in the"Benefits and Your Cost Share" • Teaching you how to read,whether or not you have section. dyslexia Disposable supplies • Educational testing Disposable supplies for home use,such as bandages, • Teaching art,dance,horse riding,music,play,or gauze,tape,antiseptics,dressings,Ace-type bandages, swimming and diapers,underpads,and other incontinence supplies. • Teaching skills for employment or vocational purposes This exclusion does not apply to disposable supplies • Vocational training or teaching vocational skills covered in accord with Medicare guidelines or under "Durable Medical Equipment("DME")for Home Use," • Professional growth courses "Home Health Care,""Hospice Care,""Ostomy, • Training for a specific job or employment counseling Urological,and Wound Care Supplies,""Outpatient • Aquatic therapy and other water therapy,except when Prescription Drugs, Supplies,and Supplements,"and "Prosthetic and Orthotic Devices"in the"Benefits and ordered as part of a physical therapy program in Your Cost Share"section. accord with Medicare guidelines Experimental or investigational Services Items and services to correct refractive defects A Service is experimental or investigational if we,in of the eye consultation with the Medical Group,determine that one Items and services(such as eye surgery or contact lenses of the following is true: to reshape the eye)for the purpose of correcting refractive defects of the eye such as myopia,hyperopia, • Generally accepted medical standards do not or astigmatism. recognize it as safe and effective for treating the condition in question(even if it has been authorized Massage therapy by law for use in testing or other studies on human Massage therapy,and services of massage therapists. patients) • It requires government approval that has not been Oral nutrition and weight loss aids obtained when the Service is to be provided Outpatient oral nutrition, such as dietary supplements, herbal supplements,formulas,food,and weight loss aids. Hair loss or growth treatment Items and services for the promotion,prevention,or This exclusion does not apply to any of the following: other treatment of hair loss or hair growth. • Amino acid—modified products and elemental dietary Intermediate care enteral formula covered under"Outpatient Prescription Drugs, Supplies,and Supplements"in Care in a licensed intermediate care facility.This the"Benefits and Your Cost Share"section exclusion does not apply to Services covered under "Durable Medical Equipment("DME")for Home Use," Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 58 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Enteral formula covered under"Prosthetic and would not apply and we would cover any Services that Orthotic Devices"in the"Benefits and Your Cost we would otherwise cover to treat that complication. Share"section Surrogacy Residential care Services for anyone in connection with a Surrogacy Care in a facility where you stay overnight,except that Arrangement,except for otherwise-covered Services this exclusion does not apply when the overnight stay is provided to a Member who is a surrogate.Refer to part of covered care in a hospital,a Skilled Nursing "Surrogacy Arrangements"under"Reductions"in this Facility,inpatient respite care covered in the"Hospice "Exclusions,Limitations,Coordination of Benefits,and Care"section for Members who do not have Part A,or Reductions"section for information about your residential treatment program Services covered in the obligations to us in connection with a Surrogacy "Substance Use Disorder Treatment"and"Mental Health Arrangement,including your obligations to reimburse us Services"sections. for any Services we cover and to provide information about anyone who may be financially responsible for Routine foot care items and services Services the baby(or babies)receive. Routine foot care items and services,except for Medically Necessary Services covered in accord with Travel and lodging expenses Medicare guidelines. Travel and lodging expenses,except as described in our Travel and Lodging Program Description. The Travel Services not approved by the federal Food and and Lodging Program Description is available online at Drug Administration kp.or2/specialty-care/travel-reimbursements or by Drugs,supplements,tests,vaccines,devices,radioactive calling Member Services. materials,and any other Services that by law require federal Food and Drug Administration("FDA")approval in order to be sold in the U.S.,but are not approved by Limitations the FDA.This exclusion applies to Services provided We will make a good faith effort to provide or arrange anywhere,even outside the U.S.,unless the Services are for covered Services within the remaining availability of covered under the"Emergency Services and Urgent facilities or personnel in the event of unusual Care"section. circumstances that delay or render impractical the provision of Services under this EOC,such as a major Services and items not covered by Medicare disaster,epidemic,war,riot,civil insurrection,disability Services and items that are not covered by Medicare, of a large share of personnel at a Plan Facility,complete including services and items that aren't reasonable and or partial destruction of facilities,and labor dispute. necessary,according to the standards of the Original Under these circumstances,if you have an Emergency Medicare plan,unless these Services are otherwise listed Medical Condition,call 911 or go to the nearest in this EOC as a covered Service. Emergency Department as described under"Emergency Services"in the"Emergency Services and Urgent Care" Services performed by unlicensed people section,and we will provide coverage and Services that are performed safely and effectively by reimbursement as described in that section. people who do not require licenses or certificates by the state to provide health care services and where the Additional limitations that apply only to a particular Member's condition does not require that the services be benefit are listed in the description of that benefit in this provided by a licensed health care provider. EOC. Services related to a noncovered Service When a Service is not covered,all Services related to the Coordination of Benefits noncovered Service are excluded, except for Services we would otherwise cover to treat complications of the If you have other medical or dental coverage,it is noncovered Service or if covered in accord with important to use your other coverage in combination Medicare guidelines.For example,if you have a with your coverage as a Senior Advantage Member to noncovered cosmetic sure we would not cover pay for the care you receive.This is called"coordination Services you receive in preparation for the surgery or for of benefits"because it involves coordinating all of the follow-up care.If you later suffer alife-threatening health benefits that are available to you.Using all of the complication such as a serious infection,this exclusion coverage you have helps keep the cost of health care more affordable for everyone. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 59 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. You must tell us if you have other health care coverage, If you have additional health coverage,please call and let us know whenever there are any changes in your Member Services to find out which rules apply to your additional coverage.The types of additional coverage situation,and how payment will be handled. that you might have include the following: • Coverage that you have from an employer's group Reductions health care coverage for employees or retirees,either through yourself or your spouse Employer responsibility • Coverage that you have under workers' compensation For any Services that the law requires an employer to because of a job-related illness or injury,or under the provide,we will not pay the employer,and,when we Federal Black Lung Program cover any such Services,we may recover the value of the • Coverage you have for an accident where no-fault Services from the employer. insurance or liability insurance is involved Government agency responsibility • Coverage you have through Medicaid For any Services that the law requires be provided only • Coverage you have through the"TRICARE for Life" by or received only from a government agency,we will program(veteran's benefits) not pay the government agency,and,when we cover any • Coverage you have for dental insurance or such Services,we may recover the value of the Services prescription drugs from the government agency. • "Continuation coverage"you have through COBRA Injuries or illnesses alleged to be caused by (COBRA is a law that requires employers with 20 or third parties more employees to let employees and their Third parties who cause you injury or illness(and/or dependents keep their group health coverage for a their insurance companies)usually must pay first before time after they leave their group health plan under Medicare or our plan.Therefore,we are entitled to certain conditions) pursue these primary payments.If you obtain a judgment or settlement from or on behalf of a third party who When you have additional health care coverage,how we allegedly caused an injury or illness for which you coordinate your benefits as a Senior Advantage Member received covered Services,you must ensure we receive with your benefits from your other coverage depends on reimbursement for those Services.Note:This"Injuries or your situation.With coordination of benefits,you will illnesses alleged to be caused by third parties"section often get your care as usual from Plan Providers,and the does not affect your obligation to pay your Cost Share other coverage you have will simply help pay for the for these Services. care you receive.In other situations,such as benefits that we don't cover,you may get your care outside of our To the extent permitted or required by law,we shall be plan directly through your other coverage. subrogated to all claims,causes of action,and other rights you may have against a third party or an insurer, In general,the coverage that pays its share of your bills government program,or other source of coverage for first is called the"primary payer."Then the other monetary damages,compensation,or indemnification on company or companies that are involved(called the account of the injury or illness allegedly caused by the "secondary payers")each pay their share of what is left third party.We will be so subrogated as of the time we of your bills.Often your other coverage will settle its mail or deliver a written notice of our exercise of this share of payment directly with us and you will not have option to you or your attorney. to be involved.However,if payment owed to us is sent directly to you,you are required under Medicare law to To secure our rights,we will have a lien and give this payment to us.When you have additional reimbursement rights to the proceeds of any judgment or coverage,whether we pay first or second,or at all, settlement you or we obtain against a third party that depends on what type or types of additional coverage results in any settlement proceeds or judgment,from you have and the rules that apply to your situation.Many other types of coverage that include but are not limited of these rules are set by Medicare. Some of them take to: liability,uninsured motorist,underinsured motorist, into account whether you have a disability or have End- personal umbrella,workers' compensation,personal Stage Renal Disease,or how many employees are injury,medical payments and all other first party types. covered by an employer's group plan. The proceeds of any judgment or settlement that you or we obtain shall first be applied to satisfy our lien, regardless of whether you are made whole and regardless of whether the total amount of the proceeds is less than Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 60 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. the actual losses and damages you incurred.We are not Surrogacy Arrangement,regardless of whether those required to pay attorney fees or costs to any attorney payments are characterized as being for medical hired by you to pursue your damages claim.If you expenses.To secure our rights,we will also have a lien reimburse us without the need for legal action,we will on those payments and on any escrow account,trust,or allow a procurement cost discount.If we have to pursue any other account that holds those payments. Those legal action to enforce its interest,there will be no payments(and amounts in any escrow account,trust,or procurement discount. other account that holds those payments)shall first be applied to satisfy our lien. The assignment and our lien Within 30 days after submitting or filing a claim or legal will not exceed the total amount of your obligation to us action against a third party,you must send written notice under the preceding paragraph. of the claim or legal action to: The Rawlings Company Within 30 days after entering into a Surrogacy Arrangement,you must send written notice of the One Eden Parkway P.O.BOX 2000 arrangement,including all of the following information: LaGrange,KY 40031-2000 • Names,addresses,and phone numbers of the other Fax: 1-502-214-1137 parties to the arrangement • Names,addresses,and phone numbers of any escrow In order for us to determine the existence of any rights agent or trustee we may have and to satisfy those rights,you must • Names,addresses,and phone numbers of the intended complete and send us all consents,releases, parents and any other parties who are financially authorizations,assignments,and other documents, responsible for Services the baby(or babies)receive, including lien forms directing your attorney,the third including names,addresses,and phone numbers for party,and the third party's liability insurer to pay us any health insurance that will cover Services that the directly.You may not agree to waive,release,or reduce baby(or babies)receive our rights under this provision without our prior,written o A signed copy of any contracts and other documents consent. explaining the arrangement If your estate,parent,guardian,or conservator asserts a • Any other information we request in order to satisfy claim against a third party based on your injury or our rights illness,your estate,parent,guardian,or conservator and any settlement or judgment recovered by the estate, You must send this information to: parent,guardian,or conservator shall be subject to our The Rawlings Company liens and other rights to the same extent as if you had One Eden Parkway asserted the claim against the third party.We may assign P.O.Box 2000 our rights to enforce our liens and other rights. LaGrange,KY 40031-2000 Surrogacy Arrangements Fax: 1-502-214-1137 If you enter into a Surrogacy Arrangement and you or You must complete and send us all consents,releases, any other payee are entitled to receive monetary authorizations,lien forms,and other documents that are compensation under the Surrogacy Arrangement,you reasonably necessary for us to determine the existence of must reimburse us for covered Services you receive any rights we may have under this"Surrogacy related to conception,pregnancy,delivery,or postpartum Arrangements"section and to satisfy those rights.You care in connection with that arrangement("Surrogacy may not agree to waive,release,or reduce our rights Health Services")to the maximum extent allowed under under this"Surrogacy Arrangements"section without California Civil Code Section 3040.Note:This our prior,written consent. "Surrogacy Arrangements"section does not affect your obligation to pay your Cost Share for these Services. If your estate,parent,guardian,or conservator asserts a After you surrender a baby to the legal parents,you are claim against another party based on the Surrogacy not obligated to reimburse us for any Services that the Arrangement,your estate,parent,guardian,or baby receives(the legal parents are financially conservator and any settlement or judgment recovered by responsible for any Services that the baby receives). the estate,parent,guardian,or conservator shall be subject to our liens and other rights to the same extent as By accepting Surrogacy Health Services,you if you had asserted the claim against the other party.We automatically assign to us your right to receive payments that are payable to you or any other payee under the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 61 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. may assign our rights to enforce our liens and other for medical services or Part D drugs that are covered by rights. our plan.There may be deadlines that you must meet to get paid back. If you have questions about your obligations under this provision,please call Member Services. There may also be times when you get a bill from a provider for the full cost of medical care you have U.S. Department of Veterans Affairs received or possibly for more than your share of cost For any Services for conditions arising from military sharing as discussed in this document.First try to resolve service that the law requires the Department of Veterans the bill with the provider.If that does not work,send the Affairs to provide,we will not pay the Department of bill to us instead of paying it.We will look at the bill and Veterans Affairs,and when we cover any such Services decide whether the services should be covered.If we we may recover the value of the Services from the decide they should be covered,we will pay the provider Department of Veterans Affairs. directly. If we decide not to pay it,we will notify the provider.You should never pay more than plan-allowed Workers' compensation or employer's liability cost sharing. If this provider is contracted,you still have benefits the right to treatment. Workers'compensation usually must pay first before Medicare or our plan.Therefore,we are entitled to Here are examples of situations in which you may need pursue primary payments under workers'compensation to ask us to pay you back or to pay a bill you have or employer's liability law.You may be eligible for received: payments or other benefits,including amounts received as a settlement(collectively referred to as"Financial When you've received emergency,urgent,or dialysis Benefit"),under workers' compensation or employer's care from a Non—Plan Provider.Outside the service liability law.We will provide covered Services even if it area,you can receive emergency or urgently needed is unclear whether you are entitled to a Financial Benefit, services from any provider,whether or not the provider but we may recover the value of any covered Services is a Plan Provider.In these cases: from the following sources: • You are only responsible for paying your share of the • From any source providing a Financial Benefit or cost for emergency or urgently needed services. from whom a Financial Benefit is due Emergency providers are legally required to provide emergency care.If you pay the entire amount yourself • From you,to the extent that a Financial Benefit is at the time you receive the care,ask us to pay you provided or payable or would have been required to back for our share of the cost. Send us the bill,along be provided or payable if you had diligently sought to with documentation of an payments you have made establish your rights to the Financial Benefit under y p y any workers' compensation or employer's liability • You may get a bill from the provider asking for law payment that you think you do not owe. Send us this bill,along with documentation of any payments you have already made Requests for Payment ♦ if the provider is owed anything,we will pay the provider directly ♦ if you have already paid more than your share of Requests for Payment of Covered the cost of the service,we will determine how Services or Part D drugs much you owed and pay you back for our share of the cost If you pay our share of the cost of your covered services or Part D drugs, or if you receive a bill, When a Plan Provider sends you a bill you think you you can ask us for payment should not pay.Plan Providers should always bill us Sometimes when you get medical care or a Part D drug, directly and ask you only for your share of the cost.But you may need to pay the full cost. Other times,you may sometimes they make mistakes and ask you to pay more find that you have paid more than you expected under than your share. the coverage rules of our plan,or you may receive a bill • You only have to pay your Cost Share amount when from a provider.In these cases,you can ask us to pay you get covered Services.We do not allow providers you back(paying you back is often called"reimbursing" to add additional separate charges,called balance you).It is your right to be paid back by our plan billing.This protection(that you never pay more than whenever you've paid more than your share of the cost your Cost Share amount)applies even if we pay the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 62 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. provider less than the provider charges for a service, When you pay the full cost for a prescription in other and even if there is a dispute and we don't pay certain situations.You may pay the full cost of the prescription provider charges because you find that the drug is not covered for some • Whenever you get a bill from a Plan Provider that you reason. think is more than you should pay,send us the bill. • For example,the drug may not be on our 2025 We will contact the provider directly and resolve the Comprehensive Formulary or it could have a billing problem requirement or restriction that you didn't know about • If you have already paid a bill to a Plan Provider,but or don't think should apply to you.If you decide to you feel that you paid too much,send us the bill along get the drug immediately,you may need to pay the with documentation of any payment you have made full cost for it and ask us to pay you back the difference between the • Save your receipt and send a copy to us when you ask amount you paid and the amount you owed under our us to pay you back.In some situations,we may need plan to get more information from your doctor in order to pay you back for our share of the cost.We may not If you are retroactively enrolled in our plan. pay you back the full cost you paid if the cash price Sometimes a person's enrollment in our plan is you paid is higher than our negotiated price for the retroactive. (This means that the first day of their prescription enrollment has already passed. The enrollment date may even have occurred last year.)If you were retroactively When you pay copayments under a drug enrolled in our plan and you paid out-of-pocket for any manufacturer patient assistance program.If you get of your covered Services or Part D drugs after your help from,and pay copayments under,a drug enrollment date,you can ask us to pay you back for our manufacturer patient assistance program outside our share of the costs.You will need to submit paperwork plan's benefit,you may submit a paper claim to have such as receipts and bills for us to handle the your out-of-pocket expense count toward qualifying you reimbursement. for catastrophic coverage. When you use allon—Plan Pharmacy to get a • Save your receipt and send a copy to us prescription filled.If you go to a Non-Plan Pharmacy, All of the examples above are types of coverage the pharmacy may not be able to submit the claim decisions. This means that if we deny your request for directly to us.When that happens,you will have to pay payment,you can appeal our decision.The"Coverage the full cost of your prescription. Decisions,Appeals,and Complaints"section has Save your receipt and send a copy to us when you ask us information about how to make an appeal. to pay you back for our share of the cost.Remember that we only cover non-plan pharmacies in limited How to Ask Us to Pay You Back or to circumstances.We may not pay you back the difference pay a Bill You Have Received between what you paid for the drug at the Non-Plan Pharmacy and the amount that we would pay at a Plan You may request us to pay you back by sending us a Pharmacy. request in writing.If you send a request in writing,send your bill and documentation of any payment you have When you pay the full cost for a prescription because made.It's a good idea to make a copy of your bill and you don't have your plan membership card with you. receipts for your records.You must submit your claim to If you do not have your plan membership card with you, us within 12 months(for Part C medical claims)paid and you can ask the pharmacy to call us or to look up your within 36 months(for Part D drug claims)of the date plan enrollment information.However,if the pharmacy you received the service,item,or drug. cannot get the enrollment information they need right away,you may need to pay the full cost of the To make sure you are giving us all the information we prescription yourself need to make a decision,you can fill out our claim form to make your request for payment.You don't have to use Save your receipt and send a copy to us when you ask us the form,but it will help us process the information to pay you back for our share of the cost.We may not faster.You can file a claim to request payment by: pay you back the full cost you paid if the cash price you paid is higher than our negotiated price for the prescription. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 63 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. To file a claim,this is what you need to do: you.Otherwise,we will consider your request and make • Completing and submitting our electronic form at a coverage decision. k .or and upload supporting documentation • If we decide that the medical care or Part D drug is • Either download a copy of the form from our website covered and you followed all the rules,we will pay (hp.oro or call Member Services and ask them to for our share of the cost.Our share of the cost might send you the form.Mail the completed form to our not be the full amount you paid(for example,if you Claims Department address listed below obtained a drug at a Non-Plan Pharmacy or if the cash price you paid for a drug is higher than our negotiated • If you are unable to get the form,you can file your price).If you have already paid for the service or request for payment by sending us the following Part D drug,we will mail your reimbursement of our information to our Claims Department address listed share of the cost to you.If you have not paid for the below: service or Part D drug yet,we will mail the payment ♦ a statement with the following information: directly to the provider — your name(member/patient name)and • If we decide that the medical care or Part D drug is medical/health record number not covered,or you did not follow all the rules,we — the date you received the services will not pay for our share of the cost.We will send — where you received the services you a letter explaining the reasons why we are not sending the payment and your right to appeal that who provided the services decision — why you think we should pay for the services - your signature and date signed. (If you want If we tell you that we will not pay for all or part of someone other than yourself to make the the medical care or Part D drug, you can make request,we will also need a completed an appeal "Appointment of Representative"form,which If you think we have made a mistake in turning down is available at kp.ora) your request for payment or the amount we are paying, ♦ a copy of the bill,your medical record(s)for these you can make an appeal.If you make an appeal,it means services,and your receipt if you paid for the you are asking us to change the decision we made when services we turned down your request for payment. • Mail your request for payment of medical care The appeals process is a formal process with detailed together with any bills or paid receipts to us at this procedures and important deadlines.For the details about address: how to make this appeal,go to the"Coverage Decisions, Kaiser Permanente Appeals,and Complaints"section. Claims Administration-NCAL P.O.Box 12923 Oakland,CA 94604-2923 Other Situations in Which You Should Save Your Receipts and Send Copies to To request payment of a Part D drug that was prescribed Us by a Plan Provider and obtained from a Plan Pharmacy, write to the address below.For all other Part D requests, In some cases, you should send copies of your send your request to the address above. receipts to us to help us track your out-of- Kaiser Foundation Health Plan,Inc. pocket drug costs Medicare Part D Unit There are some situations when you should let us know P.O.Box 1809 about payments you have made for your covered Part D Pleasanton,CA 94566 prescription drugs.In these cases,you are not asking us for payment.Instead,you are telling us about your We Will Consider Your Request for payments so that we can calculate your out-of-pocket costs correctly.This may help you to qualify for the Payment and Say Yes or No Catastrophic Coverage Stage more quickly. We check to see whether we should cover the Here is one situation when you should send us copies of service or Part D drug and how much we owe receipts to let us know about payments you have made When we receive your request for payment,we will let for your drugs: you know if we need any additional information from • When you get a drug through a patient assistance program offered by a drug manufacturer. Some Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 64 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. members are enrolled in a patient assistance program Our plan is required to give female enrollees the option offered by a drug manufacturer that is outside our of direct access to a women's health specialist within the plan benefits.If you get any drugs through a program network for women's routine and preventive health care offered by a drug manufacturer,you may pay a services. copayment to the patient assistance program ♦ save your receipt and send a copy to us so that we If providers in our network for a specialty are not can have your out-of-pocket expenses count available,it is our responsibility to locate specialty toward qualifying you for the Catastrophic providers outside the network who will provide you with Coverage Stage the necessary care.In this case,you will only pay in- ♦ note:Because you are getting your drug through network cost-sharing.If you find yourself in a situation the patient assistance program and not through our Where there are no specialists in our network that cover a plan's benefits,we will not pay for any share of service you need,call us for information on where to go these drug costs.But sending a copy of the receipt to obtain this service at in-network cost-sharing. allows us to calculate your out-of-pocket costs correctly and may help you qualify for the If you have any trouble getting information from our Catastrophic Coverage Stage more quickly plan in a format that is accessible and appropriate for you,seeing a women's health specialist or finding a Since you are not asking for payment in the case network specialist,please call to file a grievance with described above,this situation is not considered a Member Services.You may also file a complaint with coverage decision.Therefore,you cannot make an appeal Medicare by calling 1-800-MEDICARE(1-800-633- if you disagree with our decision. 4227)or directly with the Office for Civil Rights 1-800- 368-1019 or TTY 1-800-537-7697. Debemos proporcionar la informaci6n de un Your Rights and Responsibilities modo adecuado para usted y que sea coherente con sus sensibilidades culturales (en idiomas distintos al ingles, en tetra grande, en braille, en We must honor your rights and cultural archivo de audio o en CD de datos) sensitivities as a Member of our plan Nuestro plan esta obligado a garantizar que todos los servicios,tanto clinicos como no clinicos,se We must provide information in a way that proporcionen de una manera culturalmente competente y works for you and consistent with your cultural que Sean accesibles para todas las personas inscritas, sensitivities (in languages other than English, incluidas las que tienen un dominio limitado del ingles, large font, braille, audio file, or data CD) capacidades limitadas para leer,una incapacidad auditiva Our plan is required to ensure that all services,both o diversos antecedentes culturales y 6tnicos.Algunos clinical and non-clinical,are provided in a culturally ejemplos de c6mo nuestro plan puede cumplir estos competent manner and are accessible to all enrollees, requisites de accesibilidad incluyen,entre otros, including those with limited English proficiency,limited prestaci6n de servicios de traducci6n,interpretaci6n, reading skills,hearing incapacity,or those with diverse teletipo o conexi6n TTY(tel6fono de texto o teletipo). cultural and ethnic backgrounds.Examples of how our plan may meet these accessibility requirements include, Nuestro plan tiene servicios de interpretaci6n gratuitos but are not limited to:provision of translator services, disponibles para responder las preguntas de los interpreter services,teletypewriters,or TTY(text miembros que no hablan ingles.Este documento esta telephone or teletypewriter phone)connection. disponible en espafiol y en chino llamando a Servicio a los Miembros. Si la necesita,tambi6n podemos darle,sin costo,informaci6n en letra grande,en braille,en archivo Our plan has free interpreter services available to answer de audio o en CD de datos.Tenemos la obligaci6n de questions from non-English-speaking members.We can darle informaci6n acerca de los beneficios de nuestro also give you information in large font,braille,audio plan en un formato que sea accesible y adecuado para file,or data CD at no cost if you need it.We are required usted.Para obtener informaci6n de una forma que se to give you information about our plan's benefits in a adapte a sus necesidades,llame a Servicio a los format that is accessible and appropriate for you. To get Miembros. information from us in a way that works for you,please call Member Services. Nuestro plan esta obligado a ofrecer a las mujeres inscritas la opci6n de acceder directamente a un especialista en salud de la mujer dentro de la red para los Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 65 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. servicios de atenci6n medica preventiva y de rutina para protect your personal health information as required by la mujer. these laws. Si los proveedores de nuestra red para una especialidad • Your personal health information includes the no estan disponibles,es nuestra responsabilidad buscar personal information you gave us when you enrolled proveedores especializados fuera de la red que le in our plan as well as your medical records and other proporcionen la atenci6n necesaria.En este caso,usted medical and health information solo pagara el costo compartido dentro de la red. Si se • You have rights related to your information and encuentra en una situaci6n en la que no hay especialistas controlling how your health information is used.We dentro de nuestra red que cubran el servicio que necesita, give you a written notice,called a Notice of Privacy llamenos para recibir informacion sobre a d6nde acudir Practices,that tells about these rights and explains para obtener este servicio con un costo compartido how we protect the privacy of your health information dentro de la red. Si tiene algtin problema para obtener informacion de How do we protect the privacy of your health nuestro plan en un formato que sea accesible y adecuado information? para usted,consultar a un especialista en salud de la • We make sure that unauthorized people don't see or mujer o encontrar un especialista de la red,por favor change your records llame para presentar una queja formal ante Servicio a los • Except for the circumstances noted below,if we Miembros.Tambien puede presentar una queja en intend to give your health information to anyone who Medicare llamando al 1-800-MEDICARE(1-800-633- isn't providing your care or paying for your care,we 4227)o directamente en la Oficina de Derechos Civiles are required to get written permission from you or by 1-800-368-1019 o al TTY 1-800-537-7697. someone you have given legal power to make decisions for you first We must ensure that you get timely access to o Your health information is shared with your Group your covered services and Part D drugs only with your authorization or as otherwise You have the right to choose a primary care provider permitted by law (PCP)in our network to provide and arrange for your . There are certain exceptions that do not require us to covered services.You also have the right to go to a women's health specialist(such as a gynecologist),a get your written permission first. These exceptions mental health services provider,and an optometrist are allowed or required by law without a referral,as well as other providers described in ♦ we are required to release health information to the"How to Obtain Services"section. government agencies that are checking on quality of care You have the right to get appointments and covered ♦ because you are a Member of our plan through services from our network of providers within a Medicare,we are required to give Medicare your reasonable amount of time. This includes the right to get health information,including information about timely services from specialists when you need that care. your Part D prescription drugs.If Medicare You also have the right to get your prescriptions filled or releases your information for research or other refilled at any of our network pharmacies without long uses,this will be done according to federal statutes delays. and regulations;typically,this requires that information that uniquely identifies you not be If you think that you are not getting your medical care or shared Part D drugs within a reasonable amount of time,"How to make a complaint about quality of care,waiting times, You can see the information in your records and customer service,or other concerns"in the"Coverage know how it has been shared with others Decisions,Appeals,and Complaints"section tells what You have the right to look at your medical records held you can do. by our plan,and to get a copy of your records.We are allowed to charge you a fee for making copies.You also We must protect the privacy of your personal have the right to ask us to make additions or corrections health information to your medical records.If you ask us to do this,we will Federal and state laws protect the privacy of your work with your health care provider to decide whether medical records and personal health information.We the changes should be made. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 66 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. You have the right to know how your health information medical care.Your providers must explain your medical has been shared with others for any purposes that are not condition and your treatment choices in a way that you routine. can understand. If you have questions or concerns about the privacy of You also have the right to participate fully in decisions your personal health information,please call Member about your health care.To help you make decisions with Services. your doctors about what treatment is best for you,your rights include the following: We must give you information about our plan, • To know about all of your choices.You have the our Plan Providers, and your covered services right to be told about all of the treatment options that As a Member of our plan,you have the right to get are recommended for your condition,no matter what several kinds of information from us. they cost or whether they are covered by our plan.It also includes being told about programs our plan If you want any of the following kinds of information, offers to help members manage their medications and please call Member Services: use drugs safely • Information about our plan.This includes,for • To know about the risks.You have the right to be example,information about our plan's financial told about any risks involved in your care.You must condition be told in advance if any proposed medical care or • Information about our network providers and treatment is part of a research experiment.You pharmacies always have the choice to refuse any experimental ♦ you have the right to get information about the treatments qualifications of the providers and pharmacies in • The right to say"no."You have the right to refuse our network and how we pay the providers in our any recommended treatment. This includes the right network to leave a hospital or other medical facility,even • Information about your coverage and the rules if your doctor advises you not to leave.You also have you must follow when using your coverage the right to stop taking your medication.Of course, ♦ the"How to Obtain Services"and`Benefits and if you refuse treatment or stop taking a medication, Your Cost Share"sections provide information you accept full responsibility for what happens to regarding medical services your body as a result ♦ the"Outpatient Prescription Drugs, Supplies,and You have the right to give instructions about what is Supplements"in the`Benefits and Your Cost to be done if you are not able to make medical Share"section provides information about decisions for yourself coverage for certain drugs Sometimes people become unable to make health care ♦ if you have questions about the rules or decisions for themselves due to accidents or serious restrictions,please call Member Services illness.You have the right to say what you want to • Information about why something is not covered happen if you are in this situation.This means that, and what you can do about it if you want to,you can: ♦ the"Coverage Decisions,Appeals,and • Fill out a written form to give someone the legal Complaints"section provides information on authority to make medical decisions for you if you asking for a written explanation on why a medical ever become unable to make decisions for yourself service or Part D drug is not covered,or if your • Give your doctors written instructions about how you coverage is restricted want them to handle your medical care if you become ♦ the"Coverage Decisions,Appeals,and unable to make decisions for yourself Complaints"section also provides information on asking us to change a decision,also called an The legal documents that you can use to give your appeal directions in advance of these situations are called advance directives.There are different types of advance We must support your right to make decisions directives and different names for them.Documents about your care called living will and power of attorney for health care You have the right to know your treatment options are examples of advance directives. and participate in decisions about your health care You have the right to get full information from your doctors and other health care providers when you go for Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 67 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. If you want to use an advance directive to give your What can you do if you believe you are being instructions,here is what to do: treated unfairly or your rights are not being • Get the form.You can get an advance directive,a respected? form from your lawyer,from a social worker,or from If it is about discrimination,call the Office for Civil some office supply stores.You can sometimes get Rights advance directive forms from organizations that give If you believe you have been treated unfairly,your people information about Medicare.You can also dignity has not been recognized,or your rights have not contact Member Services to ask for the forms been respected due to your race,disability,religion,sex, • Fill it out and sign it.Regardless of where you get health,ethnicity,creed(beliefs),age,sexual orientation, this form,keep in mind that it is a legal document. or national origin,you should call the Department of You should consider having a lawyer help you Health and Human Services' Office for Civil Rights at prepare it 1-800-368-1019(TTY users call 1-800-537-7697)or call • Give copies to appropriate people.You should give your local Office for Civil Rights. a copy of the form to your doctor and to the person you name on the form who can make decisions for Is it about something else? you if you can't.You may want to give copies to If you believe you have been treated unfairly or your close friends or family members.Keep a copy at rights have not been respected,and it's not about home discrimination,you can get help dealing with the problem you are having: If you know ahead of time that you are going to be • You can call Member Services hospitalized,and you have signed an advance directive, • You can call the State Health Insurance Assistance take a copy with you to the hospital. Program.For details,go to the"Important Phone • The hospital will ask you whether you have signed an Numbers and Resources"section advance directive form and whether you have it with o Or you can call Medicare at 1-800-MEDICARE you (1-800-633-4227),24 hours a day,seven days a week • If you have not signed an advance directive form,the (TTY 1-877-486-2048) hospital has forms available and will ask if you want to sign one How to get more information about your rights There are several places where you can get more Remember,it is your choice whether you want to fill information about your rights: out an advance directive(including whether you want • You can call Member Services to sign one if you are in the hospital).According to law, • You can call the State Health Insurance Assistance no one can deny you care or discriminate against you Program.For details,go to the"Important Phone based on whether or not you have signed an advance Numbers and Resources"section directive. • You can contact Medicare: What if your instructions are not followed? ♦ you can visit the Medicare website to read or If you have signed an advance directive,and you believe download the publication Medicare Rights& that a doctor or hospital did not follow the instructions in Protections. (The publication is available at it,you may file a complaint with the Quality httns://www.medicare.2ov/Pubs/i)df/11534- Improvement Organization listed in the"Important Medicare-Rights-and-Protections.udf) Phone Numbers and Resources"section. ♦ or you can call 1-800-MEDICARE(1-800-633- 4227),24 hours a day,seven days a week(TTY You have the right to make complaints and to 1-877-486-2048) ask us to reconsider decisions we have made If you have any problems,concerns,or complaints and Information about new technology assessments need to request coverage,or make an appeal,the Rapidly changing technology affects health care and "Coverage Decisions,Appeals,and Complaints"section medicine as much as any other industry.To determine of this document tells what you can do. whether a new drug or other medical development has long-term benefits,our plan carefully monitors and Whatever you do—ask for a coverage decision,make an evaluates new technologies for inclusion as covered appeal,or make a complaint—we are required to treat benefits.These technologies include medical procedures, you fairly. medical devices,and new drugs. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 68 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. You can make suggestions about rights and • Pay what you owe.As a plan member,you are responsibilities responsible for these payments: As a Member of our plan,you have the right to make ♦ you must continue to pay a premium for your recommendations about the rights and responsibilities Medicare Part B to remain a Member of our plan included in this section.Please call Member Services ♦ for most of your Services or Part D drugs covered with any suggestions. by our plan,you must pay your share of the cost when you get the Service or Part D drug You have some responsibilities as a ♦ if you are required to pay the extra amount for Member of our plan Part D because of your yearly income,you must continue to pay the extra amount directly to the Things you need to do as a Member of our plan are listed government to remain a Member of our plan below.If you have any questions,please call Member • If you move within your Home Region Service Services. Area,we need to know so we can keep your • Get familiar with your covered services and the membership record up-to-date and know how to rules you must follow to get these covered services. contact you Use this EOC to learn what is covered for you and the • If you move outside of your plan's Service Area, rules you need to follow to get your covered services you cannot remain a member of our plan ♦ the"How to Obtain Services"and"Benefits and • If you move,it is also important to tell Social Your Cost Share"sections give details about your Security(or the Railroad Retirement Board) medical services ♦ the"Outpatient Prescription Drugs, Supplies,and Supplements"in the`Benefits and Your Cost Share"section gives details about your Part D Coverage Decisions, Appeals, and prescription drug coverage Complaints • If you have any other health insurance coverage or prescription drug coverage in addition to our plan, What to Do if You Have a Problem or you are required to tell us. ♦ Concern the"Exclusion,Limitations,Coordination of Benefits,and Reductions"section tells you about This section explains two types of processes for handling coordinating these benefits problems and concerns: • Tell your doctor and other health care providers • For some problems,you need to use the process for that you are enrolled in our plan.Show your plan coverage decisions and appeals membership card whenever you get your medical care . For other problems,you need to use the process for or Part D drugs making complaints,also called grievances • Help your doctors and other providers help you by giving them information,asking questions,and Both of these processes have been approved by following through on your care Medicare.Each process has a set of rules,procedures, ♦ to help get the best care,tell your doctors and and deadlines that must be followed by us and by you. other health care providers about your health problems.Follow the treatment plans and The guide under"To Deal with Your Problem,Which instructions that you and your doctors agree upon Process Should You Use?"in this"Coverage Decisions, ♦ make sure your doctors know all of the drugs you Appeals,and Complaints"section will help you identify are taking,including over-the-counter drugs, the right process to use and what you should do. vitamins,and supplements ♦ if you have any questions,be sure to ask and get Hospice care an answer you can understand If you have Medicare Part A,your hospice care is covered by Original Medicare and it is not covered under • Be considerate.We expect all our members to this EOC. Therefore,any complaints related to the respect the rights of other patients.We also expect coverage of hospice care must be resolved directly with you to act in a way that helps the smooth running of Medicare and not through any complaint or appeal your doctor's office,hospitals,and other offices procedure discussed in this EOC.Medicare complaint and appeal procedures are described in the Medicare Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 69 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. handbook Medicare&You,which is available from your also answer your questions,give you more information, local Social Security office,at and offer guidance on what to do. httus://www.medicare.2ov,or by calling toll free 1-800- MEDICARE(1-800-633-4227)(TTY users call 1-877- The services of SHIP counselors are free.You will find 486-2048),24 hours a day,seven days a week.If you do phone numbers and website URLs in the"Important not have Medicare Part A,Original Medicare does not Phone Numbers and Resources"section. cover hospice care.Instead,we will provide hospice care,and any complaints related to hospice care are Medicare subject to this"Coverage Decisions,Appeals,and You can also contact Medicare to get help.To contact Complaints"section. Medicare: What about the legal terms? • You can call 1-800-MEDICARE(1-800-633-4227), There are legal terms for some of the rules,procedures, 24 hours a day, seven days a week(TTY 1-877-486- and types of deadlines explained in this"Coverage 2048) Decisions,Appeals,and Complaints"section.Many of • You can also visit the Medicare website these terms are unfamiliar to most people and can be (httus://www.medicare.2ov) hard to understand. To make things easier,this section: To Deal with Your Problem, Which • Uses simpler words in place of certain legal terms. Process Should You Use? For example,this section generally says making a If you have a problem or concern,you only need to read complaint rather than filing a grievance,coverage the parts of this section that apply to your situation.The decision rather than organization determination or guide that follows will help. coverage determination,or at-risk determination,and independent review organization instead of Is your problem or concern about your benefits or Independent Review Entity. coverage? • It also uses abbreviations as little as possible. This includes problems about whether medical care (medical items,services and/or Part B prescription drugs)are covered or not,the way they are covered,and However,it can be helpful,and sometimes quite problems related to payment for medical care important,for you to know the correct legal terms. Knowing which terms to use will help you communicate • Yes. Go on to"A Guide to the Basics of Coverage more accurately to get the right help or information for Decisions and Appeals" your situation.To help you know which terms to use,we . No. Skip ahead to"How to Make a Complaint About include legal terms when we give the details for handling Quality of Care,Waiting Times,Customer Service,or specific types of situations. Other Concerns" Where To Get More Information and A Guide to the Basics of Coverage Personalized Assistance Decisions and Appeals We are always available to help you.Even if you have a Asking for coverage decisions and making complaint about our treatment of you,we are obligated appeals—the big picture to honor your right to complain.Therefore,you should Coverage decisions and appeals deal with problems always reach out to Member Services for help.But in related to your benefits and coverage for your medical some situations you may also want help or guidance care(services,items and Part B prescription drugs, from someone who is not connected with us.Below are including payment). To keep things simple,we generally two entities that can assist you. refer to medical items,services and Medicare Part B prescription drugs as medical care.You use the coverage State Health Insurance Assistance Program decision and appeals process for issues such as whether (SHIP) something is covered or not,and the way in which Each state has a government program with trained something is covered. counselors.The program is not connected with us or with any insurance company or health plan.The counselors at this program can help you understand which process you should use to handle a problem you are having.They can Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 70 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Asking for coverage decisions prior to receiving Level 2 appeal conducted by an independent review benefits organization that is not connected to us. A coverage decision is a decision we make about your e You do not need to do anything to start a Level 2 benefits and coverage or about the amount we will pay appeal.Medicare rules require we automatically send for your medical care. For example,if your Plan your appeal for medical care to Level 2 if we do not Physician refers you to a medical specialist not inside the fully agree with your Level 1 appeal network,this referral is considered a favorable coverage decision unless either your Plan Physician can show that • See"Step-by-step: How a Level appeal is done"of you received a standard denial notice for this medical this chapter for more information about Level specialist,or the EOC makes it clear that the referred appeals for medical care service is never covered under any condition.You or • Part D appeals are discussed further in"Your Part D your doctor can also contact us and ask for a coverage Prescription Drugs:How to Ask for a Coverage decision,if your doctor is unsure whether we will cover a Decision or Make an Appeal"of this section particular medical service or refuses to provide medical care you think that you need.In other words,if you want If you are not satisfied with the decision at the Level 2 to know if we will cover a medical care before you appeal,you may be able to continue through additional receive it,you can ask us to make a coverage decision levels of appeal. ("Taking Your Appeal to Level 3 and for you. Beyond"in this section explains the Level 3,4,and 5 appeals processes). We are making a coverage decision for you whenever we decide what is covered for you and how much we pay.In How to get help when you are asking for a some cases,we might decide medical care is not covered coverage decision or making an appeal or is no longer covered by Medicare for you.If you Here are resources if you decide to ask for any kind of disagree with this coverage decision,you can make an coverage decision or appeal a decision: appeal. • You can call us at Member Services Making an appeal • You can get free help from your State Health If we make a coverage decision,whether before or after a Insurance Assistance Program benefit is received,and you are not satisfied,you can • Your doctor can make a request for you.If your appeal the decision.An appeal is a formal way of asking doctor helps with an appeal past Level 2,they will us to review and change a coverage decision we have need to be appointed as your representative.Please made.Under certain circumstances,which we discuss call Member Services and ask for the Appointment later,you can request an expedited or fast appeal of a of Representative form.(The form is also available coverage decision.Your appeal is handled by different on Medicare's website at reviewers than those who made the original decision. httus://www.cros.aov/Medicare/CMS-Forms/ CMS-Forms/downloads/cros1696.ndf or on our When you appeal a decision for the first time,this is website at k .or called a Level 1 appeal.In this appeal,we review the ♦ for medical care or Part B prescription drugs,your coverage decision we have made to check to see if we doctor can request a coverage decision or a Level were properly following the rules.When we have 1 appeal on your behalf.If your appeal is denied at completed the review,we give you our decision. Level 1,it will be automatically forwarded to Level 2 In limited circumstances,a request for a Level 1 appeal ♦ for Part D prescription drugs,your doctor or other will be dismissed,which means we won't review the prescriber can request a coverage decision or a request.Examples of when a request will be dismissed Level 1 appeal on your behalf.If your Level 1 include if the request is incomplete,if someone makes appeal is denied,your doctor or prescriber can the request on your behalf but isn't legally authorized to request a Level 2 appeal do so or if you ask for your request to be withdrawn.If we dismiss a request for a Level 1 appeal,we will send a • You can ask someone to act on your behalf.If you notice explaining why the request was dismissed and want to,you can name another person to act for you how to ask for a review of the dismissal. as your representative to ask for a coverage decision or make an appeal If we say no to all or part of your Level 1 appeal for ♦ if you want a friend,relative,or other person to be medical care,your appeal will automatically go on to a your representative,call Member Services and ask for the Appointment of Representative form. (The Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 71 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. form is also available on Medicare's website at Your Medical Care: How to Ask for a https://www.ems.2ov/Medicare/CMS-Forms/ Coverage Decision or Make an Appeal CMS-Forms/downloads/cros1696.pdf or on our website at kp.org.)The form gives that person of a Coverage Decision permission to act on your behalf.It must be signed This section tells what to do if you have by you and by the person who you would like to problems getting coverage for medical care or act on your behalf.You must give us a copy of the if you want us to pay you back for our share of signed form the cost of your care ♦ while we can accept an appeal request without the This section is about your benefits for medical care. form,we cannot complete our review until we These benefits are described in the"Benefits and Your receive it.If we do not receive the form before our Cost Share"section.In some cases,different rules apply deadline for making a decision on your appeal, to a request for a Part B prescription drug.In those cases, your appeal request will be dismissed.If this we will explain how the rules for Part B prescription happens,we will send you a written notice drugs are different from the rules for medical items and explaining your right to ask the independent services. review organization to review our decision to dismiss your appeal This section tells what you can do if you are in any of the • You also have the right to hire a lawyer.You may following situations: contact your own lawyer,or get the name of a lawyer • You are not getting certain medical care you want, from your local bar association or other referral and you believe that this is covered by our plan.Ask service. There are also groups that will give you free for a coverage decision legal services if you qualify.However,you are not o We will not approve the medical care your doctor or required to hire a lawyer to ask for any kind of coverage decision or appeal a decision other medical provider wants to give you,and you believe that this care is covered by our plan.Ask for Which section gives the details for your a coverage decision situation? • You have received medical care that you believe There are four different situations that involve coverage should be covered by our plan,but we have said we decisions and appeals. Since each situation has different will not pay for this care.Make an appeal rules and deadlines,we give the details for each one in a • You have received and paid for medical care that you separate section: believe should be covered by our plan,and you want • "Your Medical Care:How to Ask for a Coverage to ask us to reimburse you for this care. Send us the Decision or Make an Appeal of a Coverage Decision" bill • "Your Part D Prescription Drugs:How to Ask for a • You are being told that coverage for certain medical Coverage Decision or Make an Appeal" care you have been getting that we previously approved will be reduced or stopped,and you believe • "How to Ask Us to Cover a Longer Inpatient Hospital that reducing or stopping this care could harm your Stay if You Think the Doctor Is Discharging You Too health.Make an appeal Soon" • "How to Ask Us to Keep Covering Certain Medical Note:If the coverage that will be stopped is for hospital Services if You Think Your Coverage is Ending Too Services,home health care, Skilled Nursing Facility care, Soon"(applies only to these services:home health or Comprehensive Outpatient Rehabilitation Facility care, Skilled Nursing Facility care,and (CORF)services,you need to read"How to Ask Us to Comprehensive Outpatient Rehabilitation Facility Cover a Longer Inpatient Hospital Stay if You Think the (CORF)services) Doctor Is Discharging You Too Soon"and"How to Ask Us to Keep Covering Certain Medical Services if You If you're not sure which section you should be using, Think Your Coverage is Ending Too Soon"of this please call Member Services.You can also get help or section. Special rules apply to these types of care. information from government organizations such as your SHIP. Step-by-step: How to ask for a coverage decision When a coverage decision involves your medical care,it is called an organization determination.A fast coverage decision is called an expedited determination. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 72 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step 1: Decide if you need a standard coverage take up to 14 more calendar days if your request is decision or a fast coverage decision. for a medical item or service.If we take extra A standard coverage decision is usually made within 14 days,we will tell you in writing.We can't take calendar days or 72 hours for Part B drugs.A fast extra time to make a decision if your request is for coverage decision is generally made within 72 hours,for a Medicare Part B prescription drug medical services,or 24 hours for Part B drugs.In order ♦ if you believe we should not take extra days,you to get a fast coverage decision,you must meet two can file a fast complaint.We will give you an requirements: answer to your complaint as soon as we make the ♦ you may only ask for coverage for medical items decision.(The process for making a complaint is and/or services not requests for payment for items different from the process for coverage decisions and/or services already received and appeals. See"How to Make a Complaint About Quality of Care,Waiting Times,Customer ♦ you can get a fast coverage decision only if using Service,or Other Concerns"of this section for the standard deadlines could cause serious harm to information on complaints.) your health or hurt your ability to function • If your doctor tells us that your health requires a fast For fast coverage decisions,we use an expedited time coverage decision,we will automatically agree to frame. give you a fast coverage decision • If you ask for a fast coverage decision on your own, A fast coverage decision means we will answer within 72 without your doctor's support,we will decide whether hours if your request is for a medical item or service.If your health requires that we give you a fast coverage your request is for a Medicare Part B prescription drug, decision.If we do not approve a fast coverage we will answer within 24 hours. decision,we will send you a letter that: ♦ however,if you ask for more time,or if we need ♦ explains that we will use the standard deadlines more information that may benefit you we can ♦ explains if your doctor asks for the fast coverage take up to 14 more calendar days.If we take extra decision,we will automatically give you a fast days,we will tell you in writing.We can't take coverage decision extra time to make a decision if your request is for a Medicare Part B prescription drug ♦ explains that you can file a fast complaint about ♦ if you believe we should not take extra days,you our decision to give you a standard coverage decision instead of the fast coverage decision you can file a fast complaint. See"How to Make a requested Complaint About Quality of Care,Waiting Times, Customer Service,or Other Concerns"of this Step 2: Ask our plan to make a coverage decision section for information on complaints.)We will or fast coverage decision call you as soon as we make the decision ♦ if we do not give you our answer within 72 hours • Start by calling,writing,or faxing our plan to make (or if there is an extended time period,by the end your request for us to authorize or provide coverage of that period),or within 24 hours if your request for the medical care you want.You,your doctor,or is for a Medicare Part B prescription drug,you your representative can do this.The"Important Phone have the right to appeal. "Step-by-step:How to Numbers and Resources"section has contact make a Level 1 Appeal"below tells you how to information make an appeal Step 3: We consider your request for medical care ♦ If our answer is no to part or all of what you coverage and give you our answer requested,we will send you a written statement that explains why we said no For standard coverage decisions,we use the standard deadlines. Step 4: If we say no to your request for coverage for medical care, you can appeal This means we will give you an answer within 14 • If we say no,you have the right to ask us to calendar days after we receive your request for a medical reconsider this decision by making an appeal.This item or service.If your request is for a Medicare Part B means asking again to get the medical care coverage prescription drug,we will give you an answer within 72 you want.If you make an appeal,it means you are hours after we receive your request. going on to Level 1 of the appeals process ♦ however,if you ask for more time,or if we need more information that may benefit you,we can Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 73 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step-by-step: How to make a Level 1 appeal • We will gather more information if needed possibly An appeal to our plan about a medical care coverage contacting you or your doctor decision is called a plan reconsideration.A fast appeal is also called an expedited reconsideration. Deadlines for a fast appeal Step 1: Decide if you need a standard appeal or a • For fast appeals,we must give you our answer within fast appeal 72 hours after we receive your appeal.We will give you our answer sooner if your health requires us to A standard appeal is usually made within 30 calendar days or 7 calendar days for Part B drugs.A fast ♦ however,if you ask for more time,or if we need appeal is generally made within 72 hours. more information that may benefit you,we can take up to 14 more days if your request is for a • If you are appealing a decision we made about medical item or service.If we take extra days,we coverage for care that you have not yet received,you will tell you in writing.We can't take extra time if and/or your doctor will need to decide if you need a your request is for a Medicare Part B prescription fast appeal.If your doctor tells us that your health drug requires a fast appeal,we will give you a fast appeal ♦ if we do not give you an answer within 72 hours • The requirements for getting a fast appeal are the (or by the end of the extended time period if we same as those for getting a fast coverage decision in took extra days),we are required to automatically "Your Medical Care:How to Ask for a Coverage send your request on to Level 2 of the appeals Decision or Make an Appeal"of this section process,where it will be reviewed by an independent review organization. "Step-by-Step: Step 2: Ask our plan for an appeal or a fast appeal How a Level 2 Appeal is Done"explains the Level • If you are asking for a standard appeal,submit your 2 appeal process standard appeal in writing.You may also ask for an • If our answer is yes to part or all of what you appeal by calling us. The"Important Phone Numbers requested,we must authorize or provide the coverage and Resources"section has contact information we have agreed to provide within 72 hours after we • If you are asking for a fast appeal,make your appeal receive your appeal in writing or call us.The"Important Phone Numbers • If our answer is no to part or all of what you and Resources"section has contact information requested,we will send you our decision in writing and automatically forward your appeal to the • You must make your appeal request within 65 independent review organization for a Level appeal. calendar days from the date on the written notice we The independent review organization will notify you sent to tell you our answer on the coverage decision. in writing when it receives your appeal If you miss this deadline and have a good reason for missing it,explain the reason your appeal is late when Deadlines for a standard appeal you make your appeal.We may give you more time to make your appeal.Examples of good cause may • For standard appeals,we must give you our answer include a serious illness that prevented you from within 30 calendar days after we receive your appeal. contacting us or if we provided you with incorrect or If your request is for a Medicare Part B prescription incomplete information about the deadline for drug you have not yet received,we will give you our requesting an appeal answer within 7 calendar days after we receive your • You can ask for a copy of the information regarding appeal.We will give you our decision sooner if your your medical decision.You and your doctor may add health condition requires us to more information to support your appeal.We are ♦ however,if you ask for more time,or if we need allowed to charge a fee for copying and sending this more information that may benefit you,we can information to you take up to 14 more calendar days if your request is for a medical item or service.If we take extra Step 3: We consider your appeal and we give you days,we will tell you in writing.We can't take our answer extra time to make a decision if your request is for a Medicare Part B prescription drug • When we are reviewing your appeal,we take a ♦ if you believe we should not take extra days,you careful look at all of the information.We check to see can file a fast complaint.When you file a fast if we were following all the rules when we said no to complaint,we will give you an answer to your your request complaint within 24 hours.(See"How to Make a Complaint About Quality of Care,Waiting Times, Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 74 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Customer Service,or Other Concerns"in this needs to gather more information that may benefit "Coverage Decisions,Appeals,and Complaints" you,it can take up to 14 more calendar days.The section) independent review organization can't take extra time ♦ if we do not give you an answer by the deadline to make a decision if your request is for a Medicare (or by the end of the extended time period),we Part B prescription drug will send your request to a Level 2 appeal,where an independent review organization will review If you had a standard appeal at Level 1,you will also the appeal.Later in this section,we talk about this have a standard appeal at Level 2 review organization and explain the Level 2 • For the standard appeal,if your request is for a appeal process medical item or service,the review organization must • If our answer is yes to part or all of what you give you an answer to your Level 2 appeal within 30 requested,we must authorize or provide the coverage calendar days of when it receives your appeal.If your within 30 calendar days if your request is for a request is for a Medicare Part B prescription drug,the medical item or service,or within 7 calendar days if review organization must give you an answer to your your request is for a Medicare Part B prescription Level 2 appeal within 7 calendar days of when it drug receives your appeal • If our plan says no to part or all of what your appeal, • However,if your request is for a medical item or we will automatically send your appeal to the service and the independent review organization independent review organization for a Level 2 appeal needs to gather more information that may benefit you,it can take up to 14 more calendar days.The Step-by-step: How a Level 2 appeal is done independent review organization can't take extra time The formal name for the independent review to make a decision if your request is for a Medicare organization is the Independent Review Entity.It is Part B prescription drug sometimes called the IRE. Step 2: The independent review organization gives The independent review organization is an independent you their answer organization hired by Medicare.It is not connected with The independent review organization will tell you its us and is not a government agency.This organization decision in writing and explain the reasons for it. decides whether the decision we made is correct or if it • If the review organization says yes to part or all of a should be changed.Medicare oversees its work. request for a medical item or service,we must authorize the medical care coverage within 72 hours Step 1: The independent review organization or provide the service within 14 calendar days after reviews your appeal we receive the decision from the review organization • We will send the information about your appeal to for standard requests.For expedited requests,we have this organization.This information is called your case 72 hours from the date we receive the decision from file.You have the right to ask us for a copy of your the review organization case file.We are allowed to charge you a fee for • If the review organization says yes to part or all of a copying and sending this information to you request for a Part B prescription drug,we must • You have a right to give the independent review authorize or provide the Medicare Part B prescription organization additional information to support your drug within 72 hours after we receive the decision appeal from the review organization for standard requests. For expedited requests,we have 24 hours from the • Reviewers at the independent review organization date we receive the decision from the review will take a careful look at all of the information organization related to your appeal • If this organization says no to part or all of your If you had a fast appeal at Level 1,you will also have appeal,it means they agree with us that your request a fast appeal at Level 2 (or part of your request)for coverage for medical care should not be approved. (This is called upholding the • For the fast appeal,the review organization must give decision or turning down your appeal) you an answer to your Level 2 appeal within 72 hours . In this care,the independent review organization will of when it receives your appeal send you a letter: • However,if your request is for a medical item or ♦ explaining its decision service and the independent review organization Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 75 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. ♦ notifying you of the right to a Level 3 appeal if the To make this appeal,follow the process for appeals that dollar value of the medical care coverage meets a we describe in"Step-by-step:How to make a Level 1 certain minimum.The written notice you get from Appeal."For appeals concerning reimbursement,please the independent review organization will tell you note: the dollar amount you must meet to continue the . We must give you our answer within 60 calendar days appeals process after we receive your appeal.If you are asking us to pay you back for medical care you have already Step 3: If your case meets the requirements, you received and paid for yourself,you are not allowed to choose whether you want to take your appeal ask for a fast appeal further • If the independent review organization decides we • There are three additional levels in the appeals should pay,we must send you or the provider the process after Level(for a total of five levels of payment within 30 calendar days.If the answer to appeal).If you want to go to a Level appeal the your appeal is yes at any stage of the appeals process details on how to do this are in the written notice you after Level 2,we must send the payment you get after your Level appeal requested to you or to the provider within 60 calendar • The Level 3 appeal is handled by an Administrative days Law Judge or attorney adjudicator."Taking Your Appeal to Level 3 and Beyond"in this"Coverage Decisions,Appeals,and Complaints"section explains Your Part D Prescription Drugs: HOW to the Levels 3,4,and 5 appeals processes Ask for a Coverage Decision or Make an Appeal What if you are asking us to pay you for our share of a bill you have received for medical What to do if you have problems getting a Part D care? drug or you want us to pay you back for a Part D The"Requests for Payment"section describes when you drug may need to ask for reimbursement or to pay a bill you Your benefits include coverage for many prescription have received from a provider.It also tells how to send drugs.To be covered,the drug must be used for a us the paperwork that asks us for payment. medically accepted indication.(A"medically accepted indication"is a use of the drug that is either approved by Asking for reimbursement is asking for a the Food and Drug Administration or supported by coverage decision from us certain reference books.)For details about Part D drugs, If you send us the paperwork asking for reimbursement, rules,restrictions,and costs,please see"Outpatient you are asking for a coverage decision.To make this Prescription Drugs, Supplies,and Supplements"in the decision,we will check to see if the medical care you "Benefits and Your Cost Share"section. This section is paid for is covered.We will also check to see if you about your Part D drugs only.To keep things simple, followed all the rules for using your coverage for we generally say drug in the rest of this section,instead medical care. of repeating covered outpatient prescription drug or Part D drug every time.We also use the term Drug List • If we say yes to your request:If the medical care is instead of List of Covered Drugs or 2025 covered and you followed all the rules,we will send you the payment for our share of the cost typically Comprehensive Formulary. within 30 calendar days,but no later than 60 calendar • If you do not know if a drug is covered or if you meet days after we receive your request.If you haven't the rules,you can ask us. Some drugs require that you paid for the medical care,we will send the payment get approval from us before we will cover it directly to the provider • If your pharmacy tells you that your prescription • If we say no to your request:If the medical care is not cannot be filled as written,the pharmacy will give covered,or you did not follow all the rules,we will you a written notice explaining how to contact us to not send payment.Instead,we will send you a letter ask for a coverage decision that says we will not pay for the medical care and the reasons why Part D coverage decisions and appeals An initial coverage decision about your Part D drugs is If you do not agree with our decision to turn you down, called a coverage determination. you can make an appeal.If you make an appeal,it means you are asking us to change the coverage decision we A coverage decision is a decision we make about your made when we turned down your request for payment. benefits and coverage or about the amount we will pay Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 76 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. for your drugs.This section tells what you can do if you make an exception and waive a restriction for you, are in any of the following situations: you can ask for an exception to the Copayment or • Asking to cover a Part D drug that is not on our 2025 Coinsurance amount we require you to pay for the Comprehensive Formulary.Ask for an exception Part D drug • Asking to waive a restriction on our plan's coverage Important things to know about asking for for a drug(such as limits on the amount of the drug Part D exceptions you can get,prior authorization,or the requirement to try another drug first).Ask for an exception Your doctor must tell us the medical reasons • Asking to pay a lower cost-sharing amount for a Your doctor or other prescriber must give us a statement covered drug on a higher cost-sharing tier.Ask for an that explains the medical reasons for requesting a Part D exception exception.For a faster decision,include this medical information from your doctor or other prescriber when • Asking to get pre-approval for a drug.Ask for a you ask for the exception. coverage decision • Pay for a prescription drug you already bought.Ask Typically,our Drug List includes more than one drug for us to pay you back treating a particular condition. These different possibilities are called alternative drugs.If an If you disagree with a coverage decision we have made, alternative drug would be just as effective as the drug you can appeal our decision. you are requesting and would not cause more side effects or other health problems,we will generally not approve This section tells you both how to ask for coverage your request for an exception. If you ask us for a tiering decisions and how to request an appeal. exception,we will generally not approve your request for an exception unless all the alternative drugs in the lower What is an exception? cost-sharing tier(s)won't work as well for you or are Asking for coverage of a drug that is not on our Drug likely to cause an adverse reaction or other harm. List is sometimes called asking for a formulary We can say yes or no to your request exception. • If we approve your request for a Part D exception,our Asking for removal of a restriction on coverage for a approval usually is valid until the end of the plan drug is sometimes called asking for a formulary year.This is true as long as your doctor continues to exception. prescribe the drug for you and that drug continues to be safe and effective for treating your condition If a drug is not covered in the way you would like it to be • If we say no to your request,you can ask for another covered,you can ask us to make an exception.An review by making an appeal exception is a type of coverage decision. Step-by-step: How to ask for a coverage For us to consider your exception request,your doctor or decision, including a Part D exception other prescriber will need to explain the medical reasons A fast coverage decision is called an expedited coverage why you need the exception approved.Here are two determination. examples of exceptions that you or your doctor or other Step 1: Decide if you need a standard coverage prescriber can ask us to make: decision or a fast coverage decision • Covering a Part D drug for you that is not on our Standard coverage decisions are made within 72 hours Drug List.If we agree to cover a drug that is not on after we receive your doctor's statement.Fast coverage our Drug List,you will need to pay the Cost Share decisions are made within 24 hours after we receive amount that applies to drugs in the brand-name drug your doctor's statement. tier.You cannot ask for an exception to the Copayment or Coinsurance amount we require you to pay for the drug If your health requires it,ask us to give you a fast coverage decision.To get a fast coverage decision,you • Removing a restriction for a covered Part D drug. must meet two requirements: "Outpatient Prescription Drugs, Supplies,and • You must be asking for a drug you have not yet Supplements"in the"Benefits and Your Cost Share" received. (You cannot ask for a fast coverage decision section describes the extra rules or restrictions that to be paid back for a drug you have already bought) apply to certain drugs on our Drug List.If we agree to Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 77 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • Using the standard deadlines could cause serious Step 3: We consider your request and we give you harm to your health or hurt your ability to function our answer • If your doctor or other prescriber tells us that Deadlines for a fast coverage decision your health requires a fast coverage decision,we will automatically give you a fast coverage decision • We must generally give you our answer within 24 • If you ask for a fast coverage decision on your hours after we receive your request. own,without your doctor's or prescriber's support,we ♦ for exceptions,we will give you our answer within will decide whether your health requires that we give 24 hours after we receive your doctor's supporting you a fast coverage decision.If we do not approve a statement.We will give you our answer sooner fast coverage decision,we will send you a letter that: if your health requires us to ♦ explains that we will use the standard deadlines ♦ if we do not meet this deadline,we are required to send your request to Level 2 of the appeals ♦ explains if your doctor or other prescriber asks for process,where it will be reviewed by an the fast coverage decision,we will automatically independent review organization give you a fast coverage decision ♦ tells you how you can file a fast complaint about • If our answer is yes to part or all of what you our decision to give you a standard coverage requested,we must provide the coverage we have decision instead of the fast coverage decision you agreed to provide within 24 hours after we receive requested.We will answer your complaint within your request or doctor's statement supporting your 24 hours of receipt request • If our answer is no to part or all of what you Step 2: Request a standard coverage decision or a requested,we will send you a written statement that fast coverage decision explains why we said no.We will also tell you how Start by calling,writing,or faxing OptumRx Prior you can appeal Authorization Member Services Desk to make your request for us to authorize or provide coverage for the Deadlines for a standard coverage decision about a medical care you want.You can also access the coverage Part D drug you have not yet received decision process through our website.We must accept • We must generally give you our answer within 72 any written request,including a request submitted on the hours after we receive your request CMS Model Coverage Determination Request form, ♦ for exceptions,we will give you our answer within which is available on our website."How to contact us 72 hours after we receive your doctor's supporting when you are asking for a coverage decision about your statement.We will give you our answer sooner Part D prescription drugs"in the"Important Phone if your health requires us to Numbers and Resources"section has contact information. To assist us in processing your request, ♦ if we do not meet this deadline,we are required to please be sure to include your name,contact information, send your request on to Level 2 of the appeals and information identifying which denied claim is being process,where it will be reviewed by an appealed. independent review organization • If our answer is yes to part or all of what you You,or your doctor(or other prescriber),or your requested,we must provide the coverage we have representative can do this.You can also have a lawyer agreed to provide within 72 hours after we receive act on your behalf. "How to Get Help When You are your request or doctor's statement supporting your Asking for a Coverage Decision or Making an Appeal" request of this section tells how you can give written permission o If our answer is no to part or all of what you to someone else to act as your representative. requested,we will send you a written statement that • If you are requesting a Part D exception,provide the explains why we said no.We will also tell you how supporting statement which is the medical reasons for you can appeal the exception.Your doctor or other prescriber can fax or mail the statement to us.Or your doctor or other prescriber can tell us on the phone and follow up by faxing or mailing a written statement if necessary Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 78 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Deadlines for a standard coverage decision about • For fast appeals either submit your appeal in writing payment for a drug you have already bought or call us at 1-800-443-0815."Important Phone Numbers and Resources"has contact information • We must give you our answer within 14 calendar days after we receive your request • We must accept any written request,including a ♦ if we do not meet this deadline,we are required to request submitted on the CMS Model send your request to Level 2 of the appeals Redetermination Request Form,which is available on our website.Please be sure to include your name, process,where it will be reviewed by an contact information,and information regarding your independent review organization claim to assist us in processing your request • If our answer is yes to part or all of what you • You must make your appeal request within 65 requested,we are also required to make payment to calendar days from the date on the written notice we you within 14 calendar days after we receive your sent to tell you our answer on the coverage decision. request If you miss this deadline and have a good reason for • If our answer is no to part or all of what you missing it,explain the reason your appeal is late when requested,we will send you a written statement that you make your appeal.We may give you more time explains why we said no.We will also tell you how to make your appeal.Examples of good cause may you can appeal include a serious illness that prevented you from contacting us or if we provided you with incorrect or Step 4: If we say no to your coverage request, you incomplete information about the deadline for decide if you want to make an appeal requesting an appeal If we say no,you have the right to ask us to reconsider • You can ask for a copy of the information in your this decision by making an appeal.This means asking appeal and add more information.You and your again to get the drug coverage you want.If you make an doctor may add more information to support your appeal,it means you are going to Level I of the appeals appeal.We are allowed to charge a fee for copying process. and sending this information to you Step-by-step: How to make a Level 1 appeal Step 3: We consider your appeal and we give you An appeal to our plan about a Part D drug coverage our answer decision is called a plan redetermination.A fast appeal • When we are reviewing your appeal,we take another is also called an expedited redetermination. careful look at all of the information about your coverage request.We check to see if we were Step 1: Decide if you need a standard appeal or a following all the rules when we said no to your fast appeal request.We may contact you or your doctor or other prescriber to get more information A standard appeal is usually made within 7 calendar days.A fast appeal is generally made within 72 hours. Deadlines for a fast appeal If your health requires it,ask for a fast appeal • For fast appeals,we must give you our answer within • If you are appealing a decision we made about a drug 72 hours after we receive your appeal.We will give you have not yet received,you and your doctor or you our answer sooner if your health requires us to other prescriber will need to decide if you need a fast ♦ if we do not give you an answer within 72 hours, appeal we are required to send your request on to Level 2 • The requirements for getting a"fast appeal"are the of the appeals process,where it will be reviewed same as those for getting a fast coverage decision in by an independent review organization "Step-by-step:How to ask for a coverage decision, • If our answer is yes to part or all of what you including a Part D exception"of this section requested,we must provide the coverage we have agreed to provide within 72 hours after we receive Step 2: You, your representative, doctor, or other your appeal prescriber must contact us and make your Level 1 If our answer is no to part or all of what you appeal. If your health requires a quick response, you must ask for a fast appeal requested,we will send you a written statement that explains why we said no and how you can appeal our • For standard appeals,submit a written request. decision "Important Phone Numbers and Resources"has contact information Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 79 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Deadlines for a standard appeal for a drug you have correct or if it should be changed.Medicare oversees its not yet received work. • For standard appeals,we must give you our answer within 7 calendar days after we receive your appeal. Step 1: You (or your representative or your doctor We will give you our decision sooner if you have not or other prescriber) must contact the independent received the drug yet and your health condition review organization and ask for a review of your requires us to do so case ♦ if we do not give you a decision within 7 calendar • If we say no to your Level 1 appeal,the written notice days,we are required to send your request on to we send you will include instructions on how to make Level 2 of the appeals process,where it will be a Level 2 appeal with the independent review reviewed by an independent review organization organization. These instructions will tell who can • If our answer is yes to part or all of what you make this Level 2 appeal,what deadlines you must requested,we must provide the coverage as quickly as follow,and how to reach the review organization.If, your health requires,but no later than 7 calendar days however,we did not complete our review within the after we receive your appeal applicable timeframe,or make an unfavorable decision regarding at-risk determination under our • If our answer is no to part or all of what you drug management program,we will automatically requested,we will send you a written statement that forward your claim to the IRE explains why we said no and how you can appeal our • We will send the information about your appeal to decision this organization.This information is called your case Deadlines for a standard appeal about payment for a file.You have the right to ask us for a copy of your drug you have already bought case file.We are allowed to charge you a fee for • We must give you our answer within 14 calendar days copying and sending this information to you after we receive your request • You have a right to give the independent review ♦ If we do not meet this deadline,we are required to organization additional information to support your send your request to Level 2 of the appeals appeal process,where it will be reviewed by an independent review organization Step 2: The independent review organization • If our answer is yes to part or all of what you reviews your appeal requested,we are also required to make payment to Reviewers at the independent review organization will you within 30 calendar days after we receive your take a careful look at all of the information related to request your appeal. • If our answer is no to part or all of what you Deadlines for fast appeal requested,we will send you a written statement that explains why we said no.We will also tell you how • If your health requires it,ask the independent review you can appeal our decision organization for a fast appeal Step 4: If we say no to your appeal, you decide • If the organization agrees to give you a fast appeal, if you want to continue with the appeals process the organization must give you an answer to your and make another appeal Level 2 appeal within 72 hours after it receives your appeal request • If you decide to make another appeal,it means your appeal is going on to Level 2 of the appeals process Deadlines for standard appeal Step-by-step: How to make a Level 2 appeal • For standard appeals,the review organization must give you an answer to your Level 2 appeal within 7 The formal name for the independent review calendar days after it receives your appeal if it is for a organization the Independent Review Entity.It is drug you have not yet received.If you are requesting sometimes called the IRE. that we pay you back for a drug you have already bought,the review organization must give you an The independent review organization is an answer to your Level 2 appeal within 14 calendar independent organization hired by Medicare.It is not days after it receives your request connected with us and is not a government agency. This organization decides whether the decision we made is Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 80 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Step 3: The independent review organization give Appeal to Level 3 and Beyond"tells more about you their answer Levels 3,4,and 5 of the appeals process For fast appeals: • If the independent review organization says yes to How to Ask Us to Cover a Longer part or all of what you requested,we must provide the Inpatient Hospital Stay if You Think You drug coverage that was approved by the review Are Being Discharged Too Soon organization within 24 hours after we receive the decision from the review organization When you are admitted to a hospital,you have the right to get all of your covered hospital Services that are For standard appeals: necessary to diagnose and treat your illness or injury. • If the independent review organization says yes to part or all of your request for coverage,we must During your covered hospital stay,your doctor and the provide the drug coverage that was approved by the hospital staff will be working with you to prepare for the review organization within 72 hours after we receive day when you will leave the hospital. They will help the decision from the review organization arrange for care you may need after you leave. • If the independent review organization says yes to • The day you leave the hospital is called your part or all of your request to pay you back for a drug discharge date you already bought,we are required to send payment • When your discharge date is decided,your doctor or to you within 30 calendar days after we receive the the hospital staff will tell you decision from the review organization . If you think you are being asked to leave the hospital What if the review organization says no to your too soon,you can ask for a longer hospital stay and appeal? your request will be considered If this organization says no to your appeal,it means the During your inpatient hospital stay,you will get organization agrees with our decision not to approve a written notice from Medicare that tells about your request(or part of your request.)(This is called your rights upholding the decision.It is also called turning down Within two calendar days of being admitted to the your appeal.)In this case,the independent review hospital,you will be given a written notice called An organization will send you a letter: Important Message from Medicare About Your Rights. • Explaining its decision Everyone with Medicare gets a copy of this notice If you • Notifying you of the right to a Level 3 appeal if the do not get the notice from someone at the hospital(for dollar value of the drug coverage you are requesting example,a caseworker or nurse),ask any hospital meets a certain minimum.If the dollar value of the employee for it.If you need help,please call Member drug coverage you are requesting is too low,you Services or 1-800-MEDICARE(1-800-633-4227),24 cannot make another appeal and the decision at Level hours a day,seven days a week(TTY 1-877-486-2048). 2 is final • Read this notice carefully and ask questions if you • Telling you the dollar value that must be in dispute to don't understand it.It tells you: continue with the appeals process ♦ your right to receive Medicare-covered services during and after your hospital stay,as ordered by Step 4: If your case meets the requirements, you your doctor. This includes the right to know what choose whether you want to take your appeal these services are,who will pay for them,and further where you can get them ♦• There are three additional levels in the appeals your right to be involved in any decisions about your hospital stay process after Level 2(for a total of five levels of appeal) ♦ where to report any concerns you have about the • If you want to go on to a Level appeal the details on quality of your hospital Services how to do this are in the written notice you get after ♦ your right to request an immediate review of the your Level 2 appeal decision decision to discharge you if you think you are being discharged from the hospital too soon.This • The Level 3 appeal is handled by an Administrative is a formal,legal way to ask for a delay in your Law Judge or attorney adjudicator."Taking Your discharge date so that we will cover your hospital care for a longer time Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 81 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • You will be asked to sign the written notice to immediate review of your hospital discharge. You show that you received it and understand your must act quickly rights How can you contact this organization? ♦ you or someone who is acting on your behalf will be asked to sign the notice • The written notice you received(An Important ♦ signing the notice shows only that you have Message from Medicare About Your Rights)tells you received the information about your rights.The how to reach this organization.Or find the name, notice does not give your discharge date. Signing address,and phone number of the Quality the notice does not mean you are agreeing on a Improvement Organization for your state in the discharge date "Important Phone Numbers and Resources"section • Keep your copy of the notice handy so you will have Act quickly the information about making an appeal(or reporting a concern about quality of care)if you need it • To make your appeal,you must contact the Quality ♦ if you sign the notice more than two calendar days Improvement Organization before you leave the before your discharge date,you will get another hospital and no later than midnight the day of your copy before you are scheduled to be discharged discharge ♦ to look at a copy of this notice in advance,you can ♦ if you meet this deadline,you may stay in the call Member Services or 1-800-MEDICARE hospital after your discharge date without paying (1-800-633-4227)(TTY users call 1-877-486- for it while you wait to get the decision from the 2048),24 hours a day,seven days a week.You Quality Improvement Organization can also see the notice online at ♦ if you do not meet this deadline,contact us.If you https://www.ems.eov/medicare/forms- decide to stay in the hospital after your planned notices/beneficiary-notices-initiative/ffs-ma-im discharge date,you may have to pay all of the costs for hospital Services you receive after your Step-by-step: How to make a Level 1 appeal to planned discharge date change your hospital discharge date If you want to ask for your inpatient hospital services to Once you request an immediate review of your hospital be covered by us for a longer time,you will need to use discharge,the Quality Improvement Organization will the appeals process to make this request.Before you contact us.By noon of the day after we are contacted,we start,understand what you need to do and what the will give you a Detailed Notice of Discharge.This notice deadlines are. gives your planned discharge date and explains in detail • Follow the process the reasons why your doctor,the hospital,and we think it is right(medically appropriate)for you to be discharged • Meet the deadlines on that date. • Ask for help if you need it.If you have questions or need help at any time,please call Member Services. You can get a sample of the Detailed Notice of Or call your State Health Insurance Assistance Discharge by calling Member Services or 1-800- Program,a government organization that provides MEDICARE(1-800-633-4227)24 hours a day,seven personalized assistance days a week(TTY users call 1-877-486-2048).Or you can see a sample notice online at During a Level 1 appeal,the Quality Improvement https://www.ems.zov/medicare/forms- Organization reviews your appeal.It checks to see notices/beneficiary-notices-initiative/ffs-ma-im if your planned discharge date is medically appropriate for you. Step 2: The Quality Improvement Organization conducts an independent review of your case The Quality Improvement Organization is a group of • Health professionals at the Quality Improvement doctors and other health care professionals paid by the Organization(the reviewers)will ask you(or your federal government to check on and help improve the representative)why you believe coverage for the quality of care for people with Medicare.This includes services should continue.You don't have to prepare reviewing hospital discharge dates for people with anything in writing,but you may do so if you wish Medicare. These experts are not part of our plan. • The reviewers will also look at your medical Step 1: Contact the Quality Improvement information,talk with your doctor,and review Organization for your state and ask for an Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 82 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. information that the hospital and we have given to Step 1: Contact the Quality Improvement them Organization again and ask for another review • By noon of the day after the reviewers told us of your . You must ask for this review within 60 calendar days appeal,you will get a written notice from us that after the day the Quality Improvement Organization gives your planned discharge date.This notice also said no to your Level 1 appeal.You can ask for this explains in detail the reasons why your doctor,the review only if you stay in the hospital after the date hospital,and we think it is right(medically that your coverage for the care ended appropriate)for you to be discharged on that date Step 2: The Quality Improvement Organization Step 3: Within one full day after it has all the does a second review of your situation needed information, the Quality Improvement Organization will give you its answer to your appeal • Reviewers at the Quality Improvement Organization will take another careful look at all of the information What happens if the answer is yes? related to your appeal • If the review organization says yes,we must keep Step 3: Within 14 calendar days of receipt of your providing your covered inpatient hospital services for request for a Level 2 appeal, the reviewers will as long as these services are medically necessary decide on your appeal and tell you their decision • You will have to keep paying your share of the costs (such as Cost Share,if applicable).In addition,there If the review organization says yes may be limitations on your covered hospital services . We must reimburse you for our share of the costs of What happens if the answer is no? hospital Services you have received since noon on the day after the date your first appeal was turned down • If the review organization says no,they are saying by the Quality Improvement Organization.We must that your planned discharge date is medically continue providing coverage for your inpatient appropriate.If this happens,our coverage for your hospital Services for as long as it is medically inpatient hospital services will end at noon on the day necessary after the Quality Improvement Organization gives • You must continue to pay your share of the costs,and you its answer to your appeal coverage limitations may apply • If the review organization says no to your appeal and you decide to stay in the hospital,then you may have If the review organization says no to pay the full cost of hospital Services you receive • It means they agree with the decision they made on after noon on the day after the Quality Improvement O your Level 1 appeal. This is called upholding the Organization gives you its answer to your appeal decision Step 4: If the answer to your Level 1 appeal is no, • The notice you get will tell you in writing what you you decide if you want to make another appeal can do if you wish to continue with the review process • If the Quality Improvement Organization has said no to your appeal,and you stay in the hospital after your Step 4: If the answer is no, you will need to decide planned discharge date,then you can make another whether you want to take your appeal further by appeal.Making another appeal means you are going going on to Level 3 on to Level 2 of the appeals process • There are three additional levels in the appeals Step-by-step: How to make a Level 2 appeal to process after Level 2(for a total of five levels of change your hospital discharge date appeal).If you want to go to a Level 3 appeal,the During a Level 2 appeal,you ask the Quality details on how to do this are in the written notice you Improvement Organization to take another look at their get after your Level 2 appeal decision decision on your first appeal.If the Quality Improvement • The Level 3 appeal is handled by an Administrative Organization turns down your Level 2 appeal,you may Law Judge or attorney adjudicator.The"Taking Your have to pay the full cost for your stay after your planned Appeal to Level 3 and Beyond"section tells more discharge date. about Levels 3,4,and 5 of the appeals process Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 83 Member Service:toll free 1-800-443-081 S(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. How to Ask Us to Keep Covering Certain • Ask for help if you need it.If you have questions or Medical Services if You Think Your need help at any time,please call Member Services. Coverage Is Ending Too Soon Or call your State Health Insurance Assistance Program,a government organization that provides Home health care, Skilled Nursing Facility care, personalized assistance and Comprehensive Outpatient Rehabilitation Facility (CORF) services During a Level 1 appeal,the Quality Improvement Organization reviews your appeal.It decides if the end When you are getting covered home health services, date for your care is medically appropriate. Skilled Nursing Facility care,or rehabilitation care (Comprehensive Outpatient Rehabilitation Facility), The Quality Improvement Organization is a group of you have the right to keep getting your services for that doctors and other health care experts paid by the federal type of care for as long as the care is needed to diagnose government to check on and help improve the quality of and treat your illness or injury. care for people with Medicare.This includes reviewing plan decisions about when it's time to stop covering When we decide it is time to stop covering any of the certain kinds of medical care. These experts are not part three types of care for you,we are required to tell you in of our plan. advance.When your coverage for that care ends,we will stop paying our share of the cost for your care. Step 1: Make your Level 1 appeal: contact the Quality Improvement Organization and ask for a If you think we are ending the coverage of your care too fast-track appeal. You must act quickly soon,you can appeal our decision.This section tells you How can you contact this organization? how to ask for an appeal. • The written notice you received(Notice of Medicare We will tell you in advance when your coverage Non-Coverage)tells you how to reach this will be ending organization. Or find the name,address,and phone The Notice of Medicare Non-Coverage tells how you number of the Quality Improvement Organization for can request a fast-track appeal.Requesting a fast-track your state in the"Important Phone Numbers and appeal is a formal,legal way to request a change to our Resources"section coverage decision about when to stop your care. • You receive a notice in writing at least two calendar Act quickly days before our plan is going to stop covering your . You must contact the Quality Improvement care. The notice tells you: Organization to start your appeal by noon of the day ♦ the date when we will stop covering the care for before the effective date on the Notice of Medicare you Non-Coverage.If you miss the deadline,and you ♦ how to request a fast-track appeal to request us to wish to file an appeal,you still have appeal rights. keep covering your care for a longer period of Contact your Quality Improvement Organization time Step 2: The Quality Improvement Organization • You,or someone who is acting on your behalf,will conducts an independent review of your case be asked to sign the written notice to show that you received it. Signing the notice shows only that The Detailed Explanation of Non-Coverage provides you have received the information about when your details on reasons for ending coverage. coverage will stop. Signing it does not mean you What happens during this review? agree with the plan's decision to stop care • Health professionals at the Quality Improvement Step-by-step: How to make a Level 1 appeal to Organization(the reviewers)will ask you or your have our plan cover your care for a longer time representative why you believe coverage for the If you want to ask us to cover your care for a longer services should continue.You don't have to prepare period of time,you will need to use the appeals process anything in writing,but you may do so if you wish to make this request.Before you start,understand what • The review organization will also look at your you need to do and what the deadlines are. medical information,talk with your doctor,and • Follow the process review information that our plan has given to them • Meet the deadlines Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 84 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • By the end of the day the reviewers tell us of your Step 2: The Quality Improvement Organization appeal,you will get the Detailed Explanation of does a second review of your situation Non-Coverage from us that explains in detail our Reviewers at the Quality Improvement Organization will reasons for ending our coverage for your services. take another careful look at all of the information related Step 3: Within one full day after they have all the to your appeal. information they need, the reviewers will tell you Step 3: Within 14 calendar days of receipt of your their decision appeal request, reviewers will decide on your What happens if the reviewers say yes? appeal and tell you their decision • If the reviewers say yes to your appeal,then we must What happens if the review organization says yes? keep providing your covered services for as long as it • We must reimburse you for our share of the costs of is medically necessary care you have received since the date when we said • You will have to keepa share of the costs your coverage would end.We must continue paying m g your (such as Cost Share,if applicable).There may be providing coverage for the care for as long as it is limitations on your covered services medically necessary • You must continue to pay your share of the costs and What happens if the reviewers say no? there may be coverage limitations that apply • If the reviewers say no,then your coverage will end What happens if the review organization says no? on the date we have told you • It means they agree with the decision we made to • If you decide to keep getting the home health care,or your Level 1 appeal Skilled Nursing Facility care,or Comprehensive • The notice you get will tell you in writing what you Outpatient Rehabilitation Facility(CORF)services after this date when your coverage ends,then you will can do if you wish to continue with the review have to pay the full cost of this care yourself process.It will give you the details about how to go on to the next level of appeal,which is handled by an Step 4: If the answer to your Level 1 appeal is no, Administrative Law Judge or attorney adjudicator you decide if you want to make another appeal Step 4: If the answer is no, you will need to decide • If reviewers say no to your Level 1 appeal,and you whether you want to take your appeal further choose to continue getting care after your coverage . There are three additional levels of appeal after Level for the care has ended,then you can make a Level 2 appeal 2,for a total of five levels of appeal If you want to go on to a Level 3 appeal,the details on how to do this Step-by-step: How to make a Level 2 appeal to are in the written notice you get after your Level 2 have our plan cover your care for a longer time appeal decision During a Level 2 appeal,you ask the Quality • The Level 3 appeal is handled by an Administrative Improvement Organization to take another look at the Law Judge or attorney adjudicator."Taking Your decision on your first appeal.If the Quality Improvement Appeal to Level 3 and Beyond"in this"Coverage Organization turns down your Level 2 appeal,you may Decisions,Appeals,and Complaints"section tells have to pay the full cost for your home health care,or more about Levels 3,4,and 5 of the appeals process Skilled Nursing Facility care,or Comprehensive Outpatient Rehabilitation Facility(CORF)services after Taking Your Appeal to Level 3 and the date when we said your coverage would end. Beyond Step 1: Contact the Quality Improvement Levels of Appeal 3, 4, and 5 for Medical Service Organization again and ask for another review Requests • You must ask for this review within 60 calendar days This section may be appropriate for you if you have after the day when the Quality Improvement made a Level 1 appeal and a Level 2 appeal,and both of Organization said no to your Level 1 appeal.You can your appeals have been turned down. ask for this review only if you continued getting care after the date that your coverage for the care ended If the dollar value of the item or medical service you have appealed meets certain minimum levels,you may be able to go on to additional levels of appeal.If the Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 85 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. dollar value is less than the minimum level,you cannot ♦ if we decide to appeal the decision,we will let you appeal any further. The written response you receive to know in writing your Level 2 appeal will explain how to make a Level 3 . If the answer is no or if the Council denies the appeal. review request,the appeals process may or may not be over For most situations that involve appeals,the last three levels of appeal work in much the same way.Here is ♦ if you decide to accept this decision that turns who handles the review of your appeal at each of these down your appeal,the appeals process is over levels. ♦ if you do not want to accept the decision,you may be able to continue to the next level of the review Level 3 appeal: An Administrative Law Judge or process.If the Council says no to your appeal,the an attorney adjudicator who works for the notice you get will tell you whether the rules allow federal government will review your appeal and you to go on to a Level 5 appeal and how to give you an answer continue with a Level 5 appeal • If the Administrative Law Judge or attorney Level 5 appeal: A judge at the Federal District adjudicator says yes to your appeal,the appeals process may or may not be over.Unlike a decision Court will review your appeal at a Level 2 appeal,we have the right to appeal a • A judge will review all of the information and decide Level 3 decision that is favorable to you.If we decide yes or no to your request. This is a final answer. to appeal,it will go to a Level 4 appeal There are no more appeal levels after the Federal ♦ if we decide not to appeal,we must authorize or District Court provide you with the medical care within 60 calendar days after receiving the Administrative Appeal Levels 3, 4, and 5 for Part D Drug Law Judge's or attorney adjudicator's decision Requests ♦ if we decide to appeal the decision,we will send This section may be appropriate for you if you have you a copy of the Level 4 appeal request with any made a Level 1 appeal and a Level 2 appeal,and both of accompanying documents.We may wait for the your appeals have been turned down. Level 4 appeal decision before authorizing or providing the medical care in dispute If the value of the Part D drug you have appealed meets a certain dollar amount,you may be able to go on to • If the Administrative Law Judge or attorney additional levels of appeal.If the dollar amount is less, adjudicator says no to your appeal,the appeals you cannot appeal any further.The written response you process may or may not be over receive to your Level 2 appeal will explain who to ♦ if you decide to accept this decision that turns contact and what to do to ask for a Level 3 appeal. down your appeal,the appeals process is over ♦ if you do not want to accept the decision,you can For most situations that involve appeals,the last three continue to the next level of the review process. levels of appeal work in much the same way.Here is The notice you get will tell you what to do for a who handles the review of your appeal at each of these Level 4 appeal levels. Level 4 appeal: The Medicare Appeals Council Level 3 appeal: An Administrative Law Judge or (Council)will review your appeal and give you an attorney adjudicator who works for the an answer.The Council is part of the federal federal government will review your appeal and government give you an answer • If the answer is yes,or if the Council denies our • If the answer is yes,the appeals process is over.We request to review a favorable Level 3 appeal must authorize or provide the drug coverage that was decision,the appeals process may or may not be approved by the Administrative Law Judge or over.Unlike a decision at Level 2,we have the right attorney adjudicator within 72 hours(24 hours for to appeal a Level 4 decision that is favorable to you. expedited appeals)or make payment no later than 30 We will decide whether to appeal this decision to calendar days after we receive the decision Level 5 • If the answer is no,the appeals process may or may ♦ if we decide not to appeal the decision,we must not be over authorize or provide you with the medical care ♦ If you decide to accept this decision that turns within 60 calendar days after receiving the down your appeal,the appeals process is over Council's decision Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 86 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. ♦ If you do not want to accept the decision,you can • Disrespect,poor customer service,or other continue to the next level of the review process. negative behaviors The notice you get will tell you what to do for a ♦ has someone been rude or disrespectful to you? Level appeal ♦ are you unhappy with our Member Services? Level 4 appeal: The Medicare Appeals Council ♦ do you feel you are being encouraged to leave our (Council) will review your appeal and give you plan? an answer. The Council is part of the federal . Waiting times government ♦ are you having trouble getting an appointment,or • If the answer is yes,the appeals process is over.We waiting too long to get it? must authorize or provide the drug coverage that was ♦ have you been kept waiting too long by doctors, approved by the Council within 72 hours(24 hours for expedited appeals)or make payment no later than pharmacists,or other health professionals?Or by Member Services or other staff at our plan? 30 calendar days after we receive the decision — Examples include waiting too long on the • If the answer is no,the appeals process may or may phone,in the waiting or exam room,or getting not be over a prescription ♦ if you decide to accept this decision that turns Cleanliness down your appeal,the appeals process is over ♦ if you do not want to accept the decision,you may ♦ are you unhappy with the cleanliness or condition s office? be able to continue to the next level of the review of a clinic,hospital,or doctor process.If the Council says no to your appeal or • Information you get from our plan denies your request to review the appeal,the ♦ did we fail to give you a required notice? notice will tell you whether the rules allow you to ♦ is our written information hard to understand? go on to a Level 5 appeal.It will also tell you who to contact and what to do next if you choose to Timeliness (these types of complaints are all continue with your appeal related to the timeliness of our actions related to Level 5 appeal: A judge at the Federal District coverage decisions and appeals) Court will review your appeal If you have asked for a coverage decision or made an appeal,and you think that we are not responding quickly • A judge will review all of the information and decide enough,you can make a complaint about our slowness. yes or no to your request. This is a final answer. Here are examples: There are no more appeal levels after the Federal • You asked us for a"fast coverage decision"or a"fast District Court appeal,"and we have said no,you can make a complaint How to Make a Complaint About Quality • You believe we are not meeting the deadlines for of Care, Waiting Times, Customer coverage decisions or appeals;you can make a Service, or Other Concerns complaint • You believe we are not meeting deadlines for What kinds of problems are handled by the covering or reimbursing you for certain medical services or Part D drugs that were approved;you can complaint process? make a complaint The complaint process is only used for certain types of . You believe we failed to meet required deadlines for problems. This includes problems related to quality of care,waiting times,and customer service.Here are forwarding your case to the independent review examples of the kinds of problems handled by the organization;you can make a complaint complaint process: Step-by-step: making a complaint • Quality of your medical care • A complaint is also called a grievance ♦ are you unhappy with the quality of care you have • Making a complaint is also called filing a grievance received(including care in the hospital)? • Using the process for complaints is also called • Respecting your privacy using the process for filing a grievance ♦ did someone not respect your right to privacy or share confidential information? Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 87 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • A fast complaint is also called an expedited total)to answer your complaint.If we decide to take grievance extra days,we will tell you in writing • If you are making a complaint because we denied Step 1: Contact us promptly—either by phone or in your request for a fast coverage decision or a fast writing appeal,we will automatically give you a fast • Usually calling Member Services is the first step. complaint.If you have a fast complaint,it means we If there is anything else you need to do,Member will give you an answer within 24 hours Services will let you know • If we do not agree with some or all of your • If you do not wish to call(or you called and were not complaint or don't take responsibility for the problem satisfied),you can put your complaint in writing and you are complaining about,we will include our send it to us.If you put your complaint in writing,we reasons in the response to you will respond to you in writing.We will also respond in writing when you make a complaint by phone You can also make complaints about quality of if you request a written response or your complaint is care to the Quality Improvement Organization related to quality of care When your complaint is about quality of care,you also • If you have a complaint,we will try to resolve your have two extra options: complaint over the phone.If we cannot resolve your • You can make your complaint directly to the complaint over the phone,we have a formal Quality Improvement Organization. The Quality procedure to review your complaints.Your grievance Improvement Organization is a group of practicing must explain your concern,such as why you are doctors and other health care experts paid by the dissatisfied with the services you received.Please see federal government to check and improve the care the"Important Phone Numbers and Resources" given to Medicare patients. The"Important Phone section for whom you should contact if you have a Numbers and Resources"section has contact complaint information ♦ you must submit your grievance to us(orally or in . Or you can make your complaint to both the writing)within 60 calendar days of the event or Quality Improvement Organization and us at the incident.We must address your grievance as same time quickly as your health requires,but no later than 30 calendar days after receiving your complaint. We may extend the time frame to make our You can also tell Medicare about your decision by up to 14 calendar days if you ask for complaint an extension,or if we justify a need for additional information and the delay is in your best interest You can submit a complaint about our plan directly to ♦ you can file a fast grievance about our decision not Medicare.To submit a complaint to Medicare,go to to expedite a coverage decision or appeal for htti)s://www.medicare.2ov/MedicareComplaintForm/ medical care or items,or if we extend the time we home.aspx.You may also call 1-800-MEDICARE need to make a decision about a coverage decision (1-800-633-4227).TTY/TDD users should call 1-877- or appeal for medical care or items.We must 486-2048. respond to your fast grievance within 24 hours • The deadline for making a complaint is 60 calendar Additional Review days from the time you had the problem you want to complain about You may have certain additional rights if you remain dissatisfied after you have exhausted our internal claims Step 2: We look into your complaint and give you and appeals procedure,and if applicable,external our answer review: • If possible,we will answer you right away.If you • If your Group's benefit plan is subject to the call us with a complaint,we may be able to give you Employee Retirement Income Security Act(ERISA), an answer on the same phone call you may file a civil action under section 502(a)of • Most complaints are answered within 30 calendar ERISA.To understand these rights,you should check days. If we need more information and the delay is in with your Group or contact the Employee Benefits your best interest or if you ask for more time,we can Security Administration(part of the U.S.Department take up to 14 more calendar days(44 calendar days of Labor)at 1-866-444-EBSA(1-866-444-3272) Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 88 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. • If your Group's benefit plan is not subject to ERISA As referred to in this"Binding Arbitration"section, (for example,most state or local government plans "Member Parties"include: and church plans),you may have a right to request • A Member review in state court • A Member's heir,relative,or personal representative • Any person claiming that a duty to them arises from a Binding Arbitration Member's relationship to one or more Kaiser For all claims subject to this"Binding Arbitration" Permanente Parties section,both Claimants and Respondents give up the right to a jury or court trial and accept the use of binding "Kaiser Permanente Parties"include: arbitration.Insofar as this"Binding Arbitration"section • Kaiser Foundation Health Plan,Inc. applies to claims asserted by Kaiser Permanente Parties, • Kaiser Foundation Hospitals it shall apply retroactively to all unresolved claims that accrued before the effective date of this EOC. Such • The Permanente Medical Group,Inc. retroactive application shall be binding only on the • Southern California Permanente Medical Group Kaiser Permanente Parties. • The Permanente Federation,LLC Scope of arbitration • The Permanente Company,LLC Any dispute shall be submitted to binding arbitration if • Any Southern California Permanente Medical Group all of the following requirements are met: or The Permanente Medical Group physician • The claim arises from or is related to an alleged • Any individual or organization whose contract with violation of any duty incident to or arising out of or any of the organizations identified above requires relating to this EOC or a Member Party's relationship arbitration of claims brought by one or more Member to Kaiser Foundation Health Plan,Inc.("Health Parties Plan"),including any claim for medical or hospital • Any employee or agent of any of the foregoing malpractice(a claim that medical services or items were unnecessary or unauthorized or were improperly,negligently,or incompetently rendered), "Claimant"refers to a Member Party or a Kaiser for premises liability,or relating to the coverage for, Permanente Party who asserts a claim as described or delivery of,services or items,irrespective of the above."Respondent"refers to a Member Party or a legal theories upon which the claim is asserted Kaiser Permanente Party against whom a claim is asserted. • The claim is asserted by one or more Member Parties against one or more Kaiser Permanente Parties or by Rules of Procedure one or more Kaiser Permanente Parties against one or Arbitrations shall be conducted according to the Rules more Member Parties for Kaiser Permanente Member Arbitrations Overseen • Governing law does not prevent the use of binding by the Office of the Independent Administrator("Rules arbitration to resolve the claim of Procedure")developed by the Office of the Independent Administrator in consultation with Kaiser Members enrolled under this EOC thus give up their Permanente and the Arbitration Oversight Board. Copies right to a court or jury trial,and instead accept the use of of the Rules of Procedure may be obtained from Member binding arbitration except that the following types of Services. claims are not subject to binding arbitration: • Claims within the jurisdiction of the Small Claims Initiating arbitration Court Claimants shall initiate arbitration by serving a Demand for Arbitration. The Demand for Arbitration shall include • Claims subject to a Medicare appeal procedure as the basis of the claim against the Respondents;the applicable to Kaiser Permanente Senior Advantage amount of damages the Claimants seek in the arbitration; Members the names,addresses,and phone numbers of the • Claims that cannot be subject to binding arbitration Claimants and their attorney,if any;and the names of all under governing law Respondents. Claimants shall include in the Demand for Arbitration all claims against Respondents that are based on the same incident,transaction,or related circumstances. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 89 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Serving demand for arbitration entitled to select a party arbitrator may agree to waive Health Plan,Kaiser Foundation Hospitals,The this right.If all parties agree,these arbitrations will be Permanente Medical Group,Inc., Southern California heard by a single neutral arbitrator. Permanente Medical Group,The Permanente Federation, LLC,and The Permanente Company,LLC,shall be Payment of arbitrators'fees and expenses served with a Demand for Arbitration by mailing the Health Plan will pay the fees and expenses of the neutral Demand for Arbitration addressed to that Respondent in arbitrator under certain conditions as set forth in the care of: Rules of Procedure.In all other arbitrations,the fees and Kaiser Foundation Health Plan,Inc. expenses of the neutral arbitrator shall be paid one-half Legal Department,Professional&Public Liability by the Claimants and one-half by the Respondents. 1 Kaiser Plaza, 19th Floor Oakland,CA 94612 If the parties select party arbitrators,Claimants shall be responsible for paying the fees and expenses of their Service on that Respondent shall be deemed completed ply arbitrator and Respondents shall be responsible for when received.All other Respondents,including paying the fees and expenses of their party arbitrator. individuals,must be served as required by the California Costs Code of Civil Procedure for a civil action. Except for the aforementioned fees and expenses of the Filing fee neutral arbitrator,and except as otherwise mandated by The Claimants shall pay a single,nonrefundable filing laws that apply to arbitrations under this"Binding fee of$150 per arbitration payable to"Arbitration Arbitration"section,each party shall bear the party's Account"regardless of the number of claims asserted in own attorneys' fees,witness fees,and other expenses the Demand for Arbitration or the number of Claimants incurred in prosecuting or defending against a claim or Respondents named in the Demand for Arbitration. regardless of the nature of the claim or outcome of the arbitration. Any Claimant who claims extreme hardship may request General provisions that the Office of the Independent Administrator waive the filing fee and the neutral arbitrator's fees and A claim shall be waived and forever barred if(1)on the expenses.A Claimant who seeks such waivers shall date the Demand for Arbitration of the claim is served, complete the Fee Waiver Form and submit it to the the claim,if asserted in a civil action,would be barred as Office of the Independent Administrator and to the Respondent served by the applicable statute of simultaneously serve it upon the Respondents.The Fee limitations,(2)Claimants fail to pursue the arbitration Waiver Form sets forth the criteria for waiving fees and claim in accord with the Rules of Procedure with is available by calling Member Services. reasonable diligence,or(3)the arbitration hearing is not commenced within five years after the earlier of(a)the Number of arbitrators date the Demand for Arbitration was served in accord with the procedures prescribed herein or(b)the date of The number of arbitrators may affect the Claimants' filing of a civil action based upon the same incident, responsibility for paying the neutral arbitrator's fees and transaction,or related circumstances involved in the expenses(see the Rules of Procedure). claim.A claim may be dismissed on other grounds by the neutral arbitrator based on a showing of a good cause.If If the Demand for Arbitration seeks total damages of a party fails to attend the arbitration hearing after being $200,000 or less,the dispute shall be heard and given due notice thereof,the neutral arbitrator may determined by one neutral arbitrator,unless the parties proceed to determine the controversy in the party's otherwise agree in writing after a dispute has arisen and a absence. request for binding arbitration has been submitted that the arbitration shall be heard by two party arbitrators and The California Medical Injury Compensation Reform one neutral arbitrator.The neutral arbitrator shall not Act of 1975 (including any amendments thereto), have authority to award monetary damages that are including sections establishing the right to introduce greater than$200,000. evidence of any insurance or disability benefit payment to the patient,the limitation on recovery for non- if the Demand for Arbitration seeks total damages of economic losses,and the right to have an award for more than$200,000,the dispute shall be heard and future damages conformed to periodic payments,shall determined by one neutral arbitrator and two party apply to any claims for professional negligence or any arbitrators,one jointly appointed by all Claimants and other claims as permitted or required by law. one jointly appointed by all Respondents.Parties who are Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 90 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Arbitrations shall be governed by this"Binding Termination Due to Loss of Eligibility Arbitration"section, Section 2 of the Federal Arbitration Act,and the California Code of Civil Procedure If you no longer meet the eligibility requirements provisions relating to arbitration that are in effect at the described under"Who Is Eligible"in the"Premiums, time the statute is applied,together with the Rules of Eligibility,and Enrollment"section your Group will Procedure,to the extent not inconsistent with this notify you of the date that your membership will end. "Binding Arbitration"section.In accord with the rule Your membership termination date is the first day you that applies under Sections 3 and 4 of the Federal are not covered.For example,if your termination date is Arbitration Act,the right to arbitration under this January 1,2026,your last minute of coverage was at "Binding Arbitration"section shall not be denied,stayed, 11:59 p.m. on December 31,2025. or otherwise impeded because a dispute between a Member Party and a Kaiser Permanente Party involves Also,we will terminate your Senior Advantage both arbitrable and nonarbitrable claims or because one membership on the last day of the month if you: or more parties to the arbitration is also a party to a • Are temporarily absent from our Service Area for pending court action with another party that arises out of more than six months in a row the same or related transactions and presents a possibility of conflicting rulings or findings. • Permanently move from our Service Area • No longer have Medicare Part B • Enroll in another Medicare Health Plan(for example, Termination of Membership a Medicare Advantage Plan or a Medicare prescription drug plan).The Centers for Medicare& Your Group is required to inform the Subscriber of the Medicaid Services will automatically terminate your date your membership terminates.Your membership Senior Advantage membership when your enrollment termination date is the first day you are not covered(for in the other plan becomes effective example,if your termination date is January 1,2026, • Are not a U.S. citizen or lawfully present in the your last minute of coverage was at 11:59 p.m.on United States.The Centers for Medicare&Medicaid December 31,2025).When a Subscriber's membership Services will notify us if you are not eligible to ends,the memberships of any Dependents end at the remain a Member on this basis.We must disenroll same time.You will be billed as a non-Member for any you if you do not meet this requirement Services you receive after your membership terminates. Health Plan and Plan Providers have no further liability In addition,if you are required to pay the extra Part D or responsibility under this EOC after your membership amount because of your income and you do not pay it, terminates,except: Medicare will disenroll you from our Senior Advantage • As provided under"Payments after Termination"in Plan and you will lose prescription drug coverage. this"Termination of Membership"section • If you are receiving covered Services as an acute care Note:If you lose eligibility for Senior Advantage due to hospital inpatient on the termination date,we will any of these circumstances,you may be eligible to continue to cover those hospital Services(but not transfer your membership to another Kaiser Permanente physician Services or any other Services)until you plan offered by your Group.Please contact your Group are discharged for information. Until your membership terminates,you remain a Senior Termination of Agreement Advantage Member and must continue to receive your medical care from us,except as described in the If your Group's Agreement with us terminates for any "Emergency Services and Urgent Care"section about reason,your membership ends on the same date.Your Emergency Services,Post-Stabilization Care,and Out- Group is required to notify Subscribers in writing if its of-Area Urgent Care and the"Benefits and Your Cost Agreement with us terminates. Share"section about out-of-area dialysis care. Note:If you enroll in another Medicare Health Plan or a Disenrolling from Senior Advantage prescription drug plan,your Senior Advantage membership will terminate as described under You may terminate(disenroll from)your Senior "Disenrolling from Senior Advantage"in this Advantage membership at any time.However,before "Termination of Membership"section. you request disenrollment,please check with your Group Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 91 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. to determine if you are able to continue your Group and do not enroll in a separate Medicare Part D membership. prescription drug plan,Medicare may enroll you in a drug plan,unless you have opted out of automatic If you request disenrollment during your Group's open enrollment. enrollment,your disenrollment effective date is determined by the date your written request is received Note: If you disenroll from Medicare prescription drug by us and the date your Group coverage ends. The coverage and go without creditable prescription drug effective date will not be earlier than the first day of the coverage for 63 or more days in a row,you may need to following month after we receive your written request, pay a Part D late enrollment penalty if you join a and no later than three months after we receive your Medicare drug plan later. request. If you request disenrollment at a time other than your Termination of Contract with the Group's open enrollment,your disenrollment effective Centers for Medicare & Medicaid date will be the first day of the month following our Services receipt of your disenrollment request. If our contract with the Centers for Medicare&Medicaid You may request disenrollment by calling toll free Services to offer Senior Advantage terminates,your 1-800-MEDICARE/1-800-633-4227(TTY users call Senior Advantage membership will terminate on the 1-877-486-2048),24 hours a day,seven days a week,or same date.We will send you advance written notice and sending written notice to the following address: advise you of your health care options.Also,you may be eligible to transfer your membership to another Kaiser Kaiser Foundation Health Plan,Inc. Permanente plan offered by your Group. California Service Center P.O.Box 232400 San Diego,CA 92193-2400 Termination for Cause Other Medicare Health Plans.If you want to enroll in We may terminate your membership by sending you another Medicare Health Plan or a Medicare prescription advance written notice if you commit one of the drug plan,you should first confirm with the other plan following acts: and your Group that you are able to enroll.Your new • If you continuously behave in a way that is disruptive, plan or your Group will tell you the date when your to the extent that your continued enrollment seriously membership in the new plan begins and your Senior impairs our ability to arrange or provide medical care Advantage membership will end on that same day(your for you or for our other members.We cannot make disenrollment date). you leave our Senior Advantage Plan for this reason unless we get permission from Medicare first The Centers for Medicare&Medicaid Services will let • If you let someone else use your plan membership us know if you enroll in another Medicare Health Plan, card to get medical care.We cannot make you leave so you will not need to send us a disenrollment request. our Senior Advantage Plan for this reason unless we get permission from Medicare first.If you are Original Medicare.If you request disenrollment from disenrolled for this reason,the Centers for Medicare Senior Advantage and you do not enroll in another &Medicaid Services may refer your case to the Medicare Health Plan,you will automatically be enrolled Inspector General for additional investigation in Original Medicare when your Senior Advantage . You commit theft from Health Plan,from a Plan membership terminates(your disenrollment date).On your disenrollment date,you can start using your red, Provider,or at a Plan Facility white,and blue Medicare card to get services under • You intentionally misrepresent membership status or Original Medicare.You will not get anything in writing commit fraud in connection with your obtaining that tells you that you have Original Medicare after you membership.We cannot make you leave our Senior disenroll.If you choose Original Medicare and you want Advantage Plan for this reason unless we get to continue to get Medicare Part D prescription drug permission from Medicare first coverage,you will need to enroll in a prescription drug • If you become incarcerated(go to prison) plan. • You knowingly falsify or withhold information about If you receive Extra Help from Medicare to pay for your other parties that provide reimbursement for your prescription drugs,and you switch to Original Medicare prescription drug coverage Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 92 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. If we terminate your membership for cause,you will not Group Coverage."Also,you may be able to continue be allowed to enroll in Health Plan in the future until you membership under an individual plan as described under have completed a Member Orientation and have signed a "Conversion from Group Membership to an Individual statement promising future compliance.We may report Plan."If at any time you become entitled to continuation fraud and other illegal acts to the authorities for of Group coverage,please examine your coverage prosecution. options carefully before declining this coverage. Individual plan premiums and coverage will be different Termination for Nonpayment of from the premiums and coverage under your Group plan. Premiums Continuation of Group Coverage If we do not receive Premiums for your Family,we may terminate the memberships of everyone in your Family. COBRA You may be able to continue your coverage under this Senior Advantage EOC for a limited time after you Termination of a Product or all Products would otherwise lose eligibility,if required by the federal Consolidated Omnibus Budget Reconciliation We may terminate a particular product or all products Act("COBRA").COBRA applies to most employees offered in the group market as permitted or required by (and most of their covered family Dependents)of most law.If we discontinue offering a particular product in the employers with 20 or more employees. group market,we will terminate just the particular product by sending you written notice at least 90 days If your Group is subject to COBRA and you are eligible before the product terminates.If we discontinue offering for COBRA coverage,in order to enroll,you must all products in the group market,we may terminate your submit a COBRA election form to your Group within the Group's Agreement by sending you written notice at COBRA election period.Please ask your Group for least 180 days before the Agreement terminates. details about COBRA coverage,such as how to elect coverage,how much you must pay for coverage,when Payments after Termination coverage and Premiums may change,and where to send your Premium payments. If we terminate your membership for cause or for nonpayment,we will: As described in"Conversion from Group Membership to an Individual Plan"in this"Continuation of • Refund any amounts we owe for Premiums paid after Membership"section,you may be able to convert to an the termination date individual(nongroup)plan if you don't apply for • Pay you any amounts we have determined that we COBRA coverage,or if you enroll in COBRA and your owe you for claims during your membership in COBRA coverage ends. accord with the"Requests for Payment"section.We will deduct any amounts you owe Health Plan or Plan Coverage for a disabling condition Providers from any payment we make to you If you became Totally Disabled while you were a Member under your Group's Agreement with us and Review of Membership Termination while the Subscriber was employed by your Group,and your Group's Agreement with us terminates and is not If you believe that we terminated your Senior Advantage renewed,we will cover Services for your totally membership because of your ill health or your need for disabling condition until the earliest of the following care,you may file a complaint as described in the events occurs: "Coverage Decisions,Appeals,and Complaints"section. • 12 months have elapsed since your Group's Agreement with us terminated • You are no longer Totally Disabled Continuation of Membership • Your Group's Agreement with us is replaced by another group health plan without limitation as to the If your membership under this Senior Advantage EOC disabling condition ends,you may be eligible to continue Health Plan membership without a break in coverage.You may be Your coverage will be subject to the terms of this EOC, able to continue Group coverage under this Senior including Cost Share,but we will not cover Services for Advantage EOC as described under"Continuation of any condition other than your totally disabling condition. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 93 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. For Subscribers and adult Dependents,"Totally Miscellaneous Provisions Disabled"means that,in the judgment of a Medical Group physician,an illness or injury is expected to result in death or has lasted or is expected to last for a Administration of Agreement continuous period of at least 12 months,and makes the person unable to engage in any employment or We may adopt reasonable policies,procedures,and occupation,even with training,education,and interpretations to promote orderly and efficient experience. administration of your Group's Agreement,including this EOC. For Dependent children,"Totally Disabled"means that, in the judgment of a Medical Group physician,an illness or injury is expected to result in death or has lasted or is Amendment of Agreement expected to last for a continuous period of at least 12 months and the illness or injury makes the child unable Your Group's Agreement with us will change periodically.If these changes affect this EOC,your to substantially engage in any of the normal activities of children in good health of like age. Group is required to inform you in accord with applicable law and your Group's Agreement. To request continuation of coverage for your disabling condition,you must call Member Services within 30 Applications and Statements days after your Group's Agreement with us terminates. You must complete any applications,forms,or statements that we request in our normal course of Conversion from Group Membership to business or as specified in this EOC. an Individual Plan After your Group notifies us to terminate your Group Assignment membership,we will send a termination letter to the Subscriber's address of record.The letter will include You may not assign this EOC or any of the rights, information about options that may be available to you to interests,claims for money due,benefits,or obligations remain a Health Plan Member. hereunder without our prior written consent. Kaiser Permanente Conversion Plan Attorney and Advocate Fees and If you want to remain a Health Plan Member,one option that may be available is our Senior Advantage Individual Expenses Plan.You may be eligible to enroll in our individual plan In any dispute between a Member and Health Plan,the if you no longer meet the eligibility requirements Medical Group,or Kaiser Foundation Hospitals,each described under"Who Is Eligible"in the"Premiums, ply will bear its own fees and expenses,including Eligibility,and Enrollment"section.Individual plan attorneys' fees,advocates' fees,and other expenses. coverage begins when your Group coverage ends. The premiums and coverage under our individual plan are different from those under this EOC and will include Claims Review Authority Medicare Part D prescription drug coverage. We are responsible for determining whether you are However,if you are no longer eligible for Senior entitled to benefits under this EOC and we have the Advantage and Group coverage,you may be eligible to discretionary authority to review and evaluate claims that convert to our non-Medicare individual plan,called arise under this EOC.We conduct this evaluation "Kaiser Permanente Individual—Conversion Plan."You independently by interpreting the provisions of this EOC. may be eligible to enroll in our Individual—Conversion We may use medical experts to help us review claims. Plan if we receive your enrollment application within 63 If coverage under this EOC is subject to the Employee days of the date of our termination letter or of your Retirement Income Security Act("ERISA")claims membership termination date(whichever date is later). procedure regulation(29 CFR 2560.503-1),then we are a "named claims fiduciary"to review claims under this You may not be eligible to convert if your membership EOC. ends for the reasons stated under"Termination for Cause"or"Termination of Agreement"in the "Termination of Membership"section. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 94 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. EOC Binding on Members federal law shall bind Members and Health Plan whether or not set forth in this EOC. By electing coverage or accepting benefits under this EOC,all Members legally capable of contracting,and the legal representatives of all Members incapable of Group and Members Not Our Agents contracting,agree to all provisions of this EOC. Neither your Group nor any Member is the agent or representative of Health Plan. ERISA Notices This"ERISA Notices"section applies only if your No Waiver Group's health benefit plan is subject to the Employee Retirement Income Security Act("ERISA").We provide Our failure to enforce any provision of this EOC will not these notices to assist ERISA-covered groups in constitute a waiver of that or any other provision,or complying with ERISA.Coverage for Services described impair our right thereafter to require your strict in these notices is subject to all provisions of this EOC. performance of any provision. Newborns' and Mothers' Health Protection Act Notices Regarding Your Coverage Group health plans and health insurance issuers generally may not,under Federal law,restrict benefits for any Our notices to you will be sent to the most recent address hospital length of stay in connection with childbirth for we have for the Subscriber.The Subscriber is responsible the birthing person or newborn child to less than 48 for notifying us of any change in address. Subscribers hours following a vaginal delivery,or less than 96 hours who move should call Member Services and Social following a cesarean section.However,Federal law Security toll free at 1-800-772-1213(TTY users call generally does not prohibit the birthing person's or 1-800-325-0778)as soon as possible to give us their new newborn's attending provider,after consulting with the address.If a Member does not reside with the Subscriber, birthing person,from discharging the birthing person or or needs to have confidential information sent to an their newborn earlier than 48 hours(or 96 hours as address other than the Subscriber's address,they should applicable).In any case,plans and issuers may not,under contact Member Services to discuss alternate delivery Federal law,require that a provider obtain authorization options. from the plan or the insurance issuer for prescribing a length of stay not in excess of 48 hours(or 96 hours). Note:When we tell your Group about changes to this EOC or provide your Group other information that Women's Health and Cancer Rights Act affects you,your Group is required to notify the If you have had or are going to have a mastectomy,you Subscriber within 30 days after receiving the information may be entitled to certain benefits under the Women's from us.The Subscriber is also responsible for notifying Health and Cancer Rights Act.For individuals receiving Group of any change in contact information. mastectomy-related benefits,coverage will be provided in a manner determined in consultation with the attending physician and the patient,for all stages of Notice about Medicare Secondary Paver reconstruction of the breast on which the mastectomy Subrogation Rights was performed,surgery and reconstruction of the other breast to produce a symmetrical appearance,prostheses, We have the right and responsibility to collect for and treatment of physical complications of the covered Medicare services for which Medicare is not the mastectomy,including lymphedemas.These benefits will primary payer.According to CMS regulations at 42 CFR be provided subject to the same Cost Share applicable to sections 422.108 and 423.462,Kaiser Permanente Senior other medical and surgical benefits provided under this Advantage,as a Medicare Advantage Organization,will plan. exercise the same rights of recovery that the Secretary exercises under CMS regulations in subparts B through D of part 411 of 42 CFR and the rules established in this Governing Law section supersede any state laws. Except as preempted by federal law,this EOC will be governed in accord with California law and any Overpayment Recovery provision that is required to be in this EOC by state or We may recover any overpayment we make for Services from anyone who receives such an overpayment or from Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 95 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. any person or organization obligated to pay for the How to contact us when you are asking for a Services. coverage decision or making an appeal or complaint about your Services Public Policy Participation • A coverage decision is a decision we make about your benefits and coverage or about the amount we will The Kaiser Foundation Health Plan,Inc.,Board of pay for your medical services Directors establishes public policy for Health Plan.A list e An appeal is a formal way of asking us to review and of the Board of Directors is available on our website at change a coverage decision we have made kp.or2 or from Member Services.If you would like to . You can make a complaint about us or one of our provide input about Health Plan public policy for consideration by the Board,please send written network providers,including a complaint about the quality of your care.This type of complaint does not comments to: Kaiser Foundation Health Plan,Inc. involve coverage or payment disputes Office of Board and Corporate Governance Services For more information about asking for coverage One Kaiser Plaza, 19th Floor decisions or making appeals or complaints about your Oakland,CA 94612 medical care,see the"Coverage Decisions,Appeals,and Complaints"section. Telephone Access (TTY) Coverage decisions, appeals, or complaints for Services—contact information If you use a text telephone device(TTY,also known as TDD)to communicate by phone,you can use the Call 1-800-443-0815 California Relay Service by calling 711. Calls to this number are free. Seven days a week,8 a.m.to 8 p.m. Important Phone Numbers and If your coverage decision,appeal,or complaint qualifies for a fast decision as described in the Resources "Coverage Decisions,Appeals,and Complaints"section,call the Expedited Review Unit at 1-888-987-7247, 8:30 a.m.to 5 p.m., Kaiser Permanente Senior Advantage Monday through Saturday. How to contact our plan's Member Services TTY 711 For assistance,please call or write to our plan's Member Calls to this number are free. Services.We will be happy to help you. Seven days a week,8 a.m.to 8 p.m. Member Services—contact information Fax If your coverage decision,appeal,or complaint Call 1-800-443-0815 qualifies for a fast decision,fax your request to Calls to this number are free. our Expedited Review Unit at 1-888-987-2252. Write For a standard coverage decision or Seven days a week,8 a.m.to 8 p.m. complaint,write to your local Member Services Member Services also has free language office(see the Provider Directory for locations). interpreter services available for non-English For a standard appeal,write to the address speakers. shown on the denial notice we send you. TTY 711 If your coverage decision,appeal,or complaint Calls to this number are free. qualifies for a fast decision,write to: Kaiser Permanente Seven days a week,8 a.m.to 8 p.m. Expedited Review Unit Write Your local Member Services office(see the P.O.Box 1809 Provider Directory for locations). Pleasanton,CA 94566 Website kp.or2 Medicare Website.You can submit a complaint about our plan directly to Medicare.To submit an online complaint to Medicare,go to Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 96 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. https://www.medicare.2ov/MedicareComi)laintForm/ Appeals for Part D prescription drugs—contact home.aspx. information How to contact us when you are asking for a Call 1-866-206-2973 coverage decision about your Part D Calls to this number are free. prescription drugs Seven days a week, 8:30 a.m. to 5 p.m. • A coverage decision is a decision we make about your TTY 711 benefits and coverage or about the amount we will pay for your prescription drugs covered under the Calls to this number are free. Part D benefit included in your plan Seven days a week,8:30 a.m.to 5 p.m. For more information about asking for coverage Fax 1-866-206-2974 decisions about your Part D prescription drugs,see Write Kaiser Permanente the"Coverage Decisions,Appeals,and Complaints" Medicare Part D Unit section. P.O.Box 1809 Pleasanton,CA 94566 Coverage decisions for Part D prescription drugs—contact information Website ky.or2 Call 1-877-645-1282 How to contact us when you are making a Calls to this number are free. complaint about your Part D prescription drugs You can make a complaint about us or one of our Seven days a week, 8 a.m. to 8 p.m. network pharmacies,including a complaint about the TTY 711 quality of your care.This type of complaint does not involve coverage or payment disputes.(If your problem Calls to this number are free. is about our plan's coverage or payment,you should look Seven days a week,8 a.m.to 8 p.m. at the section above about requesting coverage decisions or making appeals.)For more information about making Fax 1-844-403-1028 a complaint about your Part D prescription drugs,see the Write OptumRx "Coverage Decisions,Appeals,and Complaints"section. c/o Prior Authorization P.O.Box 2975 Complaints for Part D prescription drugs— Mission,KS 66201 contact information Website ky.or2 Call 1-800-443-0815 How to contact us when you are making an Calls to this number are free. appeal about your Part D prescription drugs Seven days a week,8 a.m.to 8 p.m. • An appeal is a formal way of asking us to review and If your complaint qualifies for a fast decision, change a coverage decision we have made call the Part D Unit at 1-866-206-2973, 8:30 a.m.to 5 p.m.,seven days a week. See the For more information on asking for appeals about "Coverage Decisions,Appeals,and your Part D prescription drugs,see the"Coverage Complaints"section to find out if your issue Decisions,Appeals,and Complaints"section.You qualifies for a fast decision. may call us if you have questions about our appeals process. TTY 711 Calls to this number are free. Seven days a week,8 a.m.to 8 p.m. Fax If your complaint qualifies for a fast review,fax your request to our Part D Unit at 1-866-206- 2974. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 97 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Write For a standard complaint,write to your local Provider,you can fax your request to 1-866- Member Services office(see the Provider 206-2974 or mail it to: Directory for locations). Kaiser Permanente If your complaint qualifies for a fast decision, Medicare Part D Unit write to: P.O.Box 1809 Kaiser Permanente Pleasanton,CA 94566 Medicare Part D Unit Website kp.or P.O.Box 1809 � Pleasanton,CA 94566 The Medicare Prescription Payment Plan— Medicare Website.You can submit a complaint about contact information our plan directly to Medicare.To submit an online Call 1-800-443-0815 complaint to Medicare,go to htti)s://www.medicare.2ov/MedicareComi)laintForm/ Calls to this number are free. home.aspx. Seven days a week,8 a.m.to 8 p.m. Where to send a request asking us to pay for Member Services also has free language our share of the cost for Services or a Part D interpreter services available for non-English drug you have received speakers. If you have received a bill or paid for services(such as a TTY 711 provider bill)that you think we should pay for,you may need to ask us for reimbursement or to pay the provider Calls to this number are free. bill. See the"Requests for Payment"section. Seven days a week,8 a.m.to 8 p.m. Note:If you send us a payment request and we deny any Write Your local Member Services office(see the part of your request,you can appeal our decision. See the Provider Directory for locations). "Coverage Decisions,Appeals,and Complaints"section Website kp.or2 for more information. Payment Requests—contact information Medicare Call 1-800-443-0815 How to get help and information directly from Calls to this number are free. the federal Medicare program Medicare is the federal health insurance program for Seven days a week,8 a.m.to 8 p.m. people 65 years of age or older,some people under age Note:If you are requesting payment of a Part D 65 with disabilities,and people with End-Stage Renal drug that was prescribed by a Plan Provider and Disease(permanent kidney failure requiring dialysis or a obtained from a Plan Pharmacy,call our Part D kidney transplant).The federal agency in charge of unit at 1-866-206-2973, 8:30 a.m.to 5 p.m., Medicare is the Centers for Medicare&Medicaid seven days a week. Services(sometimes called CMS).This agency contracts with Medicare Advantage organizations,including our TTY 711 plan. Calls to this number are free. Medicare—contact information Seven days a week,8 a.m.to 8 p.m. Write For medical care: Call 1-800-MEDICARE or 1-800-633-4227 Kaiser Permanente Calls to this number are free.24 hours a day, Claims Department seven days a week. P.O.Box 12923 TTY 1-877-486-2048 Oakland,CA 94604-2923 This number requires special telephone For Part D drugs: equipment and is only for people who have If you are requesting payment of a Part D drug that was prescribed and provided by a Plan Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 98 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. difficulties with hearing or speaking. Calls to Assistance Program is called the Health Insurance this number are free. Counseling and Advocacy Program(HICAP). Website httl)s://www.Medicare.2ov HICAP is an independent(not connected with any This is the official government website for Medicare.It insurance company or health plan)state program that gives you up-to-date information about Medicare and gets money from the federal government to give free current Medicare issues.It also has information about local health insurance counseling to people with hospitals,nursing homes,physicians,home health Medicare. agencies,and dialysis facilities.It includes documents you can print directly from your computer.You can also HICAP counselors can help you understand your find Medicare contacts in your state. Medicare rights,help you make complaints about your Services or treatment,and help you straighten out The Medicare website also has detailed information problems with your Medicare bills.HICAP counselors about your Medicare eligibility and enrollment options can also help you with Medicare questions or problems with the following tools: and help you understand your Medicare plan choices and answer questions about switching plans. Medicare Eligibility Tool:Provides Medicare eligibility Method to access SHIP and other resources: status information. • Visit https://www.shiphelp.or2 Medicare Plan Finder: Provides personalized o Click on SHIP Locator in middle of page information about available Medicare prescription drug plans,Medicare Health Plans,and Medigap(Medicare • Select your state from the list.This will take you Supplement Insurance)policies in your area.These tools to a page with phone numbers and resources provide an estimate of what your out-of-pocket costs specific to your state might be in different Medicare plans. Health Insurance Counseling and Advocacy You can also use the website to tell Medicare about any Program (California's State Health Insurance complaints you have about our plan. Assistance Program)—contact information Call 1-800-434-0222 Tell Medicare about your complaint:You can submit a complaint about our plan directly to Medicare.To Calls to this number are free. submit a complaint to Medicare,go to TTY 711 https://www.medicare.Eov/MedicareComplaintForm/ home.aspx.Medicare takes your complaints seriously Write Your HICAP office for your county. and will use this information to help improve the quality Website www.a2in2.ca.2ov/HICAP/ of the Medicare program. If you don't have a computer,your local library or senior Quality Improvement Organization center may be able to help you visit this website using its computer. Or,you can call Medicare and tell them what Paid Medicare to check on the quality of care information you are looking for.They will find the for people with Medicare information on the website and review the information There is a designated Quality Improvement Organization with you.You can call Medicare at 1-800-MEDICARE for serving Medicare beneficiaries in each state.For (1-800-633-4227)(TTY users call 1-877-486-2048),24 California,the Quality Improvement Organization is hours a day,7 days a week. called Livanta. Livanta has a group of doctors and other health care State Health Insurance Assistance professionals who are paid by Medicare to check on and Program help improve the quality of care for people with Medicare.Livanta is an independent organization.It is Free help, information, and answers to your not connected with our plan. questions about Medicare The State Health Insurance Assistance Program(SHIP) is a government program with trained counselors in every state.In California,the State Health Insurance Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 99 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. You should contact Livanta in any of these situations: Social Security—contact information • You have a complaint about the quality of care you Call 1-800-772-1213 have received Calls to this number are free.Available 8 a.m. • You think coverage for your hospital stay is ending to 7 p.m.,Monday through Friday. too soon You can use Social Security's automated • You think coverage for your home health care, telephone services and get recorded information Skilled Nursing Facility care,or Comprehensive 24 hours a day. Outpatient Rehabilitation Facility(CORF)services are ending too soon TTY 1-800-325-0778 Livanta (California's Quality Improvement This number requires special telephone equipment and is only for people who have Organization)—contact information difficulties with hearing or speaking. Calls to Call 1-877-588-1123 this number are free.Available 8 a.m.to 7 p.m., Calls to this number are free.Monday through Monday through Friday. Friday,9 a.m.to 5 p.m Weekends and holidays Website www.ssa.gov 11 a.m.to 3 p.m. TTY 1-855-887-6668 Medicaid This number requires special telephone A joint federal and state program that helps with equipment and is only for people who have medical costs for some people with limited difficulties with hearing or speaking. income and resources Write Livanta Medicaid is a joint federal and state government program BFCC—QIO Program that helps with medical costs for certain people with 10820 Guilford Road, Suite 202 limited incomes and resources. Some people with Annapolis Junction,MD 20701-1105 Medicare are also eligible for Medicaid. Website www.livantaciio.com/en In addition,there are programs offered through Medicaid that help people with Medicare pay their Medicare costs, Social Security such as their Medicare premiums.These"Medicare Savings Programs"help people with limited income and Social Security is responsible for determining eligibility resources save money each year: and handling enrollment for Medicare.U.S.citizens and . Qualified Medicare Beneficiary(QMB):Helps pay lawful permanent residents who are 65 or older,or who Medicare Part A and Part B premiums,and other Cost have a disability or end stage renal disease and meet Share. Some people with QMB are also eligible for certain conditions,are eligible for Medicare.If you are full Medicaid benefits(QMB+) already getting Social Security checks,enrollment into Medicare is automatic.If you are not getting Social • Specified Low-Income Medicare Beneficiary Security checks,you have to enroll in Medicare. To (SLMB):Helps pay Part B premiums. Some people apply for Medicare,you can call Social Security or visit with SLMB are also eligible for full Medicaid your local Social Security office. benefits(SLMB+) • Qualifying Individual(QI):Helps pay Part B Social Security is also responsible for determining who premiums has to pay an extra amount for their Part D drug coverage o Qualified Disabled&Working Individuals because they have a higher income.If you got a letter (QDWI):Helps pay Part A premiums from Social Security telling you that you have to pay the extra amount and have questions about the amount or if your income went down because of a life-changing To find out more about Medicaid and its programs, event,you can call Social Security to ask for contact Medi-Cal. reconsideration. If you move or change your mailing address,it is important that you contact Social Security to let them know. Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 100 Member Service:toll free 1-800-443-0815(TTYusers call 711)seven days a week, 8 a.m.-8 p.m. Medi-Cal (California's Medicaid program) - Group Insurance or Other Health contact information Insurance from an Employer Call 1-800-430-4263 If you have any questions about your employer- Calls to this number are free.Monday through sponsored Group plan,please contact your Group's Friday,8 a.m.to 6 p.m. benefits administrator.You can ask about your employer TTY 1-800-430-7077 or retiree health benefits,any contributions toward the Group's premium,eligibility,and enrollment periods. This number requires special telephone equipment and is only for people who have If you have other prescription drug coverage through difficulties with hearing or speaking. your(or your spouse's)employer or retiree group,please Write CA Department of Health Care Services contact that group's benefits administrator.The benefits Health Care Options administrator can help you determine how your current P.O.Box 989009 prescription drug coverage will work with our plan. West Sacramento,CA 95798-9850 Website www.healthcareoptions.dhcs.ca.gov/ Railroad Retirement Board The Railroad Retirement Board is an independent federal agency that administers comprehensive benefit programs for the nation's railroad workers and their families. If you have questions regarding your benefits from the Railroad Retirement Board,contact the agency. If you receive your Medicare through the Railroad Retirement Board,it is important that you let them know if you move or change your mailing address. Railroad Retirement Board—contact information Call 1-877-772-5772 Calls to this number are free.If you press"0," you may speak with an RRB representative from 9 a.m.to 3:30 p.m.,Monday,Tuesday, Thursday,and Friday,and from 9 a.m.to 12 p.m.on Wednesday. If you press"1,"you may access the automated RRB HelpLine and recorded information 24 hours a day,including weekends and holidays. TTY 1-312-751-4701 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. Calls to this number are not free. Website rrb.2ov/ Group ID:604334 Kaiser Permanente Senior Advantage(HMO)with Part D Contract: 1 Version:36 EOC#4 Effective: 1/1/25-12/31/25 Issue Date:October 30,2024 Page 101 Notice of Nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: • Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters. o Written information in other formats, such as large print, audio, and accessible electronic formats. • Provide no cost language services to people whose primary language is not English, such as: o Qualified interpreters. o Information written in other languages. If you need these services, call Member Services at 1-800-443-0815 (TTY 711), 8 a.m. to 8 p.m., seven days a week. If you believe that Kaiser Permanente has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator by writing to One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA 94612 or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 1-800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.htmi. KAISER PERMANEWE® 1126306860 CA June 2023 Form Approved OMB# 0938-1421 Multi-Language Insert Multi-language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-443-0815 (TTY 711). Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de interprete sin costo alguno pars responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un interprete, por favor Ilame al 1-800-443-0815 (TTY 711). Alguien que hable espanol le podra ayudar. Este es un servicio gratuito. Chinese Mandarin: WOJUtt",n 4qR*, '2kTf* �T�T7 ip7o p � _�UL JMR*, i�RF� 1-800-443-0815 (TTY 711)0 Rfl� 7�1'�CZT`> ��r;Ta Chinese Cantonese: 7,H,Ev7gmrm, ono 0� ai�kk� tT 1-800-443-0815 (TTY711)0 frigxrp7z J k�w�k ! rE fA Y�-' FO0 i �t—MtW M Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-443-0815 (TTY 711). Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interpretation pour repondre a toutes vos questions relatives a notre regime de sante ou d'assurance- medicaments. Pour acceder au service d'interpretation, it vous suffit de nous appeler au 1-800-443-0815 (TTY 711). Un interlocuteur parlant Frangais pourra vous cider. Ce service est gratuit. Vietnamese: Chung toi co dich vu thong dich mien phi d6 tra Idi cac cau hoi ve chtfdng stYc khoe va chudng trinh thuoc men. Neu qui vi can thong dich vien xin goi 1-800-443-0815 (TTY 711) se co nhan vien not tieng Viet giup dd qui vi. flay la dich vu mien phi . German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- and Arzneimittel plan. Unsere Dolmetscher erreichen Sie unter 1-800-443-0815 (TTY 711). Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Form CMS-10802 KAISER PERMANENTE® (Expires 12/31/25) Y0043_N00036258_C Form Approved OMB# 0938-1421 Korean: °l VLp�Il j,4tt -NL1 rt-1oN —,-- i!]--1-7,4 �� o A] HI�z A]o o} c}, o A]111 oI o=o}BIl mil } 1-800-443-0815 (TTY 711) T1° i �N Russian: ECrim y BaC B03HMKHyT BOnpOCbl OTHOCHTeIlbHo CTpaXOBOro wnw McAMKaMeHTHOro nllaHa, Bbl moweTe BOcnOJlb3OBaTbCA Hawomm 6ecniiaTHb[MM yCllyramm nepeBOA4HKOB. yT06bi BOCnOJlb3OBaTbCA ycnyramM nepeBOAL4MKa, n03BOHWTe Ham n0 TeneCpOHy 1-800-443-0815 (TTY 711). BaM OKa)KeT nOMOLLtb COTpyAHWK, KOTOpblO rOBOPHT nO-pyCCKM. AaHHaA ycnyra 6ecnnaTHaA. 1y�1 a�S��I J9 v 91 as,alb all S I1, avL�mil S,S 911 �,�11 �,l.o v Div l;;l :Arabic vas P .1-800-443-0815 (TTY 711) rlr- ly JL-�VI cs cSJ9� Hindi: yqr�7m-�zgqT-(Tm-qft t7yl-T-cr zft# f45tift-q%�7Ei� t-q-6 lwriwi #ZlT�3q-�W t. ITcF-q f I M qI Wric W\T�21T t , ZM-�A 1-80 0-443-0815 (TTY 711)TF IF)7;:r . ci f6-4 t fffltaMTC-fft Trj�q-qR UWTt. Zg��cr#dT . Italian: E disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare it numero 1-800-443-0815 (TTY 711). Un nostro incaricato the parla Italianovi fornira I'assistenza necessaria. E un servizio gratuito. Portuguese: Dispomos de servigos de interpretagao gratuitos pars responder a qualquer questao que tenha acerca do nosso plano de saude ou de medicagao. Para obter um interprete, contacte-nos atraves do numero 1-800-443-0815 (TTY 711). Ira encontrar alguem que fale o idioma Portugues pars o ajudar. Este servigo e gratuito. French Creole: Nou genyen sevis entepret gratis you reponn tout kesyon ou to genyen konsenan plan medikal oswa dwog nou an. Pou jwenn you entepret, jis rele nou nan 1-800-443-0815 (TTY 711). Yon moun ki pale Kreyol kapab ede w. Sa a se you sevis ki gratis. Polish: Umozliwiamy bezpkatne skorzystanie z uskug t+umacza ustnego, ktory pomo2e w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania lekow. Aby skorzystac z pomocy tkumacza znajacego jQzyk polski, nale2y zadzwonic pod numer 1-800-443-0815 (TTY 711). Ta uskuga jest bezpkatna. Japanese: �Yf 9)1 W, I W, fXrA L A� �J-L) ? rA ID W,N1I:- z fi 11-8'{0}-0-443-0815 (TTY 711) 6�-- �3 1M:K AQ �Au Au < �' � �>o F1 * l-A A bi�M L 11- 41 Y 9)-ft 7� 0 Form CMS-10802 (Expires 12/31/25) 1140823727 June 2023 KAISER PERMANEMEo Kaiser Foundation Health Plan, Inc. Northern California Region A nonprofit corporation EOC #5 - Kaiser Permanente Traditional HMO Plan Evidence of Coverage for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 36 EOC Number: 5 Issue Date: October 30, 2024 January 1,2025, through December 31, 2025 Member Services 24 hours a day, seven days a week(closed holidays) 1-800-464-4000(TTY users call 711) kp.or coaccum NGF ACA p 103 TABLE OF CONTENTS FOR EOC #5 CostShare Summary..............................................................................................................................................................1 AccumulationPeriod..........................................................................................................................................................1 Deductibles and Out-of-Pocket Maximums.......................................................................................................................1 CostShare Summary Tables by Benefit.............................................................................................................................1 CAREPlan.......................................................................................................................................................................19 Introduction..........................................................................................................................................................................20 AboutKaiser Permanente.................................................................................................................................................20 Termof this EOC.............................................................................................................................................................20 Definitions............................................................................................................................................................................21 Premiums,Eligibility,and Enrollment.................................................................................................................................26 Premiums..........................................................................................................................................................................26 WhoIs Eligible.................................................................................................................................................................27 How to Enroll and When Coverage Begins.....................................................................................................................29 Howto Obtain Services........................................................................................................................................................31 RoutineCare.....................................................................................................................................................................32 UrgentCare......................................................................................................................................................................32 Not Sure What Kind of Care You Need?.........................................................................................................................32 Your Personal Plan Physician..........................................................................................................................................32 Gettinga Referral.............................................................................................................................................................33 Traveland Lodging for Certain Services.........................................................................................................................35 SecondOpinions...............................................................................................................................................................35 Contractswith Plan Providers..........................................................................................................................................36 Receiving Care Outside of Your Home Region Service Area.........................................................................................36 YourID Card....................................................................................................................................................................36 TimelyAccess to Care.....................................................................................................................................................37 GettingAssistance............................................................................................................................................................38 PlanFacilities.......................................................................................................................................................................38 Emergency Services and Urgent Care..................................................................................................................................39 EmergencyServices.........................................................................................................................................................39 UrgentCare......................................................................................................................................................................40 Paymentand Reimbursement...........................................................................................................................................41 Benefits.................................................................................................................................................................................41 YourCost Share...............................................................................................................................................................42 AdministeredDrugs and Products....................................................................................................................................45 AmbulanceServices.........................................................................................................................................................45 BariatricSurgery..............................................................................................................................................................46 Dentaland Orthodontic Services......................................................................................................................................46 DialysisCare....................................................................................................................................................................47 Durable Medical Equipment("DME")for Home Use.....................................................................................................47 Emergency Services and Urgent Care..............................................................................................................................49 FertilityServices...............................................................................................................................................................49 Fertility Preservation Services for Iatrogenic Infertility..................................................................................................49 HealthEducation..............................................................................................................................................................50 HearingServices...............................................................................................................................................................50 HomeHealth Care............................................................................................................................................................50 HospiceCare....................................................................................................................................................................51 HospitalInpatient Services...............................................................................................................................................52 Injuryto Teeth..................................................................................................................................................................52 MentalHealth Services....................................................................................................................................................52 OfficeVisits.....................................................................................................................................................................54 Ostomyand Urological Supplies......................................................................................................................................54 Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services............................................................54 Outpatient Prescription Drugs,Supplies,and Supplements.............................................................................................55 Outpatient Surgery and Outpatient Procedures................................................................................................................58 PreventiveServices..........................................................................................................................................................59 Prostheticand Orthotic Devices.......................................................................................................................................59 ReconstructiveSurgery....................................................................................................................................................60 Rehabilitative and Habilitative Services..........................................................................................................................61 ReproductiveHealth Services..........................................................................................................................................61 Services in Connection with a Clinical Trial....................................................................................................................62 SkilledNursing Facility Care...........................................................................................................................................63 SubstanceUse Disorder Treatment..................................................................................................................................63 TelehealthVisits...............................................................................................................................................................64 TransplantServices..........................................................................................................................................................64 VisionServices for Adult Members.................................................................................................................................65 VisionServices for Pediatric Members............................................................................................................................66 Exclusions,Limitations,Coordination of Benefits,and Reductions...................................................................................67 Exclusions........................................................................................................................................................................67 Limitations........................................................................................................................................................................70 Coordinationof Benefits..................................................................................................................................................70 Reductions........................................................................................................................................................................70 Post-Service Claims and Appeals.........................................................................................................................................72 WhoMay File...................................................................................................................................................................72 SupportingDocuments.....................................................................................................................................................73 InitialClaims....................................................................................................................................................................73 Appeals.............................................................................................................................................................................74 ExternalReview...............................................................................................................................................................75 AdditionalReview............................................................................................................................................................75 DisputeResolution...............................................................................................................................................................75 Grievances........................................................................................................................................................................75 Independent Review Organization for Non-Formulary Prescription Drug Requests......................................................78 Department of Managed Health Care Complaints...........................................................................................................79 IndependentMedical Review("IMR")............................................................................................................................79 Officeof Civil Rights Complaints....................................................................................................................................80 AdditionalReview............................................................................................................................................................80 BindingArbitration..........................................................................................................................................................80 Terminationof Membership.................................................................................................................................................82 Termination Due to Loss of Eligibility............................................................................................................................82 Terminationof Agreement................................................................................................................................................83 Terminationfor Cause......................................................................................................................................................83 Termination of a Product or all Products.........................................................................................................................83 Paymentsafter Termination.............................................................................................................................................83 State Review of Membership Termination......................................................................................................................83 Continuationof Membership................................................................................................................................................83 Continuationof Group Coverage.....................................................................................................................................83 Continuation of Coverage under an Individual Plan........................................................................................................86 MiscellaneousProvisions.....................................................................................................................................................87 Administrationof Agreement...........................................................................................................................................87 AdvanceDirectives..........................................................................................................................................................87 Amendmentof Agreement................................................................................................................................................87 Applicationsand Statements............................................................................................................................................87 Assignment.......................................................................................................................................................................87 Attorney and Advocate Fees and Expenses.....................................................................................................................87 ClaimsReview Authority.................................................................................................................................................87 EOCBinding on Members...............................................................................................................................................87 ERISANotices.................................................................................................................................................................87 GoverningLaw.................................................................................................................................................................88 Group and Members Not Our Agents..............................................................................................................................88 NoWaiver........................................................................................................................................................................88 Notices Regarding Your Coverage...................................................................................................................................88 OverpaymentRecovery....................................................................................................................................................88 PrivacyPractices..............................................................................................................................................................88 PublicPolicy Participation...............................................................................................................................................89 HelpfulInformation..............................................................................................................................................................89 How to Obtain this EOC in Other Formats......................................................................................................................89 ProviderDirectory............................................................................................................................................................89 OnlineTools and Resources.............................................................................................................................................89 Document Delivery Preferences.......................................................................................................................................89 Howto Reach Us..............................................................................................................................................................90 PaymentResponsibility....................................................................................................................................................91 Cost Share Summary This"Cost Share Summary"is part of your Evidence of Coverage(EOC)and is meant to explain the amount you will pay for covered Services under this plan.It does not provide a full description of your benefits.For a full description of your benefits, including any limitations and exclusions,please read this entire EOC,including any amendments,carefully. Accumulation Period The Accumulation Period for this plan is January 1 through December 31. Deductibles and Out-of-Pocket Maximums For Services that apply to the Plan Out-of-Pocket Maximum,you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below. If your Group's plan changes during an Accumulation Period,your deductibles and out-of-pocket maximums may increase or decrease,which may change the total amount you must accumulate to reach the deductibles or out-of-pocket maximums during that Accumulation Period. Self-Only Coverage Family Coverage Family Coverage Amounts Per Accumulation Period (a Family of one Member) Each Member in a Family Entire Family of two or of two or more Members more Members Plan Deductible None None None Drug Deductible None None None Plan Out-of-Pocket Maximum("OOPM") $1,500 $1,500 $3,000 Cost Share Summary Tables by Benefit How to read the Cost Share summary tables Each table below explains the Cost Share for a category of benefits. Specific Services related to the benefit are described in the first column of each table.For a detailed description of coverage for a particular benefit,refer to the same benefit heading in the"Benefits"section of this EOC. • Copayment/Coinsurance. This column describes the Cost Share you will pay for Services after you have met your Plan Deductible or Drug Deductible,if applicable.(Please see the"Deductibles and Out-of-Pocket Maximums" section above to determine if your plan includes deductibles.)If the Services are not covered in your plan,this column will read"Not covered."If we provide an Allowance that you can use toward the cost of the Services,this column will include the Allowance. • Subject to Deductible. This column explains whether the Cost Share you pay for Services is subject to a Plan Deductible or Drug Deductible.If the Services are subject to a deductible,you will pay Charges for those Services until you have met your deductible.If the Services are subject to a deductible,there will be a"✓"or"D"in this column,depending on which deductible applies("✓"for Plan Deductible,"D"for Drug Deductible).If the Services do not apply to a deductible,or if your plan does not include a deductible,this column will be blank.For a more detailed explanation of deductibles,refer to"Plan Deductible"and"Drug Deductible"in the`Benefits"section of this EOC. • Applies to OOPM.This column explains whether the Cost Share you pay for Services counts toward the Plan Out- of-Pocket Maximum("OOPM")after you have met any applicable deductible. If the Services count toward the Plan OOPM,there will be a"✓"in this column.If the Services do not count toward the Plan OOPM,this column will be blank.For a more detailed explanation of the Plan OOPM,refer to"Plan Out-of-Pocket Maximum"in the "Benefits"section of this EOC. Group ID:604334 Kaiser Pennanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 1 Administered drugs and products Copayment/ Subject to Applies to Description of Administered Drugs and Products Services Coinsurance Deductible OOPM Whole blood,red blood cells,plasma,and platelets No charge Allergy antigens(including administration) $3 per visit Cancer chemotherapy drugs and adjuncts No charge Drugs and products that are administered via intravenous therapy or No charge injection that are not for cancer chemotherapy,including blood factor products and biological products("biologics")derived from tissue, cells,or blood All other administered drugs and products No charge Drugs and products administered to you during a home visit No charge Ambulance Services Copayment/ Subject to Applies to Description of Ambulance Services Coinsurance Deductible OOPM Emergency ambulance Services $50 per trip Nonemergency ambulance and psychiatric transport van Services $50 per trip Dialysis care Copayment/ Subject to Applies to Description of Dialysis Care Services Coinsurance Deductible OOPM Equipment and supplies for home hemodialysis and home peritoneal No charge ✓ dialysis One routine outpatient visit per month with the multidisciplinary No charge ✓ nephrology team for a consultation,evaluation,or treatment Hemodialysis and peritoneal dialysis treatment at a Plan Facility $15 per visit Group ID:604334 Kaiser Pennanente Traditional HMO Plan Contract: 1 Version:36 EOC9#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 2 Durable Medical Equipment ("DME") for home use Copayment/ Subject to Applies to Description of DME Services Coinsurance Deductible OOPM Blood glucose monitors for diabetes blood testing and their supplies 20%Coinsurance Peak flow meters 20%Coinsurance Insulin pumps and supplies to operate the pump 20%Coinsurance Other Base DME Items as described in this EOC 20%Coinsurance Supplemental DME items as described in this EOC 20%Coinsurance Retail-grade milk pumps No charge Hospital-grade milk pumps No charge Emergency Services and Urgent Care Copayment/ Subject to Applies to Description of Emergency Services and Urgent Care Coinsurance Deductible OOPM Emergency department visits $100 per visit Urgent Care visits $15 per visit Note:If you are admitted to the hospital as an inpatient from the emergency department,the emergency department visits Cost Share above does not apply.Instead,the Services you received in the emergency department,including any observation stay,if applicable,will be considered part of your hospital inpatient stay. For the Cost Share for inpatient Services,refer to "Hospital inpatient Services"in this"Cost Share Summary."The emergency department Cost Share does apply if you are admitted for observation but are not admitted as an inpatient. Fertility Services Diagnosis and treatment of Infertility Copayment/ Subject to Applies to Description of Diagnosis and Treatment of Infertility Services Coinsurance Deductible OOPM Office visits $15 per visit Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 3 Copayment/ Subject to Applies to Description of Diagnosis and Treatment of Infertility Services Coinsurance Deductible OOPM Outpatient surgery and outpatient procedures(including imaging and $15 per procedure diagnostic Services)when performed in an outpatient or ambulatory surgery center or in a hospital operating room,or any setting where a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort Any other outpatient surgery that does not require a licensed staff $15 per procedure member to monitor your vital signs as described above Outpatient imaging No charge Outpatient laboratory No charge Outpatient administered drugs No charge Hospital inpatient Services(including room and board,drugs, No charge imaging,laboratory,other diagnostic and treatment Services,and Plan Physician Services) Artificial insemination Copayment/ Subject to Applies to Description of Artificial Insemination Services Coinsurance Deductible OOPM Office visits $15 per visit Outpatient surgery and outpatient procedures(including imaging and $15 per procedure diagnostic Services)when performed in an outpatient or ambulatory surgery center or in a hospital operating room,or any setting where a licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort Any other outpatient surgery that does not require a licensed staff $15 per procedure member to monitor your vital signs as described above Outpatient imaging No charge Outpatient laboratory No charge Outpatient administered drugs No charge Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 4 Copayment/ Subject to Applies to Description of Artificial Insemination Services Coinsurance Deductible OOPM Hospital inpatient Services(including room and board,drugs, No charge imaging,laboratory,other diagnostic and treatment Services,and Plan Physician Services) Assisted reproductive technology("ART")Services Copayment/ Subject to Applies to Description of ART Services Coinsurance Deductible OOPM Assisted reproductive technology("ART")Services such as invitro Not covered fertilization("IVF"),gamete intra-fallopian transfer("GIFT"),or zygote intrafallopian transfer("ZIFT") Health education Copayment/ Subject to Applies to Description of Health Education Services Coinsurance Deductible OOPM Covered health education programs,which may include programs No charge provided online and counseling over the phone Individual counseling during an office visit related to tobacco No charge ✓ cessation Individual counseling during an office visit related to diabetes No charge ✓ management Other covered individual counseling when the office visit is solely for No charge health education Covered health education materials No charge Hearing Services Copayment/ Subject to Applies to Description of Hearing Services Coinsurance Deductible OOPM Hearing exams with an audiologist to determine the need for hearing $15 per visit ✓ correction Physician Specialist Visits to diagnose and treat hearing problems $15 per visit Group ID:604334 Kaiser Pennanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 5 Copayment/ Subject to Applies to Description of Hearing Services Coinsurance Deductible OOPM Hearing aids,including,fitting,counseling,adjustment,cleaning,and We provide a$1,000 inspection Allowance for each ear every 36 months Home health care Copayment/ Subject to Applies to Description of Home Health Care Services Coinsurance Deductible OOPM Home health care Services(100 visits per Accumulation Period) No charge ,/ Hospice care Copayment/ Subject to Applies to Description of Hospice Care Services Coinsurance Deductible OOPM Hospice Services No charge Hospital inpatient Services Copayment/ Subject to Applies to Description of Hospital Inpatient Services Coinsurance Deductible OOPM Hospital inpatient stays No charge Injury to teeth Copayment/ Subject to Applies to Description of Injury to Teeth Services Coinsurance Deductible OOPM Accidental injury to teeth Not covered Mental health Services Copayment/ Subject to Applies to Description of Mental Health Services Coinsurance Deductible OOPM Inpatient mental health hospital stays No charge Individual mental health evaluation and treatment $15 per visit Group mental health treatment $7 per visit Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC9#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 6 Copayment/ Subject to Applies to Description of Mental Health Services Coinsurance Deductible OOPM Partial hospitalization No charge Other intensive psychiatric treatment programs No charge Residential mental health treatment Services No charge Behavioral Health Treatment for Autism Spectrum Disorder No charge Electroconvulsive therapy $15 per visit Transcranial magnetic stimulation $15 per visit Office visits Copayment/ Subject to Applies to Description of Office Visit Services Coinsurance Deductible OOPM Primary Care Visits and Non-Physician Specialist Visits that are not $15 per visit ✓ described elsewhere in this"Cost Share Summary" Physician Specialist Visits that are not described elsewhere in this $15 per visit "Cost Share Summary" Group appointments that are not described elsewhere in this"Cost $7 per visit ✓ Share Summary" Acupuncture Services $15 per visit Ostomy and urological supplies Copayment/ Subject to Applies to Description of Ostomy and Urological Services Coinsurance Deductible OOPM Ostomy and urological supplies as described in this EOC No charge Outpatient imaging, laboratory, and other diagnostic and treatment Services Description of Outpatient Imaging,Laboratory,and Other Diagnostic Copayment/ Subject to Applies to and Treatment Services Coinsurance Deductible OOPM Complex imaging(other than preventive) such as CT scans,MRIs, No charge and PET scans Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 7 Description of Outpatient Imaging,Laboratory,and Other Diagnostic Copayment/ Subject to Applies to and Treatment Services Coinsurance Deductible OOPM Basic imaging Services,such as diagnostic and therapeutic X-rays, No charge ✓ mammograms,and ultrasounds Nuclear medicine No charge Routine retinal photography screenings No charge Routine laboratory tests to monitor the effectiveness of dialysis No charge Over-the-counter COVID-19 tests obtained from Plan Providers as No charge described in this EOC(up to a total of 8 tests from Plan Providers and Non-Plan Providers per calendar month) Over-the-counter COVID-19 tests obtained from Non-Plan Providers 50%Coinsurance as described in this EOC(up to a total of 8 tests from Plan Providers and Non-Plan Providers per calendar month,not to exceed$12 per test,including all fees and taxes,if you obtain the test from a Non- Plan Provider) Laboratory tests to diagnose or screen for COVID-19 obtained from No charge Plan Providers Laboratory tests to diagnose or screen for COVID-19 obtained from 50%Coinsurance Non-Plan Providers(except for providers of Emergency Services or Out-of-Area Urgent Care) All other laboratory tests(including tests for specific genetic No charge ✓ disorders for which genetic counseling is available) Diagnostic Services provided by Plan Providers who are not No charge physicians(such as EKGs and EEGs) Radiation therapy No charge Ultraviolet light treatments(including ultraviolet light therapy No charge equipment as described in this EOC) Outpatient prescription drugs, supplies, and supplements If the"Cost Share at a Plan Pharmacy"column in this section provides Cost Share for a 30-day supply and your Plan Physician prescribes more than this,you may be able to obtain more than a 30-day supply at one time up to the day supply limit for that drug.Applicable Cost Share will apply.For example,two 30-day copayments may be due when picking up a 60-day prescription,three copayments may be due when picking up a 100-day prescription at the pharmacy. Group ID:604334 Kaiser Pennanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 8 Most items Cost Share Cost Share Subject to Applies to Description of Most Items at a Plan Pharmacy by Mail Deductible OOPM Items on Tier 1 not described elsewhere in $10 for up to a 30-day $20 for up to a 100-day ✓ this"Cost Share Summary" supply supply Items on Tier 2 not described elsewhere in $20 for up to a 30-day $40 for up to a 100-day ✓ this"Cost Share Summary" supply supply Items on Tier 4 not described elsewhere in $20 for up to a 30-day Availability for mail this"Cost Share Summary" supply order varies by item. ✓ Talk to your local pharmacy Base drugs,supplies,and supplements Description of Base Drugs, Supplies and Cost Share Cost Share Subject to Applies to Supplements at a Plan Pharmacy by Mail Deductible OOPM Hematopoietic agents for dialysis No charge for up to a Not available ✓ 30-day supply Elemental dietary enteral formula when No charge for up to a Not available used as a primary therapy for regional 30-day supply ✓ enteritis All other items on Tier 1 as described in $10 for up to a 30-day Availability for mail this EOC supply order varies by item. ✓ Talk to your local pharmacy All other items on Tier 2 as described in $20 for up to a 30-day Availability for mail this EOC supply order varies by item. ✓ Talk to your local pharmacy All other items on Tier 4 as described in $20 for up to a 30-day Availability for mail this EOC supply order varies by item. ✓ Talk to your local pharmacy Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 9 Anticancer drugs and certain critical adjuncts following a diagnosis of cancer Description of Anticancer Drugs and Cost Share Cost Share Subject to Applies to Certain Critical Adjuncts at a Plan Pharmacy by Mail Deductible OOPM Oral anticancer drugs on Tier 1 $10 for up to a 30-day Availability for mail supply order varies by item. Talk to your local pharmacy Oral anticancer drugs on Tier 2 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Oral anticancer drugs on Tier 4 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Non-oral anticancer drugs on Tier 1 $10 for up to a 30-day Availability for mail supply order varies by item. Talk to your local pharmacy Non-oral anticancer drugs on Tier 2 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Non-oral anticancer drugs on Tier 4 $20 for up to a 30-day Availability for mail supply order varies by item. ✓ Talk to your local pharmacy Home infusion drugs Cost Share Cost Share Subject to Applies to Description of Home Infusion Drugs at a Plan Pharmacy by Mail Deductible OOPM Home infusion drugs No charge for up to a Not available 30-day supply Supplies necessary for administration of No charge No charge ✓ home infusion drugs Home infusion drugs are self-administered intravenous drugs,fluids,additives,and nutrients that require specific types of parenteral-infusion,such as an intravenous or intraspinal-infusion. Group ID:604334 Kaiser Pennanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 10 Certain state-mandated items Description of Certain State-Mandated Cost Share Cost Share Subject to Applies to Items at a Plan Pharmacy by Mail Deductible OOPM Amino acid—modified products used to No charge for up to a Not available treat congenital errors of amino acid 30-day supply metabolism(such as phenylketonuria) Therapeutics for COVID-19 obtained No charge for up to a Availability for mail from Plan Providers 30-day supply order varies by item. Talk to your local pharmacy Therapeutics for COVID-19 obtained 50%Coinsurance for up Not available from Non-Plan Providers(except for to a 30-day supply providers of Emergency Services or Out- of-Area Urgent Care) Ketone test strips and sugar or acetone test No charge for up to a Not available ✓ tablets or tapes for diabetes urine testing 100-day supply Insulin-administration devices:pen $10 for up to a 100-day Availability for mail delivery devices,disposable needles and supply order varies by item. ✓ syringes,and visual aids required to Talk to your local ensure proper dosage(except eyewear) pharmacy For drugs related to the treatment of diabetes(for example,insulin),and for continuous insulin delivery devices that use disposable items such as patches or pods,refer to the"Most items"table above.For insulin pumps,refer to the"Durable Medical Equipment("DME")for home use"table above. Contraceptive drugs and devices Description of Contraceptive Drugs and Cost Share Cost Share Subject to Applies to Devices at a Plan Pharmacy by Mail Deductible OOPM The following hormonal contraceptive No charge for up to a No charge for up to a items on Tier 1: 365-day supply 365-day supply • Rings Availability for mail • Patches order varies by item. Talk to your local • Oral contraceptives pharmacy The following contraceptive items on No charge for up to a Not available Tier 1: 100-day supply • Spermicide • Sponges • Contraceptive gel Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 11 Description of Contraceptive Drugs and Cost Share Cost Share Subject to Applies to Devices at a Plan Pharmacy by Mail Deductible OOPM The following hormonal contraceptive No charge for up to a No charge for up to a items on Tier 2: 365-day supply 365-day supply • Rings Availability for mail • Patches order varies by item. Talk to your local • Oral contraceptives pharmacy The following contraceptive items on No charge for up to a Not available Tier 2: 100-day supply • Spermicide • Sponges • Contraceptive gel Emergency contraception No charge Not available Diaphragms,cervical caps,and up to a 30- No charge Not available ✓ day supply of condoms Certain preventive items Cost Share Cost Share Subject to Applies to Description of Certain Preventive Items at a Plan Pharmacy by Mail Deductible OOPM Items on our Preventive Services list on No charge for up to a Not available our website at kp.m/prevention when 100-day supply prescribed by a Plan Provider Fertility and sexual dysfunction drugs Description of Fertility and Sexual Cost Share Cost Share Subject to Applies to Dysfunction Drugs at a Plan Pharmacy by Mail Deductible OOPM Drugs on Tier 1 prescribed to treat $10 for up to a 30-day $20 for up to a 100-day Infertility or in connection with covered supply supply artificial insemination Services Drugs on Tier 2 and Tier 4 prescribed to $20 for up to a 30-day $40 for up to a 100-day treat Infertility or in connection with supply supply covered artificial insemination Services Drugs on Tier 1 prescribed in connection Not covered Not covered with covered assisted reproductive technology("ART")Services Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 12 Description of Fertility and Sexual Cost Share Cost Share Subject to Applies to Dysfunction Drugs at a Plan Pharmacy by Mail Deductible OOPM Drugs on Tier 2 and Tier 4 prescribed in Not covered Not covered connection with covered assisted reproductive technology("ART") Services Drugs on Tier 1 prescribed for sexual 50%Coinsurance(not to 50%Coinsurance(not to dysfunction disorders exceed$50)for up to a exceed$50)for up to a ✓ 100-day supply 100-day supply Drugs on Tier 2 and Tier 4 prescribed for 50%Coinsurance(not to 50%Coinsurance(not to sexual dysfunction disorders exceed$100)for up to a exceed$100)for up to a ✓ 100-day supply 100-day supply Outpatient surgery and outpatient procedures Copayment/ Subject to Applies to Description of Outpatient Surgery and Outpatient Procedure Services Coinsurance Deductible OOPM Outpatient surgery and outpatient procedures(including imaging and $15 per procedure diagnostic Services)when provided in an outpatient or ambulatory surgery center or in a hospital operating room,or any setting where a ✓ licensed staff member monitors your vital signs as you regain sensation after receiving drugs to reduce sensation or minimize discomfort Any other outpatient surgery that does not require a licensed staff $15 per procedure ✓ member to monitor your vital signs as described above Preventive Services Copayment/ Subject to Applies to Description of Preventive Services Coinsurance Deductible OOPM Routine physical exams,including well-woman,postpartum follow- No charge ✓ up,and preventive exams for Members age 2 and older Well-child preventive exams for Members through age 23 months No charge ✓ Normal series of regularly scheduled preventive prenatal care exams No charge ✓ after confirmation of pregnancy Immunizations(including the vaccine)administered to you in a Plan No charge ✓ Medical Office Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC9#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 13 Copayment/ Subject to Applies to Description of Preventive Services Coinsurance Deductible OOPM Immunizations(including the vaccine)for COVID-19 administered 50%Coinsurance by Non-Plan Providers(except for providers of Emergency Services or Out-of-Area Urgent Care) Tuberculosis skin tests No charge Screening and counseling Services when provided during a routine No charge physical exam or a well-child preventive exam,such as obesity counseling,routine vision and hearing screenings,alcohol and ✓ substance abuse screenings,health education,depression screening, and developmental screenings to diagnose and assess potential developmental delays Screening colonoscopies No charge Screening flexible sigmoidoscopies No charge Routine imaging screenings such as mammograms No charge Bone density CT scans No charge Bone density DEXA scans No charge Routine laboratory tests and screenings,such as cancer screening No charge tests,sexually transmitted infection("STI")tests,cholesterol screening tests,and glucose tolerance tests Other laboratory screening tests,such as fecal occult blood tests and No charge hepatitis B screening tests Prosthetic and orthotic devices Copayment/ Subject to Applies to Description of Prosthetic and Orthotic Device Services Coinsurance Deductible OOPM External prosthetic and orthotic devices as described in this EOC No charge Supplemental prosthetic and orthotic devices as described in this No charge ✓ EOC Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 14 Rehabilitative and habilitative Services Copayment/ Subject to Applies to Description of Rehabilitative and Habilitative Services Coinsurance Deductible OOPM Individual outpatient physical,occupational,and speech therapy $15 per visit Group outpatient physical,occupational,and speech therapy $7 per visit Physical,occupational,and speech therapy provided in an organized, $15 per day multidisciplinary rehabilitation day-treatment program Reproductive Health Services Family planning Services Copayment/ Subject to Applies to Description of Family Planning Services Coinsurance Deductible OOPM Family planning counseling No charge Injectable contraceptives,internally implanted time-release No charge contraceptives or intrauterine devices("IUDs")and office visits ✓ related to their insertion,removal,and management when provided to prevent pregnancy Sterilization procedures for Members assigned female at birth if No charge performed in an outpatient or ambulatory surgery center or in a hospital operating room All other sterilization procedures for Members assigned female at No charge ✓ birth Sterilization procedures for Members assigned male at birth if No charge performed in an outpatient or ambulatory surgery center or in a hospital operating room All other sterilization procedures for Members assigned male at birth No charge Abortion and abortion-related Services Copayment/ Subject to Applies to Description of abortion and abortion-related Services Coinsurance Deductible OOPM Surgical abortion No charge Prescription drugs,in accord with our drug formulary guidelines No charge Group ID:604334 Kaiser Pennanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 15 Copayment/ Subject to Applies to Description of abortion and abortion-related Services Coinsurance Deductible OOPM Other abortion-related Services No charge ,/ Plan Doula services Copayment/ Subject to Applies to Description of Plan Doula services Coinsurance Deductible OOPM Initial,prenatal,or postpartum visits No charge Support during labor and delivery No charge Skilled nursing facility care Copayment/ Subject to Applies to Description of Skilled Nursing Facility Care Services Coinsurance Deductible OOPM Skilled nursing facility Services up to 100 days per benefit period* No charge *A benefit period begins on the date you are admitted to a hospital or Skilled Nursing Facility at a skilled level of care.A benefit period ends on the date you have not been an inpatient in a hospital or Skilled Nursing Facility,receiving a skilled level of care,for 60 consecutive days.A new benefit period can begin only after any existing benefit period ends.A prior three-day stay in an acute care hospital is not required. Substance use disorder treatment Copayment/ Subject to Applies to Description of Substance Use Disorder Treatment Services Coinsurance Deductible OOPM Inpatient detoxification No charge Individual substance use disorder evaluation and treatment $15 per visit Group substance use disorder treatment $5 per visit Intensive outpatient and day-treatment programs No charge Methadone maintenance treatment No charge Residential substance use disorder treatment No charge Group ID:604334 Kaiser Pennanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 16 Telehealth visits Interactive video visits Copayment/ Subject to Applies to Description of Interactive Video Visit Services Coinsurance Deductible OOPM Primary Care Visits and Non-Physician Specialist Visits No charge Physician Specialist Visits No charge Scheduled telephone visits Copayment/ Subject to Applies to Description of Scheduled Telephone Visit Services Coinsurance Deductible OOPM Primary Care Visits and Non-Physician Specialist Visits No charge Physician Specialist Visits No charge Vision Services for Adult Members Copayment/ Subject to Applies to Description of Vision Services for Adult Members Coinsurance Deductible OOPM Routine eye exams with a Plan Optometrist to determine the need for No charge vision correction and to provide a prescription for eyeglass lenses Physician Specialist Visits to diagnose and treat injuries or diseases $15 per visit of the eye Non-Physician Specialist Visits to diagnose and treat injuries or $15 per visit ✓ diseases of the eye Aniridia lenses:up to two Medically Necessary contact lenses per eye No charge ✓ (including fitting and dispensing)in any 12-month period Aphakia lenses:up to six Medically Necessary aphakic contact lenses No charge ✓ per eye(including fitting and dispensing)in any 12-month period Specialty contact lenses(other than aniridia and aphakia lenses)that No charge after optical will provide a significant improvement in vision not obtainable with Allowance applied eyeglass lenses: either one pair of contact lenses(including fitting and dispensing)or an initial supply of disposable contact lenses(up to six months,including fitting and dispensing)in any 24-month period Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 17 Copayment/ Subject to Applies to Description of Vision Services for Adult Members Coinsurance Deductible OOPM Eyeglasses and contact lenses as described in this EOC We provide a$175 Allowance every 24 months Replacement lenses if there has been a change in prescription of at We provide a$30 least.50 diopter in one or both eyes within 12 months of the initial Allowance for a single point of sale of an eyeglass lens or contact lens that we provided an vision eyeglass lens or Allowance toward(or otherwise covered) contact lens,a$45 Allowance for a multifocal or lenticular eyeglass lens Low vision devices(including fitting and dispensing) Not covered Vision Services for Pediatric Members Copayment/ Subject to Applies to Description of Vision Services for Pediatric Members Coinsurance Deductible OOPM Routine eye exams with a Plan Optometrist to determine the need for No charge ✓ vision correction and to provide a prescription for eyeglass lenses Physician Specialist Visits to diagnose and treat injuries or diseases $15 per visit ✓ of the eye Non-Physician Specialist Visits to diagnose and treat injuries or $15 per visit ✓ diseases of the eye Aniridia lenses:up to two Medically Necessary contact lenses per eye No charge ✓ (including fitting and dispensing)in any 12-month period Aphakia lenses:up to six Medically Necessary aphakic contact lenses No charge per eye(including fitting and dispensing)in any 12-month period Specialty contact lenses(other than aniridia and aphakia lenses)that No charge after optical will provide a significant improvement in vision not obtainable with Allowance applied eyeglass lenses: either one pair of contact lenses(including fitting and dispensing)or an initial supply of disposable contact lenses(up to six months,including fitting and dispensing)in any 24-month period Eyeglasses and contact lenses as described in this EOC We provide a$175 Allowance every 24 months Group ID:604334 Kaiser Pennanente Traditional HMO Plan Contract: 1 Version:36 EOC9#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 18 Copayment/ Subject to Applies to Description of Vision Services for Pediatric Members Coinsurance Deductible OOPM Replacement lenses if there has been a change in prescription of at No charge least.50 diopter in one or both eyes within 12 months of the initial point of sale of an eyeglass lens or contact lens that we provided an Allowance toward(or otherwise covered) Low vision devices(including fitting and dispensing) Not covered CARE Plan The California Community Assistance,Recovery,and Empowerment("CARE")Act established a system for individuals with severe mental illness to be evaluated and given a treatment plan developed by a county behavioral health agency ("CARE Plan").If a Member has a court-approved CARE Plan,we cover the Services required under that plan when provided by Plan Providers or Non-Plan Providers at no charge,with the exception of prescription drugs.Prescription drugs required under a court-approved CARE Plan are subject to the same Cost Share as drugs prescribed by Plan Providers,as described in this Cost Share Summary,and are also subject to prior authorization by Health Plan.To inform us that you have a court-approved CARE Plan,please call Member Services. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOCW 5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 19 Introduction coverage information in this EOC applies when you obtain care in your Home Region.When you visit the This Evidence of Coverage('EOC")describes the health other California Region,you may receive care as described in"Receiving Care Outside of Your Home care coverage of this Kaiser Penmanente Traditional Region Service Area"in the"How to Obtain Services" HMO Plan provided under the Group Agreement section. ("Agreement")between Kaiser Foundation Health Plan, Inc. ("Health Plan")and the entity with which Health Kaiser Penmanente provides Services directly to our Plan has entered into the Agreement(your"Group"). Members through an integrated medical care program. Health Plan,Plan Hospitals,and the Medical Group This EOC is part of the Agreement between work together to provide our Members with quality care. Health Plan and your Group. The Agreement Our medical care program gives you access to all of the contains additional terms such as Premiums, covered Services you may need,such as routine care when coverage can change, the effective date with your own personal Plan Physician,hospital of coverage, and the effective date of Services,laboratory and pharmacy Services,Emergency Services,Urgent Care,and other benefits described in termination. The Agreement must be consulted this EOC.Plus,our health education programs offer you to determine the exact terms of coverage. A great ways to protect and improve your health. copy of the Agreement is available from your Group. We provide covered Services to Members using Plan Providers located in our Service Area,which is described Once enrolled in other coverage made available through in the"Definitions"section.You must receive all Health Plan,that other plan's evidence of coverage covered care from Plan Providers inside our Service cannot be cancelled without cancelling coverage under Area,except as described in the sections listed below for this EOC,unless the change is made during open the following Services: enrollment or a special enrollment period. • Authorized referrals as described under"Getting a Referral"in the"How to Obtain Services"section For benefits provided under any other program offered . Covered Services received outside of your Home by your Group(for example,workers compensation Region Service Area as described under"Receiving benefits),refer to your Group's materials. Care Outside of Your Home Region Service Area"in the"How to Obtain Services"section In this EOC,Health Plan is sometimes referred to as "we"or"us."Members are sometimes referred to as • COVID-19 Services as described under"Outpatient "you."Some capitalized terms have special meaning in Imaging,Laboratory,and Other Diagnostic and this EOC;please see the"Definitions"section for terms Treatment Services,""Outpatient Prescription Drugs, you should know. Supplies,and Supplements,"and"Preventive Services"in the"Benefits"section It is important to familiarize yourself with your coverage • Emergency ambulance Services as described under by reading this EOC completely,so that you can take full "Ambulance Services"in the"Benefits"section advantage of your Health Plan benefits.Also,if you have • Emergency Services,Post-Stabilization Care,and special health care needs,please carefully read the Out-of-Area Urgent Care as described in the sections that apply to you. "Emergency Services and Urgent Care"section • Hospice care as described under"Hospice Care"in About Kaiser Permanente the"Benefits"section PLEASE READ THE FOLLOWING Term of this EOC INFORMATION SO THAT YOU WILL KNOW FROM WHOM OR WHAT GROUP OF This EOC is for the period January 1,2025,through PROVIDERS YOU MAY GET HEALTH CARE. December 31,2025,unless amended.Your Group can tell you whether this EOC is still in effect and give you a When you join Kaiser Pennanente,you are enrolling in current one if this EOC has expired or been amended. one of two Health Plan Regions in California(either our Northern California Region or Southern California Region),which we call your"Home Region."The Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 20 Definitions schedule of charges that Kaiser Permanente negotiates with the capitated provider Some terms have special meaning in this EOC.When we • For items obtained at a pharmacy owned and operated use a term with special meaning in only one section of by Kaiser Permanente,the amount the pharmacy this EOC,we define it in that section.The terms in this would charge a Member for the item if a Member's "Definitions"section have special meaning when benefit plan did not cover the item(this amount is an capitalized and used in any section of this EOC. estimate of:the cost of acquiring,storing,and dispensing drugs,the direct and indirect costs of Accumulation Period:A period of time no greater than providing Kaiser Permanente pharmacy Services to 12 consecutive months for purposes of accumulating Members,and the pharmacy program's contribution amounts toward any deductibles(if applicable),out-of- to the net revenue requirements of Health Plan) pocket maximums,and benefit limits.For example,the Accumulation Period may be a calendar year or contract • For air ambulance Services received from Non-Plan year.The Accumulation Period for this EOC is from Providers when you have an Emergency Medical January 1 through December 31. Condition,the amount required to be paid by Health Plan pursuant to federal law Allowance:A specified amount that you can use toward the purchase price of an item.If the price of the items • For other Emergency Services received from Non- you select exceeds the Allowance,you will pay the Plan Providers(including Post-Stabilization Care that amount in excess of the Allowance(and that payment constitutes Emergency Services under federal law), will not apply toward any deductible or out-of-pocket the amount required to be paid by Health Plan maximum). pursuant to state law,when it is applicable,or federal law Ancillary Coverage: Optional benefits such as . For all other Services received from Non-Plan acupuncture,chiropractic,or dental coverage that may be available to Members enrolled under this EOC. If your Providers(including Post-Stabilization Services that plan includes Ancillary Coverage,this coverage will be are not Emergency Services under federal law),the described in an amendment to this EOC or a separate amount(1)required to be paid pursuant to state law, agreement from the issuer of the coverage. when it is applicable,or federal law,or(2)in the event that neither state or federal law prohibiting Behavioral Health Treatment for Autism Spectrum balance billing apply,then the amount agreed to by Disorder: Professional Services and treatment programs, the Non-Plan Provider and Health Plan or,absent including applied behavior analysis and evidence-based such an agreement,the usual,customary and behavior intervention programs,that develop or restore, reasonable rate for those services as determined by to the maximum extent practicable,the functioning of a Health Plan based on objective criteria person with autism spectrum disorder(or treat mental . For all other Services,the payments that Kaiser health conditions other than autism spectrum disorder Permanente makes for the Services or,if Kaiser when this treatment is clinically indicated)that meet the Permanente subtracts your Cost Share from its following criteria: payment,the amount Kaiser Permanente would have • The treatment is prescribed by a Plan Physician,or is paid if it did not subtract your Cost Share developed by a Plan Provider who is a psychologist • The treatment is administered by a Plan Provider who Cigna Healthcare PPO Network: The Cigna is a qualified autism service provider,qualified Healthcare PPO Network refers to the health care autism service professional,or qualified autism providers(doctors,hospitals,specialists)contracted as service paraprofessional,as defined in California part of a shared administration network arrangement Health and Safety Code section 1374.73(c) called Cigna Healthcare PPO for Shared Administration. Charges: "Charges"means the following: Cigna Healthcare is an independent company and not • For Services provided by the Medical Group or affiliated with Kaiser Foundation Health Plan,Inc.,and Kaiser Foundation Hospitals,the charges in Health its subsidiary health plans.Access to the Cigna Plan's schedule of Medical Group and Kaiser Healthcare PPO Network is available through Cigna Foundation Hospitals charges for Services provided Healthcare's contractual relationship with the Kaiser to Members Permanente health plans.The Cigna Healthcare PPO • For Services for which a provider(other than the Network is provided exclusively by or through operating Medical Group or Kaiser Foundation Hospitals)is subsidiaries of The Cigna Group,including Cigna Health compensated on a capitation basis,the charges in the and Life Insurance Company.The Cigna Healthcare Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 21 name,logo,and other marks are owned by Cigna by acute symptoms of sufficient severity such that either Intellectual Property,Inc. of the following is true: Coinsurance:A percentage of Charges that you must • The person is an immediate danger to themself or to pay when you receive a covered Service under this EOC. others Copayment:A specific dollar amount that you must pay • The person is immediately unable to provide for,or when you receive a covered Service under this EOC. use,food,shelter,or clothing,due to the mental Note:The dollar amount of the Copayment can be$0 disorder (no charge). Emergency Services:All of the following with respect Cost Share: The amount you are required to pay for to an Emergency Medical Condition: covered Services.For example,your Cost Share may be • A medical screening exam that is within the a Copayment or Coinsurance.If your coverage includes a capability of the emergency department of a hospital Plan Deductible and you receive Services that are subject or an independent freestanding emergency to the Plan Deductible,your Cost Share for those department,including ancillary services(such as Services will be Charges until you reach the Plan imaging and laboratory Services)routinely available Deductible. Similarly,if your coverage includes a Drug to the emergency department to evaluate the Deductible,and you receive Services that are subject to Emergency Medical Condition the Drug Deductible,your Cost Share for those Services . Within the capabilities of the staff and facilities will be Charges until you reach the Drug Deductible. available at the facility,Medically Necessary Dependent:A Member who meets the eligibility examination and treatment required to Stabilize the requirements as a Dependent(for Dependent eligibility patient(once your condition is Stabilized, Services requirements,see"Who Is Eligible"in the"Premiums, you receive are Post-Stabilization Care and not Eligibility,and Enrollment"section). Emergency Services) Disclosure Form("DF"):A summary of coverage for • Post-Stabilization Care furnished by a Non-Plan prospective Members.For some products,the DF is Provider is covered as Emergency Services when combined with the evidence of coverage. federal law applies,as described under"Post- Drug Deductible: The amount you must pay under this Stabilization Care"in the"Emergency Services" EOC in the Accumulation Period for certain drugs, section supplies,and supplements before we will cover those EOC: This Evidence of Coverage document,including Services at the applicable Copayment or Coinsurance in any amendments,which describes the health care that Accumulation Period.Refer to the"Cost Share coverage of"Kaiser Permanente Traditional HMO Plan" Summary"section to learn whether your coverage under Health Plan's Agreement with your Group. includes a Drug Deductible,the Services that are subject Family:A Subscriber and all of their Dependents. to the Drug Deductible,and the Drug Deductible amount. Group: The entity with which Health Plan has entered Emergency Medical Condition:A medical condition into the Agreement that includes this EOC. manifesting itself by acute symptoms of sufficient Health Plan:Kaiser Foundation Health Plan,Inc.,a severity(including severe pain)such that you reasonably California nonprofit corporation.Health Plan is a health believed that the absence of immediate medical attention care service plan licensed to offer health care coverage would result in any of the following: by the Department of Managed Health Care. This EOC • Placing the person's health(or,with respect to a sometimes refers to Health Plan as"we"or"us." pregnant person,the health of the pregnant person or Home Region:The Region where you enrolled(either unborn child)in serious jeopardy the Northern California Region or the Southern • Serious impairment to bodily functions California Region). • Serious dysfunction of any bodily organ or part Infertility:A person's inability to conceive a pregnancy or cant'a pregnancy to live birth either as an individual A mental health condition is an Emergency Medical or with their partner;or,a Plan Physician's determination Condition when it meets the requirements of the of Infertility,based on a patient's medical,sexual,and paragraph above,or when the condition manifests itself reproductive history,age,physical findings,diagnostic testing,or any combination of those factors. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 22 Kaiser Permanente:Kaiser Foundation Hospitals(a Non—Plan Provider:A provider other than a Plan California nonprofit corporation),Health Plan,and the Provider. Medical Group. Non—Plan Psychiatrist:A psychiatrist who is not a Plan Kaiser Permanente State:California,Colorado,District Physician. of Columbia,Georgia,Hawaii,Maryland,Oregon, Virginia,and Washington. Out-of--Area Urgent Care:Medically Necessary Services to prevent serious deterioration of your(or your Medical Group: The Permanente Medical Group,Inc.,a unborn child's)health resulting from an unforeseen for-profit professional corporation. illness,unforeseen injury,or unforeseen complication of Medically Necessary:For Services related to mental an existing condition(including pregnancy)if all of the health or substance use disorder treatment,a Service is following are true: Medically Necessary if it is addressing your specific • You are temporarily outside our Service Area needs,for the purpose of preventing,diagnosing,or • A reasonable person would have believed that your treating an illness,injury,condition,or its symptoms, (or your unborn child's)health would seriously including minimizing the progression of that illness, deteriorate if you delayed treatment until you returned injury,condition,or its symptoms,in a manner that is all to our Service Area of the following: Physician Specialist Visits: Consultations,evaluations, • In accordance with the generally accepted standards and treatment by physician specialists,including of mental health and substance use disorder care personal Plan Physicians who are not Primary Care • Clinically appropriate in terms of type,frequency, Physicians. extent,site,and duration Plan Deductible: The amount you must pay under this • Not primarily for the economic benefit of the health EOC in the Accumulation Period for certain Services care service plan and subscribers or for the before we will cover those Services at the applicable convenience of the patient,treating physician,or Copayment or Coinsurance in that Accumulation Period. other health care provider Refer to the"Cost Share Summary"section to learn For all other Services,a Service is Medically Necessary whether your coverage includes a Plan Deductible,the if it is medically appropriate and required to prevent, Services that are subject to the Plan Deductible,and the diagnose,or treat your condition or clinical symptoms in Plan Deductible amount. accord with generally accepted professional standards of practice that are consistent with a standard of care in the Plan Doula:A contracted birth worker who provides medical community. physical,emotional,and non-medical support for pregnant and postpartum persons before,during,and Medicare:The federal health insurance program for after childbirth. people 65 years of age or older,some people under age 65 with certain disabilities,and people with end-stage Plan Facility: Any facility listed in the Provider renal disease(generally those with permanent kidney Directory on our website at kp.org/facilities.Plan failure who need dialysis or a kidney transplant). Facilities include Plan Hospitals,Plan Medical Offices, Member:A person who is eligible and enrolled under and other facilities that we designate in the directory. this EOC,and for whom we have received applicable The directory is updated periodically.The availability of Premiums. This EOC sometimes refers to a Member as Plan Facilities may change.If you have questions,please "YOU." call Member Services. Non-Physician Specialist Visits: Consultations, Plan Hospital:Any hospital listed in the Provider evaluations,and treatment by non-physician specialists Directory on our website at kp.org/facilities.In the (such as nurse practitioners,physician assistants, directory,some Plan Hospitals are listed as Kaiser optometrists,podiatrists,and audiologists).For Services Permanente Medical Centers.The directory is updated described under"Dental and Orthodontic Services"in periodically. The availability of Plan Hospitals may the"Benefits"section,non-physician specialists include change.If you have questions,please call Member dentists and orthodontists. Services. Non—Plan Hospital:A hospital other than a Plan Plan Medical Office:Any medical office listed in the Hospital. Provider Directory on our website at kp.org/facilities. In the directory,Kaiser Permanente Medical Centers may Non—Plan Physician: A physician other than a Plan include Plan Medical Offices. The directory is updated Physician. periodically. The availability of Plan Medical Offices Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 23 may change.If you have questions,please call Member Premiums:The periodic amounts that your Group is Services. responsible for paying for your membership under this Plan Optical Sales Office:An optical sales office EOC, except that you are responsible for paying owned and operated by Kaiser Permanente or another Premiums if you have Cal-COBRA coverage."Full optical sales office that we designate.Refer to the Premiums"means 100 percent of Premiums for all of the Provider Directory on our website at ky.org/facilities for coverage issued to each enrolled Member,as set forth in locations of Plan Optical Sales Offices.In the directory, the"Premiums"section of Health Plan's Agreement with Plan Optical Sales Offices may be called"Vision your Group. Essentials."The directory is updated periodically.The Preventive Services: Covered Services that prevent or availability of Plan Optical Sales Offices may change.If detect illness and do one or more of the following: you have questions,please call Member Services. • Protect against disease and disability or further Plan Optometrist:An optometrist who is a Plan progression of a disease Provider. • Detect disease in its earliest stages before noticeable Plan Out-of-Pocket Maximum: The total amount of symptoms develop Cost Share you must pay under this EOC in the Primary Care Physicians: Generalists in internal Accumulation Period for certain covered Services that medicine,pediatrics,and family practice,and specialists you receive in the same Accumulation Period.Refer to in obstetrics/gynecology whom the Medical Group the"Cost Share Summary"section to find your Plan Out- designates as Primary Care Physicians.Refer to the of-Pocket Maximum amount and to learn which Services Provider Directory on our website at ky.org/facilities for apply to the Plan Out-of-Pocket Maximum. a list of physicians that are available as Primary Care Plan Pharmacy:A pharmacy owned and operated by Physicians.The directory is updated periodically.The Kaiser Permanente or another pharmacy that we availability of Primary Care Physicians may change.If designate.Refer to the Provider Directory on our website you have questions,please call Member Services. at ku.ora/facilities for locations of Plan Pharmacies.The Primary Care Visits:Evaluations and treatment directory is updated periodically. The availability of Plan provided by Primary Care Physicians and primary care Pharmacies may change.If you have questions,please Plan Providers who are not physicians(such as nurse call Member Services. practitioners). Plan Physician:Any licensed physician who is an Provider Directory:A directory of Plan Physicians and employee of the Medical Group,or any licensed Plan Facilities in your Home Region.This directory is physician who contracts to provide Services to Members available on our website at kmorg/facilities.To obtain a (but not including physicians who contract only to printed copy,call Member Services.The directory is provide referral Services). updated periodically.The availability of Plan Physicians Plan Provider:A Plan Hospital,a Plan Physician,the and Plan Facilities may change.If you have questions, Medical Group,a Plan Pharmacy,or any other health please call Member Services. care provider that Health Plan designates as a Plan Region:A Kaiser Foundation Health Plan organization Provider. or allied plan that conducts a direct-service health care Plan Skilled Nursing Facility:A Skilled Nursing program.Regions may change on January 1 of each year Facility approved by Health Plan. and are currently the District of Columbia and parts of Northern California, Southern California,Colorado, Post-Stabilization Care:Medically Necessary Services Georgia,Hawaii,Maryland,Oregon,Virginia,and related to your Emergency Medical Condition that you Washington.For the current list of Region locations, receive in a hospital(including the emergency please visit our website at ky.org or call Member department),an independent freestanding emergency Services. department,or a skilled nursing facility after your treating physician determines that this condition is Service Area:The ZIP codes below for each county are Stabilized.Post-Stabilization Care also includes durable in our Service Area: medical equipment covered under this EOC,if it is • All ZIP codes in Alameda County are inside our Medically Necessary after discharge from an emergency Northern California Service Area: 94501-02,94505, department and related to the same Emergency Medical 94514,94536-46,94550-52,94555,94557,94560, Condition.For more information about durable medical 94566,94568,94577-80,94586-88,94601-15, equipment covered under this EOC, see"Durable 94617-21,94622-24,94649,94659-62,94666, Medical Equipment("DME")for Home Use"in the 94701-10,94712,94720,95377,95391 "Benefits"section. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 24 • The following ZIP codes in Amador County are 94247-50,94252,94254,94256-59,94261-63, inside our Northern California Service Area: 95640, 94267-69,94271,94273-74,94277-80,94282-85, 95669 94287-91,94293-98,94571,95608-11,95615, • All ZIP codes in Contra Costa County are inside our 95621,95624,95626,95628,95630,95632,95638- Northern California Service Area: 94505-07,94509, 39,95641,95652,95655,95660,95662,95670-71, 94511,94513-14,94516-31,94547-49,94551, 95673,95678,95680,95683,95690,95693,95741- 94553,94556,94561,94563-65,94569-70,94572, 42,95757-59,95763,95811-38,95840-43,95851-53, 94575,94582-83,94595-98,94706-08,94801-08, 95860,95864-67,95894,95899 94820,94850 • All ZIP codes in San Francisco County are inside our • The following ZIP codes in El Dorado County are Northern California Service Area: 94102-05,94107- inside our Northern California Service Area: 95613- 12,94114-34,94137,94139-47,94151,94158-61, 14,95619,95623,95633-35,95651,95664,95667, 94163-64,94172,94177,94188 95672,95682,95762 • All ZIP codes in San Joaquin County are inside our • The following ZIP codes in Fresno County are inside Northern California Service Area: 94514,95201-15, our Northern California Service Area: 93242,93602, 95219-20,95227,95230-31,95234,95236-37, 93606-07,93609,93611-13,93616,93618-19, 95240-42,95253,95258,95267,95269,95296-97, 93624-27,93630-31,93646,93648-52,93654, 95304,95320,95330,95336-37,95361,95366, 93656-57,93660,93662,93667-68,93675,93701- 95376-78,95385,95391,95632,95686,95690 12,93714-18,93720-30,93737,93740-41,93744-45, • All ZIP codes in San Mateo County are inside our 93747,93750,93755,93760-61,93764-65,93771- Northern California Service Area: 94002,94005, 79,93786,93790-94,93844,93888 94010-11,94014-21,94025-28,94030,94037-38, • The following ZIP codes in Kings County are inside 94044,94060-66,94070,94074,94080,94083, our Northern California Service Area: 93230,93232, 94128,94303,94401-04,94497 93242,93631,93656 • The following ZIP codes in Santa Clara County are • The following ZIP codes in Madera County are inside inside our Northern California Service Area: 94022- 24,94035,94039-43,94085-89,94301-06,94309, our Northern California Service Area: 93601-02, 94550,95002,95008-09,95011,95013-15,95020- 93604,93614,93623,93626,93636-39,93643-45, 21,95026,95030-33,95035-38,95042,95044, 93653,93669,93720 95046,95050-56,95070-71,95076,95101,95103, • All ZIP codes in Marin County are inside our 95106,95108-13,95115-36,95138-41,95148, Northern California Service Area: 94901,94903-04, 95150-61,95164,95170,95172-73,95190-94,95196 94912-15,94920,94924-25,94929-30,94933, • All ZIP codes in Santa Cruz County are inside our 94937-42,94945-50,94952,94956-57,94960, 94963-66,94970-71,94973-74,94976-79 Northern California Service Area: 95001,95003, 95005-7,95010,95017-19,95033,95041,95060-67, • The following ZIP codes in Mariposa County are 95073,95076-77 inside our Northern California Service Area: 93 60 1, • All ZIP codes in Solano County are inside our 93623,93653 Northern California Service Area: 94503,94510, • The following ZIP codes in Monterey County are 94512,94533-35,94571,94585,94589-92,95616, inside our Northern California Service Area: 93 90 1, 95618,95620,95625,95687-88,95690,95694, 93902,93905,93906,93907,93912,93915,93933, 95696 93955,93962,95004,95012,95039,95076 • The following ZIP codes in Sonoma County are • All ZIP codes in Napa County are inside our Northern inside our Northern California Service Area: 94515, California Service Area: 94503,94508,94515, 94922-23, 94926-28,94931,94951-55,94972, 94558-59,94562,94567,94573-74,94576,94581, 94975,94999,95401-07,95409,95416,95419, 94599,95476 95421,95425,95430-31,95433,95436,95439, • The following ZIP codes in Placer County are inside 95441-42,95444,95446,95448,95450,95452, our Northern California Service Area: 95602-04, 95462,95465,95471-73,95476,95486-87,95492 95610,95626,95648,95650,95658,95661,95663, • All ZIP codes in Stanislaus County are inside our 95668,95677-78,95681,95703,95722,95736, Northern California Service Area: 95230,95304, 95746-47,95765 95307,95313,95316,95319,95322-23,95326, • All ZIP codes in Sacramento County are inside our 95328-29,95350-58,95360-61,95363,95367-68, Northern California Service Area: 94203-09,94211, 95380-82,95385-87,95397 94229-30,94232,94234-37,94239-40,94244-45, Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 25 • The following ZIP codes in Sutter County are inside Stabilize: To provide the medical treatment of the our Northern California Service Area: 95626,95645, Emergency Medical Condition that is necessary to 95659,95668,95674,95676,95692,95836-7 assure,within reasonable medical probability,that no • The following ZIP codes in Tulare County are inside material deterioration of the condition is likely to result our Northern California Service Area: 93618,93 63 1, from or occur during the transfer of the person from the 93646,93654,93666,93673 facility.With respect to a pregnant person who is having contractions,when there is inadequate time to safely • The following ZIP codes in Yolo County are inside transfer them to another hospital before delivery(or the our Northern California Service Area: 95605,95607, transfer may pose a threat to the health or safety of the 95612,95615-18,95620,95645,95691,95694-95, pregnant person or unborn child),"Stabilize"means to 95697-98,95776,95798-99 deliver(including the placenta). • The following ZIP codes in Yuba County are inside Subscriber:A Member who is eligible for membership our Northern California Service Area: 95692,95903, on their own behalf and not by virtue of Dependent 95961 status and who meets the eligibility requirements as a For each ZIP code listed for a county,our Service Area Subscriber(for Subscriber eligibility requirements,see includes only the part of that ZIP code that is in that "Who Is Eligible"in the"Premiums,Eligibility,and county.When a ZIP code spans more than one county, Enrollment"section). the part of that ZIP code that is in another county is not Surrogacy Arrangement:An arrangement in which an inside our Service Area unless that other county is listed individual agrees to become pregnant and to surrender above and that ZIP code is also listed for that other the baby(or babies)to another person or persons who county. intend to raise the child(or children).The person may be If you have a question about whether a ZIP code is in our impregnated in any manner including,but not limited to, Service Area,please call Member Services. artificial insemination,intrauterine insemination,in vitro fertilization,or through the surgical implantation of a Note:We may expand our Service Area at any time by fertilized egg of another person.For the purposes of this giving written notice to your Group.ZIP codes are EOC,"Surrogacy Arrangements"includes all types of subject to change by the U.S.Postal Service. surrogacy arrangements,including traditional surrogacy Services:Health care services or items("health care" arrangements and gestational surrogacy arrangements. includes physical health care,mental health care,and Telehealth Visits:Interactive video visits and scheduled substance use disorder treatment),and Behavioral Health telephone visits between you and your provider. Treatment for Autism Spectrum Disorder covered under "Mental Health Services"in the"Benefits"section. Urgent Care:Medically Necessary Services for a condition that requires prompt medical attention but is Skilled Nursing Facility:A facility that provides not an Emergency Medical Condition. inpatient skilled nursing care,rehabilitation services,or other related health services and is licensed by the state of California.The facility's primary business must be the provision of 24-hour-a-day licensed skilled nursing care. Premiums, Eligibility, a n d The term"Skilled Nursing Facility"does not include Enrollment convalescent nursing homes,rest facilities,or facilities for the aged,if those facilities furnish primarily custodial Premiums care,including training in routines of daily living.A "Skilled Nursing Facility"may also be a unit or section Your Group is responsible for paying Full Premiums, within another facility(for example,a hospital)as long except that you are responsible for paying Full Premiums as it continues to meet this definition. as described in the"Continuation of Membership" Spouse: The person to whom the Subscriber is legally section if you have Cal-COBRA coverage under this married under applicable law.For the purposes of this EOC.If you are responsible for any contribution to the EOC,the term"Spouse"includes the Subscriber's Premiums that your Group pays,your Group will tell you domestic partner."Domestic partners"are two people the amount,when Premiums are effective,and how to who are registered and legally recognized as domestic pay your Group(through payroll deduction,for partners by California(if your Group allows enrollment example). of domestic partners not legally recognized as domestic partners by California,"Spouse"also includes the Subscriber's domestic partner who meets your Group's eligibility requirements for domestic partners). Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 26 Who Is Eligible For more information about the service areas of the other Regions,please call Member Services. To enroll and to continue enrollment,you must meet all of the eligibility requirements described in this"Who Is Eligibility as a Subscriber Eligible"section,including your Group's eligibility You may be eligible to enroll and continue enrollment as requirements and our Service Area eligibility a Subscriber if you are: requirements. • An employee of your Group Group eligibility requirements • A proprietor or partner of your Group You must meet your Group's eligibility requirements, • Otherwise entitled to coverage under a trust such as the minimum number of hours that employees agreement,retirement benefit program,or must work.Your Group is required to inform Subscribers employment contract(unless the Internal Revenue of its eligibility requirements. Service considers you self-employed) Service Area eligibility requirements Eligibility as a Dependent The"Definitions"section describes our Service Area and how it may change. Enrolling a Dependent Dependent eligibility is subject to your Group's Subscribers must live or work inside our Service Area at eligibility requirements,which are not described in this the time they enroll.If after enrollment the Subscriber no EOC.You can obtain your Group's eligibility longer lives or works inside our Service Area,the requirements directly from your Group.If you are a Subscriber can continue membership unless(1)they live Subscriber under this EOC and if your Group allows inside or move to the service area of another Region and enrollment of Dependents,Health Plan allows the do not work inside our Service Area,or(2)your Group following persons to enroll as your Dependents under does not allow continued enrollment of Subscribers who this EOC: do not live or work inside our Service Area. • Your Spouse • Your or your Spouse's Dependent children,who meet Dependent children of the Subscriber or of the the requirements described under the limit of Subscriber's Spouse may live anywhere inside or outside Dependent children,"if they are any of the following: our Service Area. Other Dependents may live anywhere, except that they are not eligible to enroll or to continue ♦ biological children enrollment if they live in or move to the service area of ♦ stepchildren another Region. ♦ adopted children ♦ children placed with you for adoption If you are not eligible to continue enrollment because you live in or move to the service area of another ♦ foster children if you or your Spouse have the Region,please contact your Group to learn about your legal authority to direct their care Group health care options: ♦ children for whom you or your Spouse is the • Regions outside California.You maybe able to court-appointed guardian(or was when the childreached age 18) enroll in the service area of another Region if there is an agreement between your Group and that Region, • Children whose parent is a Dependent child under but the plan,including coverage,premiums,and your family coverage(including adopted children and eligibility requirements,might not be the same as children placed with your Dependent child for under this EOC adoption or foster care),if they meet all of the • Southern California Region's service area.Your following requirements: Group may have an arrangement with us that permits ♦ they are not married and do not have a domestic membership in the Southern California Region,but partner(for the purposes of this requirement only, the plan,including coverage,premiums,and "domestic partner"means someone who is eligibility requirements,might not be the same as registered and legally recognized as a domestic under this EOC.All terms and conditions in your partner by California) application for enrollment in the Northern California ♦ they meet the requirements described under"Age Region,including the Arbitration Agreement,will limit of Dependent children" continue to apply if the Subscriber does not submit a new enrollment form Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 27 ♦ they receive all of their support and maintenance us documentation of the Dependent's incapacity and from you or your Spouse dependency within 60 days of receipt of our notice ♦ they permanently reside with you or your Spouse and we determine that the Dependent is eligible as a disabled dependent. If the Subscriber provides us this If you have a baby documentation in the specified time period and we do If you have a baby while enrolled under this EOC,the not make a determination about eligibility before the baby is not automatically enrolled in this plan.The termination date,coverage will continue until we Subscriber must request enrollment of the baby as make a determination.If we determine that the described under"Special enrollment"in the"How to Dependent does not meet the eligibility requirements Enroll and When Coverage Begins"section below.If the as a disabled dependent,we will notify the Subscriber Subscriber does not request enrollment within this that the Dependent is not eligible and let the special enrollment period,the baby will only be covered Subscriber know the membership termination date.If under this plan for 31 days(including the date of birth). we determine that the Dependent is eligible as a disabled dependent,there will be no lapse in Age limit of Dependent children coverage.Also,starting two years after the date that Children must be under age 26 as of the effective date of the Dependent reached the age limit,the Subscriber this EOC to enroll as a Dependent under your plan. must provide us documentation of the Dependent's incapacity and dependency annually within 60 days after we request it so that we can determine if the Dependent children are eligible to remain on the plan Dependent continues to be eligible as a disabled through the end of the month in which they reach the age dependent limit. • If the child is not a Member because you are changing Dependent children of the Subscriber or Spouse coverage,you must give us proof,within 60 days (including adopted children and children placed with you after we request it,of the child's incapacity and for adoption,but not including children placed with you dependency as well as proof of the child's coverage for foster care)who reach the age limit may continue under your prior coverage.In the future,you must coverage under this EOC if all of the following provide proof of the child's continued incapacity and conditions are met: dependency within 60 days after you receive our request,but not more frequently than annually • They meet all requirements to be a Dependent except for the age limit If the Subscriber is enrolled under a Kaiser • Your Group permits enrollment of Dependents Permanente Medicare plan • They are incapable of self-sustaining employment The dependent eligibility rules described in the because of a physically-or mentally-disabling injury, "Eligibility as a Dependent"section also apply if you are illness,or condition that occurred before they reached a subscriber under a Kaiser Permanente Medicare plan the age limit for Dependents offered by your Group(please ask your Group about your membership options).All of your dependents who • They receive 50 percent or more of their support and are enrolled under this or any other non-Medicare maintenance from you or your Spouse evidence of coverage offered by your Group must be • If requested,you give us proof of their incapacity and enrolled under the same non-Medicare evidence of dependency within 60 days after receiving our request coverage.A"non-Medicare"evidence of coverage is one (see"Disabled Dependent certification"below in this that does not require members to have Medicare. "Eligibility as a Dependent"section) Persons barred from enrolling Disabled Dependent certification You cannot enroll if you have had your entitlement to Proof may be required for a Dependent to be eligible to receive Services through Health Plan terminated for continue coverage as a disabled Dependent.If we request cause. it,the Subscriber must provide us documentation of the dependent's incapacity and dependency as follows: Members with Medicare and retirees • If the child is a Member,we will send the Subscriber This EOC is not intended for most Medicare a notice of the Dependent's membership termination beneficiaries and some Groups do not offer coverage to due to loss of eligibility at least 90 days before the retirees.If,during the term of this EOC,you are(or date coverage will end due to reaching the age limit. become)eligible for Medicare or you retire,please ask The Dependent's membership will terminate as your Group about your membership options as follows: described in our notice unless the Subscriber provides Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 28 • If a Subscriber who has Medicare Part B retires and Advantage plan applicable when Medicare is secondary the Subscriber's Group has a Kaiser Permanente may also enroll in that plan if it is available. These Senior Advantage plan for retirees,the Subscriber Members receive the benefits and coverage described in should enroll in the plan if eligible this EOC and the Kaiser Permanente Senior Advantage • If the Subscriber has dependents who have Medicare evidence of coverage applicable when Medicare is and your Group has a Kaiser Permanente Senior secondary. Advantage plan(or of one our other plans that require members to have Medicare),the Subscriber may be Medicare late enrollment penalties able to enroll them as dependents under that plan If you become eligible for Medicare Part B and do not enroll,Medicare may require you to pay a late • If the Subscriber retires and your Group does not enrollment penalty if you later enroll in Medicare Part B. offer coverage to retirees,you may be eligible to However,if you delay enrollment in Part B because you continue membership as described in the or your spouse are still working and have coverage "Continuation of Membership"section through an employer group health plan,you may not • If federal law requires that your Group's health care have to pay the penalty.Also,if you are(or become) coverage be primary and Medicare coverage be eligible for Medicare and go without creditable secondary,your coverage under this EOC will be the prescription drug coverage(drug coverage that is at least same as it would be if you had not become eligible for as good as the standard Medicare Part D prescription Medicare.However,you may also be eligible to drug coverage)for a continuous period of 63 days or enroll in Kaiser Permanente Senior Advantage more,you may have to pay a late enrollment penalty if through your Group if you have Medicare Part B you later sign up for Medicare prescription drug • If you are(or become)eligible for Medicare and are coverage.If you are(or become)eligible for Medicare, in a class of beneficiaries for which your Group's your Group is responsible for informing you about health care coverage is secondary to Medicare,you whether your drug coverage under this EOC is creditable should consider enrollment in Kaiser Permanente prescription drug coverage at the times required by the Senior Advantage through your Group if you are Centers for Medicare&Medicaid Services and upon eligible your request. • If none of the above applies to you and you are eligible for Medicare or you retire,please ask your How to Enroll and When Coverage Group about your membership options Begins Note:If you are enrolled in a Medicare plan and lose Your Group is required to inform you when you are Medicare eligibility,you may be able to enroll under this eligible to enroll and what your effective date of EOC if permitted by your Group(please ask your Group coverage is.If you are eligible to enroll as described for details). under"Who Is Eligible"in this"Premiums,Eligibility, and Enrollment"section,enrollment is permitted as When Medicare is primary described below and membership begins at the beginning Your Group's Premiums may increase if you are(or (12:00 a.m.)of the effective date of coverage indicated become)eligible for Medicare Part A or B as primary below,except that your Group may have additional coverage,and you are not enrolled through your Group requirements,which allow enrollment in other situations. in Kaiser Permanente Senior Advantage for any reason (even if you are not eligible to enroll or the plan is not If you are eligible to be a Dependent under this EOC but available to you). the subscriber in your family is enrolled under a Kaiser Permanente Senior Advantage evidence of coverage When Medicare is secondary offered by your Group,the rules for enrollment of Medicare is the primary coverage except when federal Dependents in this"How to Enroll and When Coverage law requires that your Group's health care coverage be Begins"section apply,not the rules for enrollment of primary and Medicare coverage be secondary.Members dependents in the subscriber's evidence of coverage. who have Medicare when Medicare is secondary by law are subject to the same Premiums and receive the same New employees benefits as Members who are under age 65 and do not When your Group informs you that you are eligible to have Medicare.In addition,any such Member for whom enroll as a Subscriber,you may enroll yourself and any Medicare is secondary by law and who meets the eligible Dependents by submitting a Health Plan— eligibility requirements for the Kaiser Permanente Senior approved enrollment application to your Group within 31 days. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 29 Effective date of coverage Subscriber.Enrollments of newly acquired Dependent The effective date of coverage for new employees and children are effective as follows: their eligible family Dependents is determined by your • Enrollments due to birth are effective on the date of Group in accord with waiting period requirements in birth state and federal law.Your Group is required to inform the Subscriber of the date your membership becomes • Enrollments due to adoption are effective on the date effective.For example,if the hire date of an otherwise- of adoption eligible employee is January 19,the waiting period • Enrollments due to placement for adoption or foster begins on January 19 and the effective date of coverage care are effective on the date you or your Spouse have cannot be any later than April 19.Note:If the effective newly assumed a legal right to control health care date of your Group's coverage is always on the first day of the month,in this example the effective date cannot be Special enrollment due to loss of other coverage any later than April 1. You may enroll as a Subscriber(along with any eligible Dependents),and existing Subscribers may add eligible Open enrollment Dependents,if all of the following are true: You may enroll as a Subscriber(along with any eligible • The Subscriber or at least one of the Dependents had Dependents),and existing Subscribers may add eligible other coverage when they previously declined all Dependents,by submitting a Health Plan—approved enrollment application to your Group during your coverage through your Group Group's open enrollment period.Your Group will let you • The loss of the other coverage is due to one of the know when the open enrollment period begins and ends following: and the effective date of coverage. ♦ exhaustion of COBRA coverage ♦ termination of employer contributions for non- Special enrollment COBRA coverage If you do not enroll when you are first eligible and later ♦ loss of eligibility for non-COBRA coverage,but want to enroll,you can enroll only during open not termination for cause or termination from an enrollment unless one of the following is true: individual(nongroup)plan for nonpayment.For • You become eligible because you experience a example,this loss of eligibility may be due to legal qualifying event(sometimes called a"triggering separation or divorce,moving out of the plan's event")as described in this"Special enrollment" service area,reaching the age limit for dependent section children,or the subscriber's death,termination of • You did not enroll in any coverage offered by your employment,or reduction in hours of employment Group when you were first eligible and your Group ♦ loss of eligibility(but not termination for cause) does not give us a written statement that verifies you for coverage through Covered California, signed a document that explained restrictions about Medicaid coverage(known as Medi-Cal in enrolling in the future.The effective date of an California),Children's Health Insurance Program enrollment resulting from this provision is no later coverage,or Medi-Cal Access Program coverage than the first day of the month following the date your ♦ reaching a lifetime maximum on all benefits Group receives a Health Plan—approved enrollment or change of enrollment application from the Subscriber Note:If you are enrolling yourself as a Subscriber along with at least one eligible Dependent,only one of you Special enrollment due to new Dependents must meet the requirements stated above. You may enroll as a Subscriber(along with eligible Dependents),and existing Subscribers may add eligible To request enrollment,the Subscriber must submit a Dependents,within 30 days after marriage,establishment Health Plan—approved enrollment or change of of domestic partnership,birth,adoption,placement for enrollment application to your Group within 30 days adoption,or placement for foster care by submitting to after loss of other coverage,except that the timeframe for your Group a Health Plan—approved enrollment submitting the application is 60 days if you are application. requesting enrollment due to loss of eligibility for coverage through Covered California,Medicaid, The effective date of an enrollment resulting from Children's Health Insurance Program,or Medi-Cal marriage or establishment of domestic partnership is no Access Program coverage.The effective date of an later than the first day of the month following the date enrollment resulting from loss of other coverage is no your Group receives an enrollment application from the later than the first day of the month following the date Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 30 your Group receives an enrollment or change of • You are a Dependent of someone who becomes enrollment application from the Subscriber. entitled to Medicare Special enrollment due to court or administrative order • You become divorced or legally separated Within 30 days after the date of a court or administrative • You are a Dependent of someone who dies order requiring a Subscriber to provide health care • A Health Benefit Exchange(such as Covered coverage for a Spouse or child who meets the eligibility California)determines that one of the following requirements as a Dependent,the Subscriber may add the occurred because of misconduct on the part of a non- Spouse or child as a Dependent by submitting to your Exchange entity that provided enrollment assistance Group a Health Plan—approved enrollment or change of or conducted enrollment activities: enrollment application. ♦ a qualified individual was not enrolled in a qualified health plan The effective date of coverage resulting from a court or ♦ a qualified individual was not enrolled in the administrative order is the first of the month following qualified health plan that the individual selected the date we receive the enrollment request,unless your Group specifies a different effective date(if your Group ♦ a qualified individual is eligible for,but is not specifies a different effective date,the effective date receiving,advance payments of the premium tax cannot be earlier than the date of the order). credit or cost share reductions Special enrollment due to eligibility for premium To request special enrollment,you must submit a Health assistance Plan-approved enrollment application to your Group You may enroll as a Subscriber(along with eligible within 30 days after loss of other coverage.You may be Dependents),and existing Subscribers may add eligible required to provide documentation that you have Dependents,if you or a dependent become eligible for experienced a qualifying event.Membership becomes premium assistance through the Medi-Cal program. effective either on the first day of the next month(for Premium assistance is when the Medi-Cal program pays applications that are received by the fifteenth day of a all or part of premiums for employer group coverage for month)or on the first day of the month following the a Medi-Cal beneficiary.To request enrollment in your next month(for applications that are received after the Group's health care coverage,the Subscriber must fifteenth day of a month). submit a Health Plan—approved enrollment or change of enrollment application to your Group within 60 days Note:If you are enrolling as a Subscriber along with at after you or a dependent become eligible for premium least one eligible Dependent,only one of you must meet assistance.Please contact the California Department of one of the requirements stated above. Health Care Services to find out if premium assistance is available and the eligibility requirements. How to Obtain Services Special enrollment due to reemployment after military service As a Member,you are selecting our medical care If you terminated your health care coverage because you program to provide your health care.You must receive were called to active duty in the military service,you all covered care from Plan Providers inside our Service may be able to reenroll in your Group's health plan if Area,except as described in the sections listed below for required by state or federal law.Please ask your Group the following Services: for more information. • Authorized referrals as described under"Getting a Other special enrollment events Referral"in this"How to Obtain Services"section You may enroll as a Subscriber(along with any eligible • Covered Services received outside of your Home Dependents)if you or your Dependents were not Region Service Area as described under"Receiving previously enrolled,and existing Subscribers may add Care Outside of Your Home Region Service Area"in eligible Dependents not previously enrolled,if any of the this"How to Obtain Services"section following are true: • COVID-19 Services as described under"Outpatient • You lose employment for a reason other than gross Imaging,Laboratory,and Other Diagnostic and misconduct Treatment Services,""Outpatient Prescription Drugs, • Your employment hours are reduced Supplies,and Supplements,"and"Preventive Services"in the`Benefits"section Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 31 • Emergency ambulance Services as described under days a week.Here are some of the ways they can help "Ambulance Services"in the"Benefits"section you: • Emergency Services,Post-Stabilization Care,and • They can answer questions about a health concern, Out-of-Area Urgent Care as described in the and instruct you on self-care at home if appropriate "Emergency Services and Urgent Care"section • They can advise you about whether you should get • Hospice care as described under"Hospice Care"in medical care,and how and where to get care(for the`Benefits"section example,if you are not sure whether your condition is an Emergency Medical Condition,they can help you Our medical care program gives you access to all of the decide whether you need Emergency Services or covered Services you may need,such as routine care Urgent Care,and how and where to get that care) with your own personal Plan Physician,hospital • They can tell you what to do if you need care and a Services,laboratory and pharmacy Services,Emergency Plan Medical Office is closed or you are outside our Services,Urgent Care,and other benefits described in Service Area this EOC. You can reach one of these licensed health care Routine Care professionals by calling the appointment or advice phone number(for phone numbers,refer to our Provider If you need the following Services,you should schedule Directory or call Member Services).When you call,a an appointment: trained support person may ask you questions to help determine how to direct your call. • Preventive Services • Periodic follow-up care(regularly scheduled follow- up care,such as visits to monitor a chronic condition) Your Personal Plan Physician • Other care that is not Urgent Care Personal Plan Physicians provide primary care and play an important role in coordinating care,including hospital To request a non-urgent appointment,you can call your stays and referrals to specialists. local Plan Facility or request the appointment online.For appointment phone numbers,refer to our Provider We encourage you to choose a personal Plan Physician. Directory or call Member Services.To request an You may choose any available personal Plan Physician. appointment online,go to our website at kp•org. Parents may choose a pediatrician as the personal Plan Physician for their child. Most personal Plan Physicians are Primary Care Physicians(generalists in internal Urgent Care medicine,pediatrics,or family practice,or specialists in An Urgent Care need is one that requires prompt medical obstetrics/gynecology whom the Medical Group attention but is not an Emergency Medical Condition.If designates as Primary Care Physicians). Some specialists you think you may need Urgent Care,call the who are not designated as Primary Care Physicians but appropriate appointment or advice phone number at a who also provide primary care may be available as Plan Facility.For phone numbers,refer to our Provider personal Plan Physicians.For example,some specialists Directory or call Member Services. in internal medicine and obstetrics/gynecology who are not designated as Primary Care Physicians may be For information about Out-of-Area Urgent Care,refer to available as personal Plan Physicians.However,if you "Urgent Care"in the"Emergency Services and Urgent choose a specialist who is not designated as a Primary Care"section. Care Physician as your personal Plan Physician,the Cost Share for a Physician Specialist Visit will apply to all visits with the specialist except for routine preventive Not Sure What Kind of Care You Need? visits listed under"Preventive Services"in the "Benefits"section. Sometimes it's difficult to know what kind of care you need,so we have licensed health care professionals To learn how to select or change to a different personal available to assist you by phone 24 hours a day,seven Plan Physician,visit our website at kp•org or call Member Services.Refer to our Provider Directory for a list of physicians that are available as Primary Care Physicians.The directory is updated periodically.The availability of Primary Care Physicians may change.If Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 32 you have questions,please call Member Services.You be covered("prior authorization"means that the Medical can change your personal Plan Physician at any time for Group must approve the Services in advance): any reason. • Durable medical equipment • Ostomy and urological supplies Getting a Referral . Services not available from Plan Providers Referrals to Plan Providers • Transplants A Plan Physician must refer you before you can receive care from specialists,such as specialists in surgery, Utilization Management("UM")is a process that orthopedics,cardiology,oncology,dermatology,and determines whether a Service recommended by your physical,occupational,and speech therapies.Also,a treating provider is Medically Necessary for you.Prior Plan Physician must refer you before you can get authorization is a UM process that determines whether Behavioral Health Treatment for Autism Spectrum the requested services are Medically Necessary before Disorder covered under"Mental Health Services"in the care is provided.If it is Medically Necessary,then you "Benefits"section.However,you do not need a referral will receive authorization to obtain that care in a or prior authorization to receive most care from any of clinically appropriate place consistent with the terms of the following Plan Providers: your health coverage.Decisions regarding requests for • Your personal Plan Physician authorization will be made only by licensed physicians or other appropriately licensed medical professionals. • Generalists in internal medicine,pediatrics,and family practice For the complete list of Services that require prior • Specialists in optometry,mental health Services, authorization,and the criteria that are used to make substance use disorder treatment,and authorization decisions,please visit our website at obstetrics/gynecology kp.ore/UM or call Member Services to request a printed copy. A Plan Physician must refer you before you can get care from a specialist in urology except that you do not need a Refer to"Post-Stabilization Care"under"Emergency referral to receive Services related to sexual or Services"in the"Emergency Services and Urgent Care" reproductive health,such as a vasectomy. section for authorization requirements that apply to Post- Stabilization Care from Non—Plan Providers. Although a referral or prior authorization is not required to receive most care from these providers,a referral may Additional information about prior authorization for be required in the following situations: durable medical equipment and ostomy and urological • The provider may have to get prior authorization for supplies certain Services in accord with"Medical Group The prior authorization process for durable medical authorization procedure for certain referrals"in this equipment and ostomy and urological supplies includes "Getting a Referral"section the use of formulary guidelines.These guidelines were developed by a multidisciplinary clinical and operational • The provider may have to refer you to a specialist work group with review and input from Plan Physicians who has a clinical background related to your illness and medical professionals with clinical expertise. The or condition formulary guidelines are periodically updated to keep pace with changes in medical technology and clinical Standing referrals practice. If a Plan Physician refers you to a specialist,the referral will be for a specific treatment plan.Your treatment plan If your Plan Physician prescribes one of these items,they may include a standing referral if ongoing care from the will submit a written referral in accord with the UM specialist is prescribed.For example,if you have a life- process described in this"Medical Group authorization threatening,degenerative,or disabling condition,you can procedure for certain referrals"section. If the formulary get a standing referral to a specialist if ongoing care from guidelines do not specify that the prescribed item is the specialist is required. appropriate for your medical condition,the referral will be submitted to the Medical Group's designee Plan Medical Group authorization procedure for Physician,who will make an authorization decision as certain referrals described under"Medical Group's decision time frames" The following are examples of Services that require prior in this"Medical Group authorization procedure for authorization by the Medical Group for the Services to certain referrals"section. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 33 Additional information about utilization review for limited coverage of that Non—Plan Provider's determination criteria for mental health Services or Services. substance use disorder treatment Utilization review determination criteria and any Terminated provider education program materials for individuals making If you are currently receiving covered Services in one of authorization decisions related to mental health Services the cases listed below under"Eligibility"from a Plan or substance use disorder treatment are available at Hospital or a Plan Physician(or certain other providers) kp•or2 at no cost. when our contract with the provider ends(for reasons other than medical disciplinary cause or criminal Medical Group's decision time frames activity),you may be eligible for limited coverage of that The applicable Medical Group designee will make the terminated provider's Services. authorization decision within the time frame appropriate for your condition,but no later than five business days Eligibility after receiving all of the information(including The cases that are subject to this completion of Services additional examination and test results)reasonably provision are: necessary to make the decision,except that decisions . Acute conditions,which are medical conditions that about urgent Services will be made no later than 72 involve a sudden onset of symptoms due to an illness, hours after receipt of the information reasonably injury,or other medical problem that requires prompt necessary to make the decision.If the Medical Group medical attention and has a limited duration.We may needs more time to make the decision because it doesn't cover these Services until the acute condition ends have information reasonably necessary to make the decision,or because it has requested consultation by a • Serious chronic conditions until the earlier of(1) 12 particular specialist,you and your treating physician will months from your effective date of coverage if you be informed about the additional information,testing,or are a new Member,(2) 12 months from the specialist that is needed,and the date that the Medical termination date of the terminated provider,or(3)the Group expects to make a decision. first day after a course of treatment is complete when it would be safe to transfer your care to a Plan Your treating physician will be informed of the decision Provider,as determined by Kaiser Permanente after within 24 hours after the decision is made.If the Services consultation with the Member and Non—Plan Provider are authorized,your physician will be informed of the and consistent with good professional practice. scope of the authorized Services.If the Medical Group Serious chronic conditions are illnesses or other does not authorize all of the Services,Health Plan will medical conditions that are serious,if one of the send you a written decision and explanation within two following is true about the condition: business days after the decision is made.Any written ♦ it persists without full cure criteria that the Medical Group uses to make the decision ♦ it worsens over an extended period of time to authorize,modify,delay,or deny the request for authorization will be made available to you upon request. ♦ it requires ongoing treatment maintain remission or prevent deterioration If the Medical Group does not authorize all of the • Pregnancy and immediate postpartum care.We may Services requested and you want to appeal the decision, cover these Services for the duration of the pregnancy you can file a grievance as described under"Grievances" and immediate postpartum care in the"Dispute Resolution"section. o Mental health conditions in pregnant Members that occur,or can impact the Member,during pregnancy For these referral Services,you pay the Cost Share or during the postpartum period including,but not required for Services provided by a Plan Provider as limited to,postpartum depression.We may cover described in this EOC. completion of these Services for up to 12 months from the mental health diagnosis or from the end of Completion of Services from Non—Plan pregnancy,whichever occurs later Providers • Terminal illnesses,which are incurable or irreversible New Member illnesses that have a high probability of causing death If you are currently receiving Services from a Non—Plan within a year or less.We may cover completion of Provider in one of the cases listed below under these Services for the duration of the illness "Eligibility"and your prior plan's coverage of the • Children under age 3.We may cover completion of provider's Services has ended or will end when your these Services until the earlier of(1) 12 months from coverage with us becomes effective,you may be eligible Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 34 the child's effective date of coverage if the child is a Travel and Lodging for Certain Services new Member,(2) 12 months from the termination date of the terminated provider,or(3)the child's third The following are examples of when we will arrange or birthday provide reimbursement for certain travel and lodging • Surgery or another procedure that is documented as expenses in accord with our Travel and Lodging part of a course of treatment and has been Program Description: recommended and documented by the provider to • If Medical Group refers you to a provider that is more occur within 180 days of your effective date of than 50 miles from where you live for certain coverage if you are a new Member or within 180 days specialty Services such as bariatric surgery,complex of the termination date of the terminated provider thoracic surgery,transplant nephrectomy,or inpatient chemotherapy for leukemia and lymphoma To qualify for this completion of Services coverage,all . If Medical Group refers you to a provider that is of the following requirements must be met: outside your Home Region Service Area for certain • Your Health Plan coverage is in effect on the date you specialty Services such as a transplant or transgender receive the Services surgery • For new Members,your prior plan's coverage of the • If you are outside of California and you need an provider's Services has ended or will end when your abortion on an emergency or urgent basis,and the coverage with us becomes effective abortion can't be obtained in a timely manner due to a • You are receiving Services in one of the cases listed near total or total ban on health care providers' ability above from a Non—Plan Provider on your effective to provide such Services date of coverage if you are a new Member,or from the terminated Plan Provider on the provider's For the complete list of specialty Services for which we termination date will arrange or provide reimbursement for travel and lodging expenses,the amount of reimbursement, • For new Members,when you enrolled in Health Plan, limitations and exclusions,and how to request you did not have the option to continue with your reimbursement,refer to the Travel and Lodging Program previous health plan or to choose another plan Description.The Travel and Lodging Program (including an out-of-network option)that would cover Description is available online at kp.org/specialty- the Services of your current Non—Plan Provider care/travel-reimbursements or by calling Member • The provider agrees to our standard contractual terms Services. and conditions, such as conditions pertaining to payment and to providing Services inside our Service Second Opinions Area(the requirement that the provider agree to providing Services inside our Service Area doesn't If you want a second opinion,you can ask Member apply if you were receiving covered Services from the Services to help you arrange one with a Plan Physician provider outside our Service Area when the who is an appropriately qualified medical professional provider's contract terminated) for your condition.If there isn't a Plan Physician who is • The Services to be provided to you would be covered an appropriately qualified medical professional for your Services under this EOC if provided by a Plan condition,Member Services will help you arrange a Provider consultation with a Non—Plan Physician for a second • You request completion of Services within 30 days opinion.For purposes of this"Second Opinions" (or as soon as reasonably possible)from your provision,an"appropriately qualified medical effective date of coverage if you are a new Member professional"is a physician who is acting within their or from the termination date of the Plan Provider scope of practice and who possesses a clinical background,including training and expertise,related to For completion of Services,you pay the Cost Share the illness or condition associated with the request for a required for Services provided by a Plan Provider as second medical opinion. described in this EOC. Here are some examples of when a second opinion may More information be provided or authorized: For more information about this provision,or to request • Your Plan Physician has recommended a procedure the Services or a copy of our"Completion of Covered and you are unsure about whether the procedure is Services"policy,please call Member Services. reasonable or necessary Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 35 • You question a diagnosis or plan of care for a to receive Services from a terminated provider;refer to condition that threatens substantial impairment or loss "Completion of Services from Non—Plan Providers" of life,limb,or bodily functions under"Getting a Referral"in this"How to Obtain • The clinical indications are not clear or are complex Services"section. and confusing Provider groups and hospitals • A diagnosis is in doubt due to conflicting test results If you are assigned to a provider group or hospital whose • The Plan Physician is unable to diagnose the contract with us terminates,or if you live within 15 miles condition of a hospital whose contract with us terminates,we will • The treatment plan in progress is not improving your give you written notice at least 60 days before the medical condition within an appropriate period of termination(or as soon as reasonably possible). time,given the diagnosis and plan of care • You have concerns about the diagnosis or plan of care Receiving Care Outside of Your Home Region Service Area An authorization or denial of your request for a second opinion will be provided in an expeditious manner,as For information about your coverage when you are away appropriate for your condition.If your request for a from home,visit our website at kp.org/travel.You can second opinion is denied,you will be notified in writing also call the Away from Home Travel Line at of the reasons for the denial and of your right to file a 1-951-268-3900 24 hours a day,seven days a week grievance as described under"Grievances"in the (closed holidays). "Dispute Resolution"section. Receiving care in another Kaiser Permanente For these referral Services,you pay the Cost Share service area required for Services provided by a Plan Provider as If you are visiting in another Kaiser Permanente service described in this EOC. area,you may receive certain covered Services from designated providers in that other Kaiser Permanente service area,subject to exclusions,limitations,prior Contracts with Plan Providers authorization or approval requirements,and reductions. How Plan Providers are paid For more information about receiving covered Services in another Kaiser Permanente service area,including Health Plan and Plan Providers are independent provider and facility locations,please visit kp.orE/travel contractors.Plan Providers are paid in a number of ways, or call our Away from Home Travel Line at 1-951-268- such as salary,capitation,per diem rates,case rates,fee 3900 24 hours a day,seven days a week(closed for service,and incentive payments. To learn more about holidays). how Plan Physicians are paid to provide or arrange medical and hospital Services for Members,please visit For covered Services you receive in another Kaiser our website at kp.or2 or call Member Services. Permanente service area,you pay the Cost Share required for Services provided by a Plan Provider inside Financial liability our Service Area as described in this EOC. Our contracts with Plan Providers provide that you are not liable for any amounts we owe.However,you may Receiving care outside of any Kaiser have to pay the full price of noncovered Services you Permanente service area obtain from Plan Providers or Non—Plan Providers. If you are traveling outside of any Kaiser Permanente service area,we cover Emergency Services and Urgent When you are referred to a Plan Provider for covered Care as described in the"Emergency Services and Services,you pay the Cost Share required for Services Urgent Care"section. from that provider as described in this EOC. Termination of a Plan Provider's contract Your ID Card If our contract with any Plan Provider terminates while you are under the care of that provider,we will retain Each Member's Kaiser Permanente ID card has a financial responsibility for the covered Services you medical record number on it,which you will need when receive from that provider until we make arrangements you call for advice,make an appointment,or go to a for the Services to be provided by another Plan Provider provider for covered care.When you get care,please and notify you of the arrangements.You may be eligible bring your ID card and a photo ID.Your medical record Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 36 number is used to identify your medical records and Timely access to telephone assistance membership information.Your medical record number DMHC developed the following standards for answering should never change.Please call Member Services if we telephone questions: ever inadvertently issue you more than one medical . For telephone advice about whether you need to get record number or if you need to replace your ID card. care and where to get care:within 30 minutes,24 Your ID card is for identification only.To receive hours a day,seven days a week covered Services,you must be a current Member. • For general questions:within 10 minutes during Anyone who is not a Member will be billed as a non- normal business hours Member for any Services they receive.If you let someone else use your ID card,we may keep your ID Interpreter services card and terminate your membership as described under If you need interpreter services when you call us or when "Termination for Cause"in the"Termination of you get covered Services,please let us know.Interpreter Membership"section. services,including sign language,are available during all business hours at no cost to you.For more information on the interpreter services we offer,please call Member Timely Access to Care Services. Standards for appointment availability Access to mental health Services and substance The California Department of Managed Health Care use disorder treatment ("DMHC")developed the following standards for appointment availability. This information can help you State law requires evidence of coverage documents to include the following notice: know what to expect when you request an appointment. • Urgent care appointment:within 48 hours You have a right to receive timely and • Routine(non-urgent)primary care appointment geographically accessible Mental (including adult/internal medicine,pediatrics,and Health/Substance Use Disorder(MH/SUD) family medicine):within 10 business days services when you need them. If Health Plan • Routine(non-urgent)specialty care appointment with fails to arrange those services for you with a physician:within 15 business days an appropriate provider who is in the health • Routine(non-urgent)mental health care or substance plan's network,the health plan must cover use disorder treatment appointment with a practitioner other than a physician:within 10 business days and arrange needed services for you from an out-of-network provider. If that happens, • Follow-up(non-urgent)mental health care or substance use disorder treatment appointment with a you do not have to pay anything other than practitioner other than a physician,for those your ordinary in-network cost-sharing. undergoing a course of treatment for an ongoing mental health or substance use disorder condition: If you do not need the services urgently, within 10 business days your health plan must offer an appointment If you prefer to wait for a later appointment that will for you that is no more than 10 business days better fit your schedule or to see the Plan Provider of from when you requested the services from your choice,we will respect your preference.In some the health plan. If you urgently need the cases,your wait may be longer than the time listed if a services,your health plan must offer you an licensed health care professional decides that a later appointment within 48 hours of your request appointment won't have a negative effect on your health. (if the health plan does not require prior The standards for appointment availability do not apply authorization for the appointment) or within to Preventive Services.Your Plan Provider may 96 hours (if the health plan does require recommend a specific schedule for Preventive Services, prior authorization). depending on your needs.Except as specified above for mental health care and substance use disorder treatment, If your health plan does not arrange for you the standards also do not apply to periodic follow-up care to receive services within these timeframes for ongoing conditions or standing referrals to and within geographic access standards,you specialists. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 37 can arrange to receive services from any Visit Member Services office at a Plan Facility(for licensed provider, even if the provider is not addresses,refer to our Provider Directory or in your health plan's network. To be covered call Member Services) by your health plan,your first appointment Write Member Services office at a Plan Facility(for with the provider must be within 90 addresses,refer to our Provider Directory or calendar days of the date you first asked the call Member Services) plan for the MH/SUD services. Website kp.org If you have questions about how to obtain Cost Share estimates For information about estimates,see"Getting an MH/SUD services or are having difficulty estimate of your Cost Share"under"Your Cost Share"in obtaining services you can: 1) call your the`Benefits"section. health plan at the telephone number on the back of your health plan identification card; 2) call the California Department of Plan Facilities I Managed Care's Help Center at 1-888-466- 2219; or 3) contact the California Plan Medical Offices and Plan Hospitals are listed in the Department of Managed Health Care Provider Directory for your Home Region.The directory through its website at describes the types of covered Services that are available from each Plan Facility,because some facilities provide http://www.healthhelp.ca.2ov to request only specific types of covered Services.This directory is assistance in obtaining MH/SUD services. available on our website at kp.om/facilities.To obtain a printed copy,call Member Services.The directory is updated periodically.The availability of Plan Facilities Getting Assistance may change. If you have questions,please call Member Services. We want you to be satisfied with the health care you receive from Kaiser Permanente.If you have any At most of our Plan Facilities,you can usually receive all questions or concerns,please discuss them with your of the covered Services you need,including specialty personal Plan Physician or with other Plan Providers care,pharmacy,and lab work.You are not restricted to a who are treating you.They are committed to your particular Plan Facility,and we encourage you to use the satisfaction and want to help you with your questions. facility that will be most convenient for you: Member Services • All Plan Hospitals provide inpatient Services and are Member Services representatives can answer any open 24 hours a day, seven days a week questions you have about your benefits,available • Emergency Services are available from Plan Hospital Services,and the facilities where you can receive care. emergency departments(for emergency department For example,they can explain the following: locations,refer to our Provider Directory or call • Your Health Plan benefits Member Services) • How to make your first medical appointment • Same-day Urgent Care appointments are available at many locations(for Urgent Care locations,refer to • What to do if you move our Provider Directory or call Member Services) • How to replace your Kaiser Permanente ID card . Many Plan Medical Offices have evening and weekend appointments You can reach Member Services in the following ways: o Many Plan Facilities have a Member Services office Call 1-800-464-4000(English and more than 150 (for locations,refer to our Provider Directory or call languages using interpreter services) Member Services) 1-800-788-0616(Spanish) 1-800-757-7585(Chinese dialects) Note: State law requires evidence of coverage documents TTY users call 711 to include the following notice: 24 hours a day,seven days a week(closed Some hospitals and other providers do not holidays) provide one or more of the following services Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 38 that may be covered under your plan Cigna Healthcare PPO Network facility for an contract and that you or your family Emergency Medical Condition,Cigna Payer member might need: family planning; Solutions is responsible for authorizing any Post- Stabilization Care contraceptive services,including emergency Post-Stabilization Care authorization from other contraception; sterilization,including tubal Non-Plan Providers(including Cigna Healthcare ligation at the time of labor and delivery; PPO Network facilities inside a Kaiser infertility treatments; or abortion. You Permanente State): To request prior authorization, should obtain more information before you the Non—Plan Provider must call 1-800-225-8883 or enroll. Call your prospective doctor, medical the notification phone number on your Kaiser group,independent practice association, or Permanente ID card before you receive the care. We will discuss your condition with the Non—Plan clinic, or call Kaiser Permanente Member Provider.If we determine that you require Post- Services,to ensure that you can obtain the Stabilization Care and that this care is part of your health care services that you need. covered benefits,we will authorize your care from the Non—Plan Provider or arrange to have a Plan Provider Please be aware that if a Service is covered but not (or other designated provider)provide the care.If we available at a particular Plan Facility,we will make it decide to have a Plan Hospital,Plan Skilled Nursing available to you at another facility. Facility,or designated Non—Plan Provider provide your care,we may authorize special transportation services that are medically required to get you to the provider.This may include transportation that is Emergency Services and Urgent otherwise not covered Care Be sure to ask the Non—Plan Provider to tell you what Emergency Services care(including any transportation)we have authorized because we will not cover Post- If you have an Emergency Medical Condition,call 911 Stabilization Care or related transportation provided (where available)or go to the nearest emergency by Non—Plan Providers that has not been authorized. department.You do not need prior authorization for If you receive care from a Non—Plan Provider that we Emergency Services.When you have an Emergency have not authorized,you may have to pay the full cost Medical Condition,we cover Emergency Services you of that care.If you are admitted to a Non—Plan receive from Plan Providers or Non—Plan Providers Hospital or independent freestanding emergency anywhere in the world. department,please notify us as soon as possible by calling 1-800-225-8883 or the notification phone Emergency Services are available from Plan Hospital number on your ID card emergency departments 24 hours a day,seven days a week. When you receive Post-Stabilization Care from a Non- Plan Provider that is not a Cigna Healthcare PPO Post-Stabilization Care Network provider outside of California After you receive Emergency Services from Non-Plan When you receive Post-Stabilization Care from a Non- Providers and your condition is Stabilized,Post- Plan Provider inside of California,or from a Cigna Stabilization Care is considered Emergency Services Healthcare PPO Network facility outside of a Kaiser under federal law if either of the following are true: Permanente State • Y When you receive Emergency Services,we cover Post- Your treating physician determines that you are not Stabilization Care from a Non—Plan Provider only if able to travel using nonemergency transportation to prior authorization for the care is obtained as described an available Plan Provider located within a reasonable below,or if otherwise required by applicable law("prior travel distance,taking into account your medical authorization"means that the Services must be approved condition;or in advance). • Your treating physician,using appropriate medical • Post-Stabilization Care authorization at a Cigna judgment,determines that you are not in a condition Healthcare PPO Network facility outside of a to receive,and/or to provide consent to,the Non-Plan Kaiser Permanente State:If you are outside of a Provider's notice and consent form,in accordance Kaiser Permanente state and you were treated at a with applicable state informed consent law Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 39 If the Post-Stabilization Care is considered Emergency Urgent Care Services under the criteria above,prior authorization for Post-Stabilization Care at a Non-Plan Provider will not Inside our Service Area be required. An Urgent Care need is one that requires prompt medical attention but is not an Emergency Medical Condition.If If the Post-Stabilization Care is not considered you think you may need Urgent Care,call the Emergency Services,the Services are not covered unless appropriate appointment or advice phone number at a you have received prior authorization from Health Plan Plan Facility.For appointment and advice phone as described under"Post-Stabilization Care authorization numbers,refer to our Provider Directory or call Member from other Non-Plan Providers(including Cigna Services. Healthcare PPO Network facilities inside a Kaiser Permanente State)"above.Non-Plan Providers outside of Out-of-Area Urgent Care California may provide notice and seek your consent to If you need Urgent Care due to an unforeseen illness, waive your balance billing protections under the federal unforeseen injury,or unforeseen complication of an No Surprises Act,if such consent is permissible under existing condition(including pregnancy),we cover applicable state informed consent law.If you consent to Medically Necessary Services to prevent serious waive your balance billing protections and receive deterioration of your(or your unborn child's)health Services from the Non-Plan Provider,you will have to from a Non—Plan Provider if all of the following are true: pay the full cost of the Services. • You receive the Services from Non—Plan Providers Your Cost Share while you are temporarily outside our Service Area Your Cost Share for covered Emergency Services and • A reasonable person would have believed that your Post-Stabilization Care is described in the"Cost Share (or your unborn child's)health would seriously Summary"section of this EOC.Your Cost Share is the deteriorate if you delayed treatment until you returned same whether you receive the Services from a Plan to our Service Area Provider or a Non—Plan Provider.For example: • If you receive Emergency Services in the emergency You do not need prior authorization for Out-of-Area Urgent Care.We cover Out-of-Area Urgent Care you department of a Non—Plan Hospital,you pay the Cost receive from Non—Plan Providers if the Services would Share for an emergency department visit as described have been covered under this EOC if you had received in the"Cost Share Summary"under"Emergency them from Plan Providers. Services and Urgent Care" • If we gave prior authorization for inpatient Post- To obtain follow-up care from a Plan Provider,call the Stabilization Care in a Non—Plan Hospital,you pay appointment or advice phone number at a Plan Facility. the Cost Share for hospital inpatient Services as For phone numbers,refer to our Provider Directory or described in the"Cost Share Summary"under call Member Services.We do not cover follow-up care "Hospital inpatient Services" from Non—Plan Providers after you no longer need • If we gave prior authorization for durable medical Urgent Care,except for durable medical equipment equipment after discharge from a Non—Plan Hospital, covered under this EOC.For more information about you pay the Cost Share for durable medical durable medical equipment covered under this EOC,see equipment as described in the"Cost Share Summary" "Durable Medical Equipment("DME")for Home Use" under"Durable Medical Equipment("DME")for in the"Benefits"section.If you require durable medical home use" equipment related to your Urgent Care after receiving • If you receive COVID-19 laboratory testing or Out-of-Area Urgent Care,your provider must obtain prior authorization as described under Getting a immunizations in the emergency department,you pay Referral"in the"How to Obtain Services"section. the Cost Share for an emergency department visit as described in the"Cost Share Summary"under Your Cost Share "Emergency Services and Urgent Care" Your Cost Share for covered Urgent Care is the Cost • If you obtain a prescription in the emergency Share required for Services provided by Plan Providers department related to your Emergency Medical as described in the"Cost Share Summary"section of this Condition,you pay the Cost Share for"Most items" EOC.For example: in the"Cost Share Summary"under"Outpatient • If you receive an Urgent Care evaluation as part of prescription drugs,supplies,and supplements"in covered Out-of-Area Urgent Care from a Non—Plan addition to the Cost Share for the emergency Provider,you pay the Cost Share for Urgent Care department visit Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 40 consultations,evaluations,and treatment as described For information on how to file a claim,please see the in the"Cost Share Summary"under"Emergency "Post-Service Claims and Appeals"section. Services and Urgent Care" • If the Out-of-Area Urgent Care you receive includes an X-ray,you pay the Cost Share for an X-ray as Benefits described in the"Cost Share Summary"under "Outpatient imaging,laboratory,and other diagnostic This section describes the Services that are covered and treatment Services,"in addition to the Cost Share under this EOC. for the Urgent Care evaluation • If the Out-of-Area Urgent Care you receive includes a Services are covered under this EOC as specifically COVID-19 test,you may have to pay the Cost Share described in this EOC. Services that are not specifically for a COVID-19 test as described in the"Cost Share described in this EOC are not covered,except as required Summary"under"Outpatient imaging,laboratory, by state or federal law. Services are subject to exclusions and other diagnostic and treatment Services,"in and limitations described in the"Exclusions,Limitations, addition to the Cost Share for the Urgent Care Coordination of Benefits,and Reductions"section. evaluation Except as otherwise described in this EOC,all of the • If you obtain a prescription as part of an Out-of-Area following conditions must be satisfied: Urgent Care visit related to the condition for which • You are a Member on the date that you receive the you obtained Urgent Care,you pay the Cost Share for Services "Most items"in the"Cost Share Summary"under • The Services are Medically Necessary "Outpatient prescription drugs,supplies,and supplements"in addition to the Cost Share for the • The Services are one of the following: Urgent Care evaluation ♦ Preventive Services • If we gave prior authorization for durable medical ♦ health care items and services for diagnosis, equipment provided as part of Out-of-Area Urgent assessment,or treatment Care,you pay the Cost Share for durable medical ♦ health education covered under"Health equipment as described in the"Cost Share Summary" Education"in this"Benefits"section under"Durable Medical Equipment("DME")for ♦ other health care items and services home use" • The Services are provided,prescribed,authorized,or Note:If you receive Urgent Care in an emergency directed by a Plan Physician,except for: department,you pay the Cost Share for an emergency ♦ covered Services received outside of your Home department visit as described in the"Cost Share Region Service Area,as described under Summary"under"Emergency Services and Urgent "Receiving Care Outside of Your Home Region Care." Service Area"in the"How to Obtain Services" section Payment and Reimbursement ♦ COVID-19 Services from Non-Plan Providers as described under"Outpatient Imaging,Laboratory, If you receive Emergency Services Post-Stabilization and Other Diagnostic and Treatment Services," y g y Care,or Out-of--Area Urgent Care from allon—Plan "Outpatient Prescription Drugs, Supplies,and Provider as described in this"Emergency Services and Supplements,"and"Preventive Services"below Urgent Care"section,or emergency ambulance Services ♦ drugs prescribed by dentists,as described under described under"Ambulance Services"in the"Benefits" "Outpatient Prescription Drugs, Supplies,and section,you are not responsible for any amounts beyond Supplements"below your Cost Share for covered Services.However,if the ♦ emergency ambulance Services,as described provider does not agree to bill us,you may have to pay under"Ambulance Services"below for the Services and file a claim for reimbursement.Also, ♦ Emergency Services,Post-Stabilization Care,and you may be required to pay and file a claim for any Out-of-Area Urgent Care,as described in the Services prescribed by a Non—Plan Provider as part of "Emergency Services and Urgent Care"section covered Emergency Services,Post-Stabilization Care, Non— and Out-of--Area Urgent Care even if you receive the ♦ eyeglasses and contact lenses prescribed by Non— Services from a Plan Provider,such as a Plan Pharmacy. Plan Providers,as described under"Vision Services for Adult Members"and"Vision Services for Pediatric Members"below Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 41 • You receive the Services from Plan Providers inside Refer to the"Cost Share Summary"section of this EOC our Service Area,except for: for the amount you will pay for Services. ♦ authorized referrals,as described under"Getting a Referral"in the"How to Obtain Services"section General rules, examples, and exceptions ♦ covered Services received outside of your Home Your Cost Share for covered Services will be the Cost Region Service Area,as described under Share in effect on the date you receive the Services, "Receiving Care Outside of Your Home Region except as follows: Service Area"in the"How to Obtain Services" • If you are receiving covered hospital inpatient or section Skilled Nursing Facility Services on the effective date ♦ COVID-19 Services from Non-Plan Providers as of this EOC,you pay the Cost Share in effect on your described under"Outpatient Imaging,Laboratory, admission date until you are discharged if the and Other Diagnostic and Treatment Services," Services were covered under your prior Health Plan "Outpatient Prescription Drugs, Supplies,and evidence of coverage and there has been no break in Supplements,"and"Preventive Services"below coverage.However,if the Services were not covered ♦ emergency ambulance Services,as described under your prior Health Plan evidence of coverage,or under"Ambulance Services"below if there has been a break in coverage,you pay the Cost Share in effect on the date you receive the ♦ Emergency Services,Post-Stabilization Care,and Services Out-of-Area Urgent Care,as described in the "Emergency Services and Urgent Care"section • For items ordered in advance,you pay the Cost Share in effect on the order date(although we will not cover ♦ hospice care,as described under"Hospice Care" the item unless you still have coverage for it on the below date you receive it)and you may be required to pay • The Medical Group has given prior authorization for the Cost Share when the item is ordered.For the Services,if required,as described under"Medical outpatient prescription drugs,the order date is the Group authorization procedure for certain referrals" date that the pharmacy processes the order after in the"How to Obtain Services"section receiving all of the information they need to fill the prescription Please also refer to: • The"Emergency Services and Urgent Care"section Cost Share for Services received by newborn children for information about how to obtain covered of a Member Emergency Services,Post-Stabilization Care,and During the 31 days of automatic coverage for newborn Out-of-Area Urgent Care children described under"If you have a baby"under "Who Is Eligible"in the"Premiums,Eligibility,and • Our Provider Directory for the types of covered Enrollment"section,the parent or guardian of the Services that are available from each Plan Facility, newborn must pay the Cost Share indicated in the"Cost because some facilities provide only specific types of Share Summary"section of this EOC for any Services covered Services that the newborn receives,whether or not the newborn is enrolled.When the"Cost Share Summary"indicates the Your Cost Share Services are subject to the Plan Deductible,the Cost Share for those Services will be Charges if the newborn Your Cost Share is the amount you are required to pay has not met the Plan Deductible. for covered Services.For example,your Cost Share may be a Copayment or Coinsurance. Payment toward your Cost Share(and when you may be billed) If your coverage includes a Plan Deductible and you In most cases,your provider will ask you to make a receive Services that are subject to the Plan Deductible, payment toward your Cost Share at the time you receive your Cost Share for those Services will be Charges until Services.If you receive more than one type of Services you reach the Plan Deductible. Similarly,if your (such as a routine physical maintenance exam and coverage includes a Drug Deductible,and you receive laboratory tests),you may be required to pay separate Services that are subject to the Drug Deductible,your Cost Share for each of those Services.Keep in mind that Cost Share for those Services will be Charges until you your payment toward your Cost Share may cover only a reach the Drug Deductible. portion of your total Cost Share for the Services you receive,and you will be billed for any additional amounts that are due.The following are examples of when you may be asked to pay(or you may be billed for) Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 42 Cost Share amounts in addition to the amount you pay at Charges for Services. That could be because your check-in: payment was recorded before the Charges for the • You receive non-preventive Services during a Services were processed.If so,the Charges will appear preventive visit.For example,you go in for a routine on a future bill.Also,you may receive more than one bill physical maintenance exam,and at check-in you pay for a single outpatient visit or inpatient stay.For your Cost Share for the preventive exam(your Cost example,you may receive a bill for physician services Share may be"no charge").However,during your and a separate bill for hospital services.If you don't see preventive exam your provider finds a problem with all the Charges for Services on one bill,they will appear your health and orders non-preventive Services to on a future bill.If we determine that you overpaid and diagnose your problem(such as laboratory tests).You are due a refund,then we will send a refund to you may be asked to pay(or you will be billed for)your within four weeks after we make that determination.If Cost Share for these additional non-preventive you have questions about a bill,please call the phone diagnostic Services number on the bill. • You receive diagnostic Services during a treatment In some cases,a Non—Plan Provider may be involved in visit.For example,you go in for treatment of an the provision of covered Services at a Plan Facility or a existing health condition,and at check-in you pay contracted facility where we have authorized you to your Cost Share for a treatment visit.However, receive care.You are not responsible for any amounts during the visit your provider finds a new problem beyond your Cost Share for the covered Services you with your health and performs or orders diagnostic receive at Plan Facilities or at contracted facilities where Services(such as laboratory tests).You may be asked we have authorized you to receive care.However,if the to pay(or you will be billed for)your Cost Share for provider does not agree to bill us,you may have to pay these additional diagnostic Services for the Services and file a claim for reimbursement.For • You receive treatment Services during a diagnostic information on how to file a claim,please see the"Post- visit.For example,you go in for a diagnostic exam, Service Claims and Appeals"section. and at check-in you pay your Cost Share for a diagnostic exam.However,during the diagnostic Please refer to the"Emergency Services and Urgent exam your provider confirms a problem with your Care"section for more information about when you may health and performs treatment Services(such as an be billed for Emergency Services,Post-Stabilization outpatient procedure).You may be asked to pay(or Care,and Out-of-Area Urgent Care. you will be billed for)your Cost Share for these additional treatment Services Reimbursement for COVID-19 Services from Non-Plan • You receive Services from a second provider during Providers your visit.For example,you go in for a diagnostic If you receive covered COVID-19 Services from Non- exam,and at check-in you pay your Cost Share for a Plan Providers as described under"Outpatient Imaging, diagnostic exam.However,during the diagnostic Laboratory,and Other Diagnostic and Treatment exam your provider requests a consultation with a Services,""Outpatient Prescription Drugs,Supplies,and specialist.You may be asked to pay(or you will be Supplements,"and"Preventive Services"in the billed for)your Cost Share for the consultation with "Benefits"section,you may have to pay for the Services the specialist and file a claim for reimbursement.For information on how to file a claim,please see"Initial Claims"in the In some cases,your provider will not ask you to make a "the"Post-Service Claims and Appeals"section. payment at the time you receive Services,and you will be billed for your Cost Share(for example,some Primary Care Visits,Non-Physician Specialist Visits, Laboratory Departments are not able to collect Cost and Physician Specialist Visits Share,or your Plan Provider is not able to collect Cost The Cost Share for a Primary Care Visit applies to Share,if any,for Telehealth Visits you receive at home). evaluations and treatment provided by generalists in internal medicine,pediatrics,or family practice,and by When we send you a bill,it will list Charges for the specialists in obstetrics/gynecology whom the Medical Services you received,payments and credits applied to Group designates as Primary Care Physicians. Some your account,and any amounts you still owe.Your physician specialists provide primary care in addition to current bill may not always reflect your most recent specialty care but are not designated as Primary Care Charges and payments.Any Charges and payments that Physicians.If you receive Services from one of these are not on the current bill will appear on a future bill. specialists,the Cost Share for a Physician Specialist Visit Sometimes,you may see a payment but not the related will apply to all consultations,evaluations,and treatment Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 43 provided by the specialist except for routine preventive call 711)Monday through Friday 6 a.m.to 5 p.m. counseling and exams listed under"Preventive Services" Refer to the"Cost Share Summary"section of this in this"Benefits"section.For example,if your personal EOC to find out if you have a Plan Deductible Plan Physician is a specialist in internal medicine or • For all other Cost Share estimates,please call 1-800- obstetrics/gynecology who is not a Primary Care 464-4000(TTY users call 711)24 hours a day,seven Physician,you will pay the Cost Share for a Physician days a week(closed holidays) Specialist Visit for all consultations,evaluations,and treatment by the specialist except routine preventive Cost Share estimates are based on your benefits and the counseling and exams listed under"Preventive Services" Services you expect to receive. They are a prediction of in this"Benefits"section.The Non-Physician Specialist cost and not a guarantee of the final cost of Services. Visit Cost Share applies to consultations,evaluations, Your final cost may be higher or lower than the estimate and treatment provided by non-physician specialists since not everything about your care can be known in (such as nurse practitioners,physician assistants, advance. optometrists,podiatrists,and audiologists). Noncovered Services Drug Deductible If you receive Services that are not covered under this This EOC does not include a Drug Deductible. EOC,you may have to pay the full price of those Plan Deductible Services.Payments you make for noncovered Services do not apply to any deductible or out-of-pocket This EOC does not include a Plan Deductible. maximum. Copayments and Coinsurance Benefit limits The Copayment or Coinsurance you must pay for each Some benefits may include a limit on the number of covered Service,after you meet any applicable visits,days,treatment cycles,or dollar amount that will deductible,is described in this EOC. be covered under your plan during a specified time period.If a benefit includes a limit,this will be indicated Note:If Charges for Services are less than the in the"Cost Share Summary"section of this EOC. The Copayment described in this EOC,you will pay the time period associated with a benefit limit may not be the lesser amount,subject to any applicable deductible or same as the term of this EOC.We will count all Services out-of-pocket maximum. you receive during the benefit limit period toward the benefit limit,including Services you received under a Plan Out-of-Pocket Maximum prior Health Plan EOC(as long as you have continuous There is a limit to the total amount of Cost Share you coverage with Health Plan).Note:We will not count must pay under this EOC in the Accumulation Period for Services you received under a prior Health Plan EOC covered Services that you receive in the same when you first enroll in individual plan coverage or a Accumulation Period. The Services that apply to the Plan new employer group's plan,when you move from group Out-of-Pocket Maximum are described under the to individual plan coverage(or vice versa),or when you "Payments that count toward the Plan Out-of-Pocket received Services under a Kaiser Permanente Senior Maximum"section below.Refer to the"Cost Share Advantage evidence of coverage.If you are enrolled in Summary"section of this EOC for your applicable Plan the Kaiser Permanente POS Plan,refer to your KPIC Out-of-Pocket Maximum amounts. Certificate of Insurance and Schedule of Coverage for benefit limits that apply to your separate indemnity If you are a Member in a Family of two or more coverage provided by the Kaiser Permanente Insurance Members,you reach the Plan Out-of-Pocket Maximum Company("KPIC"). either when you reach the maximum for any one Member,or when your Family reaches the Family Getting an estimate of your Cost Share maximum.For example,suppose you have reached the If you have questions about the Cost Share for specific Plan Out-of-Pocket Maximum for any one Member.For Services that you expect to receive or that your provider Services subject to the Plan Out-of-Pocket Maximum, orders during a visit or procedure,please visit our you will not pay any more Cost Share during the website at kp•org to use our cost estimate tool or call remainder of the Accumulation Period,but every other Member Services. Member in your Family must continue to pay Cost Share • If you have a Plan Deductible and would like an during the remainder of the Accumulation Period until either they reach the maximum for any one Member or estimate for Services that are subject to the Plan your Family reaches the Family maximum. Deductible,please call 1-800-390-3507(TTY users Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 44 Payments that count toward the Plan Out-of-Pocket and they are administered to you in a Plan Facility or Maximum during home visits. Any payments you make toward the Plan Deductible or Drug Deductible,if applicable,apply toward the Certain administered drugs are Preventive Services. maximum. Refer to"Reproductive Health Services"for information about administered contraceptives and refer to Most Copayments and Coinsurance you pay for covered "Preventive Services"for information on immunizations. Services apply to the maximum,however some may not. To find out whether a Copayment or Coinsurance for a covered Service will apply to the maximum refer to the Ambulance Services "Cost Share Summary"section of this EOC. Emergency If your plan includes pediatric dental Services described We cover Services of a licensed ambulance anywhere in in a Pediatric Dental Services Amendment to this EOC, the world without prior authorization(including those Services will apply toward the maximum. If your transportation through the 911 emergency response plan has a Pediatric Dental Services Amendment,it will system where available)in the following situations: be attached to this EOC,and it will be listed in the • You reasonably believed that the medical condition EOC's Table of Contents. was an Emergency Medical Condition which required ambulance Services Accrual toward deductibles and out-of-pocket • Your treating physician determines that you must be maximums transported to another facility because your To see how close you are to reaching your deductibles,if Emergency Medical Condition is not Stabilized and any,and out-of-pocket maximums,use our online Out- the care you need is not available at the treating of-Pocket Summary tool at kp•ora or call Member facility Services.We will provide you with accrual balance information for every month that you receive Services If you receive emergency ambulance Services that are until you reach your individual out-of-pocket maximums not ordered by a Plan Provider,you are not responsible or your Family reaches the Family out-of-pocket for any amounts beyond your Cost Share for covered maximums. emergency ambulance Services.However,if the provider does not agree to bill us,you may have to pay for the We will provide accrual balance information by mail Services and file a claim for reimbursement.For unless you have opted to receive notices electronically. information on how to file a claim,please see the"Post- You can change your document delivery preferences at Service Claims and Appeals"section. any time at kp•org or by calling Member Services. Nonemergency Administered Drugs and Products Inside our Service Area,we cover nonemergency ambulance and psychiatric transport van Services if a Administered drugs and products are medications and Plan Physician determines that your condition requires products that require administration or observation by the use of Services that only a licensed ambulance(or medical personnel,such as: psychiatric transport van)can provide and that the use of other means of transportation would endanger your • Whole blood,red blood cells,plasma,and platelets health.These Services are covered only when the vehicle • Allergy antigens(including administration) transports you to or from covered Services. • Cancer chemotherapy drugs and adjuncts Ambulance Services exclusions • Drugs and products that are administered via • Transportation by car,taxi,bus,gurney van, intravenous therapy or injection that are not for cancer chemotherapy,including blood factor products wheelchair van,and any other type of transportation and biological products("biologics")derived from (other than a licensed ambulance or psychiatric tissue,cells,or blood transport van),even if it is the only way to travel to a Plan Provider • Other administered drugs and products We cover these items when prescribed by a Plan Provider,in accord with our drug formulary guidelines, Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 45 Bariatric Surgery certain referrals"under"Getting a Referral"in the"How to Obtain Services"section). We cover hospital inpatient Services related to bariatric surgical procedures(including room and board,imaging, Dental Services for transplants laboratory,other diagnostic and treatment Services,and We cover dental services that are Medically Necessary to Plan Physician Services)when performed to treat obesity free the mouth from infection in order to prepare for a by modification of the gastrointestinal tract to reduce transplant covered under"Transplant Services"in this nutrient intake and absorption,if all of the following `Benefits"section,if a Plan Physician provides the requirements are met: Services or if the Medical Group authorizes a referral to • You complete the Medical Group—approved pre- a dentist for those Services(as described in"Medical surgical educational preparatory program regarding Group authorization procedure for certain referrals" lifestyle changes necessary for long term bariatric under"Getting a Referral"in the"How to Obtain surgery success Services"section). • A Plan Physician who is a specialist in bariatric care Dental anesthesia determines that the surgery is Medically Necessary For dental procedures at a Plan Facility,we provide For covered Services related to bariatric surgical general anesthesia and the facility's Services associated procedures that you receive,you will pay the Cost Share with the anesthesia if all of the following are true: you would pay if the Services were not related to a • You are under age 7,or you are developmentally bariatric surgical procedure.For example,see"Hospital disabled,or your health is compromised inpatient Services"in the"Cost Share Summary"section • Your clinical status or underlying medical condition of this EOC for the Cost Share that applies for hospital requires that the dental procedure be provided in a inpatient Services. hospital or outpatient surgery center For the following Services, refer to these • The dental procedure would not ordinarily require sections general anesthesia • Outpatient prescription drugs(refer to"Outpatient We do not cover any other Services related to the dental Prescription Drugs, Supplies,and Supplements") procedure,such as the dentist's Services. • Outpatient administered drugs(refer to"Administered Drugs and Products") Dental and orthodontic Services for cleft palate We cover dental extractions,dental procedures necessary to prepare the mouth for an extraction,and orthodontic Dental and Orthodontic Services Services,if they meet all of the following requirements: We do not cover most dental and orthodontic Services • The Services are an integral part of a reconstructive under this EOC,but we do cover some dental and surgery for cleft palate that we are covering under orthodontic Services as described in this"Dental and "Reconstructive Surgery"in this"Benefits"section Orthodontic Services"section. ("cleft palate"includes cleft palate,cleft lip,or other craniofacial anomalies associated with cleft palate) For covered dental and orthodontic procedures that you • A Plan Provider provides the Services or the Medical may receive,you will pay the Cost Share you would pay Group authorizes a referral to a Non—Plan Provider if the Services were not related to dental and orthodontic who is a dentist or orthodontist(as described in Services.For example,see"Hospital inpatient Services" "Medical Group authorization procedure for certain in the"Cost Share Summary"section of this EOC for the referrals"under"Getting a Referral"in the"How to Cost Share that applies for hospital inpatient Services. Obtain Services"section) Dental Services for radiation treatment For the following Services, refer to these We cover dental evaluation,X-rays,fluoride treatment, sections and extractions necessary to prepare your jaw for o Accidental injury to teeth(refer to"Injury to Teeth") radiation therapy of cancer in your head or neck if a Plan Physician provides the Services or if the Medical Group • Office visits not described in the"Dental and authorizes a referral to a dentist for those Services(as Orthodontic Services"section(refer to"Office described in"Medical Group authorization procedure for Visits") Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 46 • Outpatient imaging,laboratory,and other diagnostic • Outpatient administered drugs(refer to"Administered and treatment Services(refer to"Outpatient Imaging, Drugs and Products") Laboratory,and Other Diagnostic and Treatment . Telehealth Visits(refer to"Telehealth Visits") Services") • Outpatient administered drugs(refer to"Administered Dialysis care exclusions Drugs and Products"),except that we cover outpatient . Comfort convenience or lux 'equipment,supplies e ui ment lies administered drugs under"Dental anesthesia"in this and features "Dental and Orthodontic Services"section • Outpatient prescription drugs(refer to"Outpatient • Nonmedical items,such as generators or accessories Prescription Drugs, Supplies,and Supplements") to make home dialysis equipment portable for travel • Telehealth Visits(refer to"Telehealth Visits") Durable Medical Equipment ("DME") for Dialysis Care Home Use DME coverage rules We cover acute and chronic dialysis Services if all of the DME for home use is an item that meets the following following requirements are met: criteria: • The Services are provided inside our Service Area . The item is intended for repeated use • You satisfy all medical criteria developed by the • The item is primarily and customarily used to serve a Medical Group and by the facility providing the medical purpose dialysis • The item is generally useful only to an individual • A Plan Physician provides a written referral for care with an illness or injury at the facility • The item is appropriate for use in the home After you receive appropriate training at a dialysis facility we designate,we also cover equipment and For a DME item to be covered,all of the following medical supplies required for home hemodialysis and requirements must be met: home peritoneal dialysis inside our Service Area. o Your EOC includes coverage for the requested DME Coverage is limited to the standard item of equipment or item supplies that adequately meets your medical needs.We . A Plan Physician has prescribed the DME item for decide whether to rent or purchase the equipment and supplies,and we select the vendor.You must return the your medical condition equipment and any unused supplies to us or pay us the • The item has been approved for you through the fair market price of the equipment and any unused Plan's prior authorization process,as described in supply when we are no longer covering them. "Medical Group authorization procedure for certain referrals"under"Getting a Referral"in the"How to For the following Services, refer to these Obtain Services"section sections • The Services are provided inside our Service Area • Durable medical equipment for home use(refer to "Durable Medical Equipment("DME")for Home Coverage is limited to the standard item of equipment Use") that adequately meets your medical needs.We decide • Hospital inpatient Services(refer to"Hospital whether to rent or purchase the equipment,and we select Inpatient Services") the vendor.You must return the equipment to us or pay us the fair market price of the equipment when we are no • Office visits not described in the"Dialysis Care" longer covering it. section(refer to"Office Visits") • Outpatient laboratory(refer to"Outpatient Imaging, Base DME Items Laboratory,and Other Diagnostic and Treatment We cover Base DME Items(including repair or Services") replacement of covered equipment)if all of the • Outpatient prescription drugs(refer to"Outpatient requirements described under"DME coverage rules"in Prescription Drugs, Supplies,and Supplements") this"Durable Medical Equipment("DME")for Home Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 47 Use"section are met. "Base DME Items"means the • Blood glucose monitors for diabetes blood testing and following items: their supplies(such as blood glucose monitor test • Blood glucose monitors for diabetes blood testing and strips,lancets,and lancet devices)from a Plan their supplies(such as blood glucose monitor test Pharmacy strips,lancets,and lancet devices) • Canes(standard curved handle) • Bone stimulator • Crutches(standard) • Canes(standard curved handle or quad)and • Insulin pumps and supplies to operate the pump,after replacement supplies completion of training and education on the use of the • Cervical traction(over door) PUMP • Crutches(standard or forearm)and replacement • Nebulizers and their supplies for the treatment of supplies pediatric asthma • Dry pressure pad for a mattress • Peak flow meters from a Plan Pharmacy • Infusion pumps(such as insulin pumps)and supplies For the following Services, refer to these to operate the pump sections • IV pole e Dialysis equipment and supplies required for home • Nebulizer and supplies hemodialysis and home peritoneal dialysis(refer to • Peak flow meters "Dialysis Care") • Phototherapy blankets for treatment of jaundice in • Diabetes urine testing supplies and insulin- newborns administration devices other than insulin pumps(refer to"Outpatient Prescription Drugs, Supplies,and Supplemental DME items Supplements") We cover DME that is not described under"Base DME • Durable medical equipment related to an Emergency Items"or"Lactation supplies,"including repair and Medical Condition or Urgent Care episode(refer to replacement of covered equipment,if all of the "Post-Stabilization Care"and"Out-of-Area Urgent requirements described under"DME coverage rules"in Care") this"Durable Medical Equipment("DME")for Home • Durable medical equipment related to the terminal Use"section are met. illness for Members who are receiving covered hospice care(refer to"Hospice Care") Lactation supplies . Insulin and any other drugs administered with an We cover one retail-grade milk pump(also known as a infusion pump(refer to"Outpatient Prescription breast pump)per pregnancy and associated supplies,as Drugs,Supplies,and Supplements") listed on our website at ky.orWyrevention.We will decide whether to rent or purchase the item and we DME for home use exclusions choose the vendor.We cover this pump for convenience purposes.The pump is not subject to prior authorization • Comfort,convenience,or luxury equipment or requirements. features except for retail-grade milk pumps as described under"Lactation supplies"in this"Durable If you or your baby has a medical condition that requires Medical Equipment("DME")for Home Use"section the use of a milk pump,we cover a hospital-grade milk . Items not intended for maintaining normal activities pump and the necessary supplies to operate it,in accord of daily living,such as exercise equipment(including with the coverage rules described under"DME coverage devices intended to provide additional support for rules"in this"Durable Medical Equipment("DME")for recreational or sports activities) Home Use"section. • Hygiene equipment Outside our Service Area • Nonmedical items,such as sauna baths or elevators We do not cover most DME for home use outside our . Modifications to your home or car Service Area.However,if you live outside our Service • Devices for testing blood or other body substances Area,we cover the following DME(subject to the Cost Share and all other coverage requirements that apply to (except diabetes blood glucose monitors and their DME for home use inside our Service Area)when the supplies) item is dispensed at a Plan Facility: Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 48 • Electronic monitors of the heart or lungs except infant • Outpatient surgery and outpatient procedures apnea monitors • Outpatient imaging and laboratory Services • Repair or replacement of equipment due to loss,theft, • Outpatient administered drugs that require or misuse administration or observation by medical personnel. We cover these items when they are prescribed by a Emergency Services and Urgent Care Plan Provider,in accord with our drug formulary guidelines,and they are administered to you in a Plan We cover the following Services: Facility • Emergency department visits • Hospital inpatient stays directly related to diagnosis • Urgent Care consultations,evaluations,and treatment and treatment of Infertility For the following Services, refer to these Assisted reproductive technology("ART")Services sections ART Services such as in vitro fertilization("IVF"), • Abortion and abortion-related Services(refer to gamete intra-fallopian transfer("GIFT"),or zygote "Reproductive Health Services") intrafallopian transfer("ZIFT")are not covered under this EOC. Fertility Services For the following Services, refer to these "Fertility Services"means treatments and procedures to sections help you become pregnant. • Fertility preservation Services for iatrogenic Infertility(refer to"Fertility Preservation Services for Before starting or continuing a course of fertility Iatrogenic Infertility") Services,you may be required to pay initial and • Diagnostic Services provided by Plan Providers who subsequent deposits toward your Cost Share for some or are not physicians,such as EKGs and EEGs(refer to all of the entire course of Services,along with any past- "Outpatient Imaging,Laboratory,and Other due fertility-related Cost Share.Any unused portion of Diagnostic and Treatment Services") your deposit will be returned to you.When a deposit is not required,you must pay the Cost Share for the • Outpatient drugs,supplies,and supplements(refer to procedure,along with any past-due fertility-related Cost "Outpatient Prescription Drugs, Supplies,and Share,before you can schedule a fertility procedure. Supplements") Diagnosis and treatment of Infertility Fertility Services exclusions We cover the following Services for the diagnosis and • Reversal of surgical sterilization originally performed treatment of Infertility: for family planning purposes • Office visits • Semen and eggs(and Services related to their • Outpatient surgery and outpatient procedures procurement and storage) • Outpatient imaging and laboratory Services • ART Services,such as ovum transplants,GIFT,IVF, and ZIFT • Outpatient administered drugs that require administration or observation by medical personnel. We cover these items when they are prescribed by a Fertility Preservation Services for Plan Provider,in accord with our drug formulary Iatrogenic Infertility guidelines,and they are administered to you in a Plan Facility Standard fertility preservation Services are covered for • Hospital inpatient stay directly related to diagnosis Members undergoing treatment or receiving covered and treatment of Infertility Services that may directly or indirectly cause iatrogenic Infertility.Fertility preservation Services do not include Artificial insemination diagnosis or treatment of Infertility. We cover the following Services for artificial For covered fertility preservation Services that you insemination: receive,you will pay the Cost Share you would pay if the • Office visits Services were not related to fertility preservation.For Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 49 example,see"Outpatient surgery and outpatient and models of hearing aids furnished by the provider or procedures"in the"Cost Share Summary"section of this vendor. EOC for the Cost Share that applies for outpatient procedures. For the following Services, refer to these sections Health Education • Routine hearing screenings when performed as part of a routine physical maintenance exam(refer to We cover a variety of health education counseling, "Preventive Services") programs,and materials that your personal Plan Physician or other Plan Providers provide during a visit • Services related to the ear or hearing other than those covered under another part of this EOC. described in this section, such as outpatient care to treat an ear infection or outpatient prescription drugs, We also cover a variety of health education counseling, supplies,and supplements(refer to the applicable programs,and materials to help you take an active role in heading in this"Benefits"section) protecting and improving your health,including • Cochlear implants and osseointegrated hearing programs for tobacco cessation,stress management,and devices(refer to"Prosthetic and Orthotic Devices") chronic conditions(such as diabetes and asthma).Kaiser Permanente also offers health education counseling, Hearing Services exclusions programs,and materials that are not covered,and you • Internally implanted hearing aids may be required to pay a fee. • Replacement parts and batteries,repair of hearing For more information about our health education aids,and replacement of lost or broken hearing aids counseling,programs,and materials,please contact a (the manufacturer warranty may cover some of these) Health Education Department or Member Services or go to our website at kp.m. Home Health Care Hearing Services "Home health care"means Services provided in the home by nurses,medical social workers,home health We cover the following: aides,and physical,occupational,and speech therapists. • Hearing exams with an audiologist to determine the need for hearing correction We cover home health care only if all of the following are true: • Physician Specialist Visits to diagnose and treat . You are substantially confined to your home(or a hearing problems friend's or relative's home) Hearing aids • Your condition requires the Services of a nurse, We provide an Allowance for each ear toward the physical therapist,occupational therapist,or speech purchase price of a hearing aid(including fitting, therapist(home health aide Services are not covered counseling,adjustment,cleaning,and inspection)when unless you are also getting covered home health care prescribed by a Plan Physician or by a Plan Provider who from a nurse,physical therapist,occupational is an audiologist.We will cover hearing aids for both therapist,or speech therapist that only a licensed ears only if both aids are required to provide significant provider can provide) improvement that is not obtainable with only one hearing • A Plan Physician determines that it is feasible to aid.We will not provide the Allowance if we have maintain effective supervision and control of your provided an Allowance toward(or otherwise covered)a care in your home and that the Services can be safely hearing aid within the previous 36 months.Also,the and effectively provided in your home Allowance can only be used at the initial point of sale.If you do not use all of your Allowance at the initial point • The Services are provided inside our Service Area of sale,you cannot use it later.Refer to"Hearing Services"in the"Cost Share Summary"section of this We cover only part-time or intermittent home health EOC for your Allowance amount. care,as follows: • Up to two hours per visit for visits by a nurse, We select the provider or vendor that will furnish the medical social worker,or physical,occupational,or covered hearing aids.Coverage is limited to the types speech therapist,and up to four hours per visit for visits by a home health aide Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 50 • Up to three visits per day(counting all home health discomforts of a Member experiencing the last phases of visits) life due to a terminal illness.It also provides support to • Up to 100 visits per Accumulation Period(counting the primary caregiver and the Member's family.A all home health visits) Member who chooses hospice care is choosing to receive palliative care for pain and other symptoms associated Note:If a visit by a nurse,medical social worker,or with the terminal illness,but not to receive care to try to physical,occupational,or speech therapist lasts longer cure the terminal illness.You may change your decision than two hours,then each additional increment of two to receive hospice care benefits at any time. hours counts as a separate visit.If a visit by a home health aide lasts longer than four hours,then each We cover the hospice Services listed below only if all of additional increment of four hours counts as a separate the following requirements are met: visit.For example,if a nurse comes to your home for • A Plan Physician has diagnosed you with a terminal three hours and then leaves,that counts as two visits. illness and determines that your life expectancy is 12 Also,each person providing Services counts toward months or less these visit limits.For example,if a home health aide and • The Services are provided inside our Service Area or a nurse are both at your home during the same two hours, inside California but within 15 miles or 30 minutes that counts as two visits. from our Service Area(including a friend's or For the following Services, refer to these relative's home even if you live there temporarily) sections • The Services are provided by a licensed hospice agency that is a Plan Provider • Behavioral Health Treatment for Autism Spectrum Disorder(refer to"Mental Health Services") • A Plan Physician determines that the Services are necessary for the palliation and management of your • Dialysis care(refer to"Dialysis Care") terminal illness and related conditions • Durable medical equipment(refer to"Durable Medical Equipment("DME")for Home Use") If all of the above requirements are met,we cover the • Ostomy and urological supplies(refer to"Ostomy and following hospice Services,if necessary for your hospice Urological Supplies") care: • Outpatient drugs,supplies,and supplements(refer to • Plan Physician Services "Outpatient Prescription Drugs, Supplies,and • Skilled nursing care,including assessment, Supplements") evaluation,and case management of nursing needs, • Outpatient physical,occupational,and speech therapy treatment for pain and symptom control,provision of visits(refer to"Rehabilitative and Habilitative emotional support to you and your family,and Services") instruction to caregivers • Prosthetic and orthotic devices(refer to"Prosthetic • Physical,occupational,and speech therapy for and Orthotic Devices") purposes of symptom control or to enable you to maintain activities of daily living Home health care exclusions • Respiratory therapy • Care of a type that an unlicensed family member or • Medical social services other layperson could provide safely and effectively • Home health aide and homemaker services in the home setting after receiving appropriate training.This care is excluded even if we would cover • Palliative drugs prescribed for pain control and the care if it were provided by a qualified medical symptom management of the terminal illness for up to professional in a hospital or a Skilled Nursing Facility a 100-day supply in accord with our drug formulary guidelines.You must obtain these drugs from a Plan • Care in the home if the home is not a safe and Pharmacy.Certain drugs are limited to a maximum effective treatment setting 30-day supply in any 30-day period(your Plan Pharmacy can tell you if a drug you take is one of Hospice Care these drugs) • Durable medical equipment Hospice care is a specialized form of interdisciplinary • Respite care when necessary to relieve your health care designed to provide palliative care and to caregivers.Respite care is occasional short-term alleviate the physical,emotional,and spiritual Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 51 inpatient Services limited to no more than five • Behavioral Health Treatment for Autism Spectrum consecutive days at a time Disorder • Counseling and bereavement services • Respiratory therapy • Dietary counseling • Physical,occupational,and speech therapy(including treatment in our organized,multidisciplinary We also cover the following hospice Services only rehabilitation program) during periods of crisis when they are Medically • Medical social services and discharge planning Necessary to achieve palliation or management of acute medical symptoms: For the following Services, refer to these • Nursing care on a continuous basis for as much as 24 sections hours a day as necessary to maintain you at home • Abortion and abortion-related Services(refer to • Short-term inpatient Services required at a level that "Reproductive Health Services") cannot be provided at home • Bariatric surgical procedures(refer to"Bariatric Surgery") Hospital Inpatient Services • Dental and orthodontic procedures(refer to"Dental and Orthodontic Services") We cover the following inpatient Services in a Plan • Dialysis care(refer to"Dialysis Care") Hospital,when the Services are generally and customarily provided by acute care general hospitals • Fertility preservation Services for iatrogenic inside our Service Area: Infertility(refer to"Fertility Preservation Services for • Room and board,including a private room if Iatrogenic Infertility") Medically Necessary • Services related to diagnosis and treatment of • Specialized care and critical care units Infertility,artificial insemination,or assisted reproductive technology(refer to"Fertility Services") • General and special nursing care • Hospice care(refer to"Hospice Care") • Operating and recovery rooms • Mental health Services(refer to"Mental Health • Services of Plan Physicians,including consultation Services") and treatment by specialists • Prosthetics and orthotics(refer to"Prosthetic and • Anesthesia Orthotic Devices") • Drugs prescribed in accord with our drug formulary . Reconstructive surgery Services(refer to guidelines(for discharge drugs prescribed when you "Reconstructive Surgery") are released from the hospital,refer to"Outpatient Prescription Drugs, Supplies,and Supplements"in • Services in connection with a clinical trial(refer to this"Benefits"section) "Services in Connection with a Clinical Trial") • Radioactive materials used for therapeutic purposes • Skilled inpatient Services in a Plan Skilled Nursing Facility(refer to"Skilled Nursing Facility Care") • Durable medical equipment and medical supplies • Substance use disorder treatment Services(refer to • Imaging,laboratory,and other diagnostic and "Substance Use Disorder Treatment") treatment Services,including MRI,CT,and PET . Transplant Services(refer to"Transplant Services") scans • Whole blood,red blood cells,plasma,platelets,and their administration I n]u ry to Teeth • Obstetrical care and delivery(including cesarean Services for accidental injury to teeth are not covered section).Note: If you are discharged within 48 hours under this EOC. after delivery(or within 96 hours if delivery is by cesarean section),your Plan Physician may order a follow-up visit for you and your newborn to take Mental Health Services place within 48 hours after discharge(for visits after you are released from the hospital,refer to"Office We cover Services specified in this"Mental Health Visits"in this"Benefits"section) Services"section only when the Services are for the prevention,diagnosis,or treatment of Mental Health Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 52 Conditions.A"Mental Health Condition"is a mental accord with our drug formulary guidelines if they are health condition that falls under any of the diagnostic administered to you in the facility by medical categories listed in the mental and behavioral disorders personnel(for discharge drugs prescribed when you chapter of the most recent edition of the International are released from the residential treatment facility, Classification of Diseases or that is listed in the most refer to"Outpatient Prescription Drugs, Supplies,and recent version of the Diagnostic and Statistical Manual Supplements"in this"Benefits"section) of Mental Disorders. • Discharge planning Outpatient mental health Services Gender-affirming Services We cover the following Services when provided by Plan For covered Services you receive for treatment of gender Physicians or other Plan Providers who are licensed dysphoria,you will pay the Cost Share you would pay if health care professionals acting within the scope of their the Services were not related to gender dysphoria.For license: example: • Individual and group mental health evaluation and • See"Administered Drugs"for administered drugs treatment,including treatment of first episode psychosis • See"Office Visits"for consultations for gender dysphoria treatment,such as hormone therapy,and • Psychological testing when necessary to evaluate a hair removal procedures Mental Health Condition • See"Outpatient Laboratory,Imaging,and Other • Outpatient Services for the purpose of monitoring Diagnostic and Treatment Services"for laboratory drug therapy and imaging Services • Behavioral Health Treatment for Autism Spectrum • See"Outpatient Prescription Drugs, Supplies and Disorder Supplements"for drugs,supplies,and supplements • Electroconvulsive therapy • See"Reconstructive Surgery"for surgical Services • Transcranial magnetic stimulation • See"Rehabilitative and Habilitative Services"for speech(voice)therapy Intensive psychiatric treatment programs We cover intensive psychiatric treatment programs at a Inpatient psychiatric hospitalization Plan Facility,such as: We cover inpatient psychiatric hospitalization in a Plan • Partial hospitalization Hospital. Coverage includes room and board,drugs,and • Multidisciplinary treatment in an intensive outpatient Services of Plan Physicians and other Plan Providers or day-treatment program who are licensed health care professionals acting within the scope of their license. • Psychiatric observation for an acute psychiatric crisis Services from Non-Plan Providers Residential treatment If we are not able to offer an appointment with a Plan Inside our Service Area,we cover the following Services Provider within required geographic and timely access when the Services are provided in a licensed residential standards,we will offer to refer you to a Non-Plan treatment facility that provides 24-hour individualized Provider(as described in"Medical Group authorization mental health treatment,the Services are generally and procedure for certain referrals"under"Getting a customarily provided by a mental health residential Referral'in the"How to Obtain Services"section). treatment program in a licensed residential treatment facility,and the Services are above the level of custodial Additionally,we cover Services provided by a 988 care: center,mobile crisis team,or other provider of • Individual and group mental health evaluation and behavioral health crisis services(collectively,"988 treatment Services")for medically necessary treatment of a mental • Medical services health or substance use disorder without prior authorization until the condition is stabilized,as required • Medication monitoring by state law.After the mental health or substance use • Room and board disorder condition has been stabilized,post-stabilization care from Non-Plan Providers is subject to prior • Social services authorization as described under"Post-Stabilization • Drugs prescribed by a Plan Provider as part of your Care"in the"Emergency Services"section. plan of care in the residential treatment facility in Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 53 For these referral Services and 988 Services,you pay the • The item has been approved for you through the Cost Share required for Services provided by a Plan Plan's prior authorization process,as described in Provider as described in this EOC. "Medical Group authorization procedure for certain referrals"under"Getting a Referral"in the"How to For the following Services, refer to these Obtain Services"section sections • The Services are provided inside our Service Area • Behavioral Health Treatment for Autism Spectrum Disorder provided during a covered stay in a Plan Coverage is limited to the standard item of equipment Hospital or Skilled Nursing Facility(refer to that adequately meets your medical needs.We decide "Hospital Inpatient Services"and"Skilled Nursing whether to rent or purchase the equipment,and we select Facility Care") the vendor. • Outpatient drugs,supplies,and supplements(refer to "Outpatient Prescription Drugs, Supplies,and Ostomy and urological supplies exclusions Supplements") • Comfort,convenience,or luxury equipment or • Outpatient laboratory and sleep studies(refer to features "Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services") Outpatient Imaging, Laboratory, and • Outpatient physical,occupational,and speech therapy Other Diagnostic and Treatment visits(refer to"Rehabilitative and Habilitative Services") Services • Telehealth Visits(refer to"Telehealth Visits") We cover the following Services only when part of care covered under other headings in this"Benefits"section. Office Visits The Services must be prescribed by a Plan Provider. • Complex imaging(other than preventive)such as CT We cover the following: scans,MRIs,and PET scans • Primary Care Visits and Non-Physician Specialist • Basic imaging Services,such as diagnostic and Visits therapeutic X-rays,mammograms,and ultrasounds • Physician Specialist Visits • Nuclear medicine • Group appointments • Routine retinal photography screenings • Acupuncture Services(typically provided only for the • Laboratory tests,including tests to monitor the treatment of nausea or as part of a comprehensive effectiveness of dialysis and tests for specific genetic pain management program for the treatment of disorders for which genetic counseling is available chronic pain) • Diagnostic Services provided by Plan Providers who • House calls by a Plan Physician(or a Plan Provider are not physicians(such as EKGs,EEGs,and sleep who is a registered nurse)inside our Service Area studies) when care can best be provided in your home as • Radiation therapy determined by a Plan Physician • Ultraviolet light treatments,including ultraviolet light For the following Services, refer to these therapy equipment for home use,if(1)the equipment sections has been approved for you through the Plans prior authorization process,as described in"Medical Group • Abortion and abortion-related Services(refer to authorization procedure for certain referrals"under "Reproductive Health Services") "Getting a Referral"in the"How to Obtain Services" section and(2)the equipment is provided inside our Service Area.(Coverage for ultraviolet light therapy Ostomy and Urological Supplies equipment is limited to the standard item of We cover ostomy and urological supplies if the equipment that adequately meets your medical needs. following requirements are met: We decide whether to rent or purchase the equipment, and we select the vendor.You must return the • A Plan Physician has prescribed ostomy and equipment to us or pay us the fair market price of the urological supplies for your medical condition equipment when we are no longer covering it.) Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 54 We cover laboratory tests to diagnose or screen for items described in this section when prescribed as COVID-19 from Plan Providers or Non-Plan Providers, follows: including a provider visit for purposes of receiving the . Items prescribed by Plan Providers,within the scope laboratory test. of their licensure and practice We cover up to a total of eight FDA-authorized over-the- • Items prescribed by the following Non—Plan counter COVID-19 tests per calendar month from Plan Providers: Providers or Non-Plan Providers. Over-the-counter tests ♦ Dentists if the drug is for dental care are self-administered tests that deliver results at home ♦ Non—Plan Physicians if the Medical Group and are available without a prescription.For purposes of authorizes a written referral to the Non—Plan this section,"Plan Provider"means a Plan Pharmacy, Physician(in accord with"Medical Group mail order delivery through our website at kp.org,or a authorization procedure for certain referrals" participating retail pharmacy.For purposes of this under"Getting a Referral"in the"How to Obtain section,a"Non-Plan Provider"means a pharmacy or Services"section)and the drug, supply,or online retailer that isn't a Plan Provider. To find out supplement is covered as part of that referral more about coverage and limitations,including the ♦ Non—Plan Physicians if the prescription was current list of Plan Providers,visit our website or call obtained as part of covered Emergency Services, Member Services. Post-Stabilization Care,or Out-of-Area Urgent For the following Services, refer to these Care described in the"Emergency Services and sections Urgent Care"section(if you fill the prescription at a Plan Pharmacy,you may have to pay Charges • Abortion and abortion-related Services(refer to for the item and file a claim for reimbursement as "Reproductive Health Services") described under"Payment and Reimbursement"in • Outpatient imaging and laboratory Services that are the"Emergency Services and Urgent Care" Preventive Services,such as routine mammograms, section) bone density scans,and laboratory screening tests ♦ Non—Plan Providers that are not providers of (refer to"Preventive Services") Emergency Services or Out-of-Area Urgent Care • Outpatient procedures that include imaging and if the prescription is for COVID-19 therapeutics diagnostic Services(refer to"Outpatient Surgery and (if you fill the prescription at a Plan Pharmacy, you may have to pay Charges for the item and file Outpatient Procedures") a claim for reimbursement as described in the • Services related to diagnosis and treatment of "Post-Service Claims and Appeals"section) Infertility,artificial insemination,or assisted reproductive technology("ART")Services(refer to Note:If you obtain a prescription from a Non-Plan "Fertility Services") Provider related to dental care or for COVID-19 therapeutics as described above,we do not cover an Outpatient Imaging, Laboratory, and Other office visit or any other services from the Non-Plan Diagnostic and Treatment Services exclusions Provider. • Ultraviolet light therapy comfort,convenience,or luxury equipment or features How to obtain covered items • Repair or replacement of ultraviolet light therapy You must obtain covered items at a Plan Pharmacy or equipment due to loss,theft,or misuse through our mail-order service unless you obtain the item from a Non-Plan Provider as part of covered Emergency Services,Post-Stabilization Care,or Out-of-Area Urgent Outpatient Prescription Drugs, Supplies, Care described in the"Emergency Services and Urgent and Supplements Care"section or a Non-Plan Provider prescribes COVID- 19 therapeutics for you. We cover outpatient drugs,supplies,and supplements specified in this"Outpatient Prescription Drugs, For the locations of Plan Pharmacies,refer to our Supplies,and Supplements"section,in accord with our Provider Directory or call Member Services. drug formulary guidelines,subject to any applicable exclusions or limitations under this EOC.We cover Refills You may be able to order refills at a Plan Pharmacy, through our mail-order service,or through our website at kp.org/rxrefill.A Plan Pharmacy can give you more Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 55 information about obtaining refills,including the options About the drug formulary available to you for obtaining refills.For example,a few The drug formulary includes a list of drugs that our Plan Pharmacies don't dispense refills and not all drugs Pharmacy and Therapeutics Committee has approved for can be mailed through our mail-order service.Please our Members.Our Pharmacy and Therapeutics check with a Plan Pharmacy if you have a question about Committee,which is primarily composed of Plan whether your prescription can be mailed or obtained at a Physicians and pharmacists,selects drugs for the drug Plan Pharmacy.Items available through our mail-order formulary based on several factors,including safety and service are subject to change at any time without notice. effectiveness as determined from a review of medical literature.The drug formulary is updated monthly based Day supply limit on new information or new drugs that become available. The prescribing physician or dentist determines how To find out which drugs are on the formulary for your much of a drug,supply,item,or supplement to prescribe. plan,please refer to the California Commercial HMO For purposes of day supply coverage limits,Plan formulary on our website at ky.org/formulary.The Physicians determine the amount of an item that formulary also discloses requirements or limitations that constitutes a Medically Necessary 30-or 100-day supply apply to specific drugs,such as whether there is a limit (or 365-day supply if the item is a hormonal on the amount of the drug that can be dispensed and contraceptive)for you.Upon payment of the Cost Share whether the drug must be obtained at certain specialty specified in the"Outpatient prescription drugs,supplies, pharmacies.If you would like to request a copy of this and supplements"section of the"Cost Share Summary," drug formulary,please call Member Services.Note: The you will receive the supply prescribed up to the day presence of a drug on the drug formulary does not supply limit specified in this section or in the drug necessarily mean that it will be prescribed for a particular formulary for your plan(see"About the drug formulary" medical condition. below).The maximum you may receive at one time of a covered item,other than a hormonal contraceptive,is Formulary exception process either one 30-day supply in a 30-day period or one 100- Drug formulary guidelines allow you to obtain a non- day supply in a 100-day period.If you wish to receive formulary prescription drug(those not listed on our drug more than the covered day supply limit,then you must formulary for your condition)if it would otherwise be pay Charges for any prescribed quantities that exceed the covered by your plan,as described above,and it is day supply limit. Medically Necessary.If you disagree with a Health Plan determination that a non-formulary prescription drug is If your plan includes coverage for hormonal not covered,you may file a grievance as described in the contraceptives,the maximum you may receive at one "Dispute Resolution"section. time of contraceptive drugs is a 365-day supply.To obtain a 365-day supply,talk to your prescribing Continuity drugs provider.Refer to the"Cost Share Summary"section of If this EOC is amended to exclude a drug that we have this EOC to find out if your plan includes coverage for been covering and providing to you under this EOC,we hormonal contraceptives. will continue to provide the drug if a prescription is required by law and a Plan Physician continues to If your plan includes coverage for sexual dysfunction prescribe the drug for the same condition and for a use drugs,the maximum you may receive at one time of approved by the federal Food and Drug Administration. episodic drugs prescribed for the treatment of sexual dysfunction disorders is eight doses in any 30-day period About drug tiers or up to 27 doses in any 100-day period.Refer to the Drugs for your plan are categorized into tiers as "Cost Share Summary"section of this EOC to find out if described in the table below(your plan doesn't have a your plan includes coverage for sexual dysfunction Tier 3).Your Cost Share for covered items may vary drugs. based on the tier.Refer to"Outpatient prescription drugs, supplies,and supplements"in the"Cost Share The pharmacy may reduce the day supply dispensed at Summary"section of this EOC for Cost Share for items the Cost Share specified in the"Outpatient prescription covered under this section.Refer to the drug formulary drugs,supplies,and supplements"section of the"Cost to find out which tier a particular drug is on and for the Share Summary"for any drug to a 30-day supply in any definition of"generic drug,""brand-name drug,"and 30-day period if the pharmacy determines that the item is "specialty drug." in limited supply in the market or for specific drugs (your Plan Pharmacy can tell you if a drug you take is one of these drugs). Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 56 Schedule H drugs Tier Description You or the prescribing provider can request that the pharmacy dispense less than the prescribed amount of a Tier 1 Most generic drugs,supplies and covered oral,solid dosage form of a Schedule II drug supplements(also includes certain (your Plan Pharmacy can tell you if a drug you take is brand-name drugs,supplies,and one of these drugs).Your Cost Share will be prorated supplements) based on the amount of the drug that is dispensed.If the pharmacy does not prorate your Cost Share,we will send Tier 2 Most brand-name drugs,supplies, you a refund for the difference. and supplements(also includes certain generic drugs,supplies,and Mail-order service supplements) Prescription refills can be mailed within 3 to 5 days at no extra cost for standard U.S.postage.The appropriate Tier 4 High-cost brand-name or generic Cost Share(according to your drug coverage)will apply drugs,supplies,and supplements and must be charged to a valid credit card. (sometimes called"specialty drugs") You may request mail-order service in the following ways: These tiers apply to formulary and non-formulary drugs, . To order online,visit kp.org/rxrefill(you can register supplies and supplements.If you need help determining for a secure account at kp.m/re0sternow)or use whether a formulary or non-formulary drug,supply,or the KP app from your smartphone or other mobile supplement is categorized as Tier 1,Tier 2,or Tier 4, device please call Member Services.Note:Non-formulary drugs are not covered unless Medically Necessary as described • Call the pharmacy phone number highlighted on your prescription label and select the mail delivery option under"Formulary exception process"in the"About the drug formulary"section above. • On your next visit to a Kaiser Permanente pharmacy, ask our staff how you can have your prescriptions General rules about coverage and your Cost mailed to you Share We cover the following outpatient drugs,supplies,and Note:Restrictions and limitations apply.For example, supplements as described in this"Outpatient Prescription not all drugs can be mailed and we cannot mail drugs to Drugs,Supplies,and Supplements"section: all states. • Drugs for which a prescription is required by law.We Manufacturer coupon program also cover certain over-the-counter drugs and items (drugs and items that do not require a prescription by For outpatient prescription drugs or items that are law)if they are listed on our drug formulary and covered under this"Outpatient Prescription Drugs, prescribed by a Plan Physician,except a prescription Supplies,and Supplements"section and obtained at a is not required for over-the-counter contraceptives Plan Pharmacy,you maybe able to use approved manufacturer coupons as payment for the Cost Share that • Disposable needles and syringes needed for injecting you owe,as allowed under Health Plan's coupon covered drugs and supplements program.You will owe any additional amount if the • Inhaler spacers needed to inhale covered drugs coupon does not cover the entire amount of your Cost Share for your prescription.When you use an approved Note: coupon for payment of your Cost Share,the coupon • If Charges for the drug,supply,or supplement are less amount and any additional payment that you make will accumulate to your out-of-pocket maximum if than the Copayment,you will pay the lesser amount, applicable.Refer to the"Cost Share Summary"section subject to any applicable deductible or out-of-pocket of this EOC to find your applicable out-of-pocket maximum maximum amount and to learn which drugs and items • Items can change tier at any time,in accord with apply to the maximum. Certain health plan coverages are formulary guidelines,which may impact your Cost not eligible for coupons.You can get more information Share(for example,if a brand-name drug is added to regarding the Kaiser Permanente coupon program rules the specialty drug list,you will pay the Cost Share and limitations at k%or2/rxcoup0ns. that applies to drugs on Tier 4,not the Cost Share for drugs on Tier 2) Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 57 Base drugs,supplies,and supplements Outpatient prescription drugs, supplies, and Cost Share for the following items may be different than supplements limitations other drugs,supplies,and supplements.Refer to"Base . When you are prescribed drugs solely for the drugs,supplies,and supplements"in the"Cost Share purposes of losing weight,we may require you to be Summary"section of this EOC: enrolled in a covered comprehensive weight loss • Certain drugs for the treatment of life-threatening program,for a reasonable period of time prior to or ventricular arrhythmia concurrent with receiving the prescription drug • Drugs for the treatment of tuberculosis Outpatient prescription drugs, supplies, and • Elemental dietary enteral formula when used as a supplements exclusions primary therapy for regional enteritis • Any requested packaging(such as dose packaging) • Hematopoietic agents for dialysis other than the dispensing pharmacy's standard • Hematopoietic agents for the treatment of anemia in packaging chronic renal insufficiency • Compounded products unless the drug is listed on our • Human growth hormone for long-term treatment of drug formulary or one of the ingredients requires a pediatric patients with growth failure from lack of prescription by law adequate endogenous growth hormone secretion • Drugs prescribed to shorten the duration of the • Immunosuppressants and ganciclovir and ganciclovir common cold prodrugs for the treatment of cytomegalovirus when • Prescription drugs for which there is an over-the- prescribed in connection with a transplant counter equivalent(the same active ingredient, • Phosphate binders for dialysis patients for the strength,and dosage form as the prescription drug). treatment of hyperphosphatemia in end stage renal This exclusion does not apply to: disease ♦ insulin ♦ over-the-counter drugs covered under"Preventive For the following Services, refer to these Services"in this"Benefits"section(this includes sections tobacco cessation drugs and contraceptive drugs) • Drugs prescribed for abortion or abortion-related ♦ an entire class of prescription drugs when one drug Services(refer to"Reproductive Health Services") within that class becomes available over-the- • Administered contraceptives(refer to"Reproductive counter Health Services") • All drugs,supplies,and supplements related to • Diabetes blood-testing equipment and their supplies, assisted reproductive technology("ART")Services and insulin pumps and their supplies(refer to "Durable Medical Equipment("DME")for Home Use") Outpatient Surgery and Outpatient Procedures • Drugs covered during a covered stay in a Plan Hospital or Skilled Nursing Facility(refer to We cover the following outpatient care Services: "Hospital Inpatient Services"and"Skilled Nursing . Outpatient surgery Facility Care") • Drugs prescribed for pain control and symptom • Outpatient procedures(including imaging and management of the terminal illness for Members who diagnostic Services)when provided in an outpatient are receiving covered hospice care(refer to"Hospice or ambulatory surgery center or in a hospital Care") operating room,or in any setting where a licensed staff member monitors your vital signs as you regain • Durable medical equipment used to administer drugs sensation after receiving drugs to reduce sensation or (refer to"Durable Medical Equipment("DME")for to minimize discomfort Home Use") • Outpatient administered drugs that are not For the following Services, refer to these contraceptives(refer to"Administered Drugs and sections Products") • Fertility preservation Services for iatrogenic Infertility(refer to"Fertility Preservation Services for Iatrogenic Infertility") Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 58 • Outpatient procedures(including imaging and need other care,such as diagnostic or treatment Services. diagnostic Services)that do not require a licensed If you receive any other covered Services that are not staff member to monitor your vital signs(refer to the Preventive Services before,during,or after a visit that section that would otherwise apply for the procedure; includes Preventive Services,you will pay the applicable for example,for radiology procedures that do not Cost Share for those other Services.For example,if require a licensed staff member to monitor your vital laboratory tests or imaging Services ordered during a signs,refer to"Outpatient Imaging,Laboratory,and preventive office visit are not Preventive Services,you Other Diagnostic and Treatment Services") will pay the applicable Cost Share for those Services. For the following Services, refer to these Preventive Services sections We cover a variety of Preventive Services from Plan • Milk pumps and lactation supplies(refer to"Lactation Providers,as listed on our website at kp.org/prevention, supplies"under"Durable Medical Equipment including the following: ("DME")for Home Use") • Services recommended by the United States • Health education programs(refer to"Health Preventive Services Task Force with rating of"A"or Education") "B."The complete list of these services can be found • Outpatient drugs,supplies,and supplements that are at uspreventiveservicestaskforce.org Preventive Services(refer to"Outpatient Prescription • Immunizations recommended by the Advisory Drugs,Supplies,and Supplements") Committee on Immunization Practices of the Centers o Family planning counseling,consultations,and for Disease Control and Prevention.The complete list sterilization Services(refer to"Reproductive Health of recommended immunizations can be found at Services") cdc.gov/vaccines/schedules • Preventive services recommended by the Health Prosthetic and Orthotic Devices Resources and Services Administration and incorporated into the Affordable Care Act.The Prosthetic and orthotic devices coverage rules complete list of these services can be found at We cover the prosthetic and orthotic devices specified in hrsa.gov/womens-guidelines this"Prosthetic and Orthotic Devices"section if all of Note:We cover immunizations to prevent COVID-19 the following requirements are met: that are administered in a Plan Medical Office or by a • The device is in general use,intended for repeated Non-Plan Provider.If you obtain this immunization from use,and primarily and customarily used for medical a Non-Plan Provider(except for providers of Emergency purposes Services or Out-of-Area Urgent Care),we do not cover . The device is the standard device that adequately an office visit or any other services from the Non-Plan meets your medical needs Provider other than administration of the vaccine. . you receive the device from the provider or vendor The list of Preventive Services recommended by the that we select above organizations is subject to change.These • The item has been approved for you through the Preventive Services are subject to all coverage Plan's prior authorization process,as described in requirements described in this"Benefits"section and all "Medical Group authorization procedure for certain provisions in the"Exclusions,Limitations,Coordination referrals"under"Getting a Referral"in the"How to of Benefits,and Reductions"section. Obtain Services"section • The Services are provided inside our Service Area If you are enrolled in a grandfathered plan,certain preventive items listed on our website,such as over-the- Coverage includes fitting and adjustment of these counter drugs,may not be covered.Refer to the"Certain devices,their repair or replacement,and Services to preventive items"table in the"Cost Share Summary" determine whether you need a prosthetic or orthotic section of this EOC for coverage information.If you device. If we cover a replacement device,then you pay have questions about Preventive Services,please call the Cost Share that you would pay for obtaining that Member Services. device. Note:Preventive Services help you stay healthy,before you have symptoms.If you have symptoms,you may Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 59 Base prosthetic and orthotic devices Supplemental prosthetic and orthotic devices If all of the requirements described under"Prosthetic and If all of the requirements described under"Prosthetic and orthotic coverage rules"in this"Prosthetics and Orthotic orthotic coverage rules"in this"Prosthetics and Orthotic Devices"section are met,we cover the items described Devices"section are met,we cover the following items: in this"Base prosthetic and orthotic devices"section. • Prosthetic devices required to replace all or part of an organ or extremity,but only if they also replace the Internally implanted devices function of the organ or extremity We cover prosthetic and orthotic devices such as • Rigid and semi-rigid orthotic devices required to pacemakers,intraocular lenses,cochlear implants, osseointegrated hearing devices,and hip joints,if they support or correct a defective body part are implanted during a surgery that we are covering under another section of this"Benefits"section. For the following Services, refer to these sections For internally implanted prosthetic and orthotic devices, • Eyeglasses and contact lenses,including contact you pay the Cost Share for the procedure to implant the lenses to treat aniridia or aphakia(refer to"Vision device.For example,see"Outpatient Surgery and Services for Adult Members"and"Vision Services Outpatient Procedures"in the"Cost Share Summary" for Pediatric Members") section of this EOC for the Cost Share that applies for • Hearing aids other than internally implanted devices Outpatient Surgery. described in this section(refer to"Hearing Services") External devices • Injectable implants(refer to"Administered Drugs and We cover the following external prosthetic and orthotic Products") devices: Prosthetic and orthotic devices exclusions • Prosthetic devices and installation accessories to restore a method of speaking following the removal • Multifocal intraocular lenses and intraocular lenses to of all or part of the larynx(this coverage does not correct astigmatism include electronic voice-producing machines,which • Nonrigid supplies,such as elastic stockings and wigs, are not prosthetic devices) except as otherwise described above in this • After Medically Necessary removal of all or part of a "Prosthetic and Orthotic Devices"section breast: • Comfort,convenience,or luxury equipment or ♦ prostheses,including custom-made prostheses features when Medically Necessary • Repair or replacement of device due to loss,theft,or ♦ up to three brassieres required to hold a prosthesis misuse in any 12-month period • Shoes,shoe inserts,arch supports,or any other • Podiatric devices(including footwear)to prevent or footwear,even if custom-made,except footwear treat diabetes-related complications when prescribed described above in this"Prosthetic and Orthotic by a Plan Physician or by a Plan Provider who is a Devices"section for diabetes-related complications podiatrist • Prosthetic and orthotic devices not intended for • Compression burn garments and lymphedema wraps maintaining normal activities of daily living and garments (including devices intended to provide additional • Enteral formula for Members who require tube support for recreational or sports activities) feeding in accord with Medicare guidelines • Enteral pump and supplies Reconstructive Surgery • Tracheostomy tube and supplies We cover the following reconstructive surgery Services: • Prostheses to replace all or part of an external facial . Reconstructive surgery to correct or repair abnormal body part that has been removed or impaired as a structures of the body caused by congenital defects, result of disease,injury,or congenital defect developmental abnormalities,trauma,infection, tumors,or disease,if a Plan Physician determines that it is necessary to improve function,or create a normal appearance,to the extent possible Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 60 • Following Medically Necessary removal of all or part We cover the following Services: of a breast,we cover reconstruction of the breast, • Individual outpatient physical,occupational,and surgery and reconstruction of the other breast to speech therapy produce a symmetrical appearance,and treatment of physical complications,including lymphedemas • Group outpatient physical,occupational,and speech therapy For covered Services related to reconstructive surgery • Physical,occupational,and speech therapy provided that you receive,you will pay the Cost Share you would in an organized,multidisciplinary rehabilitation day- pay if the Services were not related to reconstructive treatment program surgery.For example,see"Hospital inpatient Services" in the"Cost Share Summary"section of this EOC for the For the following Services, refer to these Cost Share that applies for hospital inpatient Services, sections and see"Outpatient surgery and outpatient procedures" e Behavioral Health Treatment for Autism Spectrum in the"Cost Share Summary"for the Cost Share that Disorder(refer to"Mental Health Services") applies for outpatient surgery. • Home health care(refer to"Home Health Care") For the following Services, refer to these • Durable medical equipment(refer to"Durable sections Medical Equipment("DME")for Home Use") • Dental and orthodontic Services that are an integral • Ostomy and urological supplies(refer to"Ostomy and part of reconstructive surgery for cleft palate(refer to Urological Supplies") "Dental and Orthodontic Services") • Prosthetic and orthotic devices(refer to"Prosthetic • Office visits not described in the"Reconstructive and Orthotic Devices") Surgery"section(refer to"Office Visits") • Physical,occupational,and speech therapy provided • Outpatient imaging and laboratory(refer to during a covered stay in a Plan Hospital or Skilled "Outpatient Imaging,Laboratory,and Other Nursing Facility(refer to"Hospital Inpatient Diagnostic and Treatment Services") Services"and"Skilled Nursing Facility Care") • Outpatient prescription drugs(refer to"Outpatient Prescription Drugs, Supplies,and Supplements") Rehabilitative and habilitative Services • Outpatient administered drugs(refer to"Administered exclusions Drugs and Products") • Items and services that are not health care items and services(for example,respite care,day care, • Prosthetics and orthotics(refer to"Prosthetic and recreational care,residential treatment,social Orthotic Devices ) services,custodial care,or education services of any • Telehealth Visits(refer to"Telehealth Visits") kind,including vocational training) Reconstructive surgery exclusions • Surgery that,in the judgment of a Plan Physician Reproductive Health Services specializing in reconstructive surgery,offers only a Family planning Services minimal improvement in appearance We cover the following Services when provided for family planning purposes: Rehabilitative and Habilitative Services • Family planning counseling • Injectable contraceptives,internally implanted time- We cover the Services described in this"Rehabilitative release contraceptives or intrauterine devices and requirements ar Services"section if all of the following ("IUDs")and office visits related to their insertion, requirements are met: removal,and management when provided to prevent • The Services are to address a health condition pregnancy • The Services are to help you keep,learn,or improve • Sterilization procedures for Members assigned female skills and functioning for daily living at birth • You receive the Services at a Plan Facility unless a • Sterilization procedures for Members assigned male Plan Physician determines that it is Medically at birth Necessary for you to receive the Services in another location Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 61 Plan Doula services ♦ Clinical or medical Services(such as taking blood If you are pregnant or were pregnant within the last 12 pressure or temperature,fetal heart tone checks, months and want Plan Doula services,talk to your care vaginal examinations,or postpartum clinical care) team.We cover the following Plan Doula services: ♦ Assistance with activities of daily living • One initial visit ♦ Alternative or complementary modalities(such as • Up to eight one-hour visits that maybe provided in aromatherapy,childbirth education,massagetherapy,or placenta encapsulation) any combination of prenatal and postpartum visits • Support during labor and delivery ♦ Yoga ♦ Birthing ceremonies Up to two additional postpartum visits may be available. ♦ Over-the-counter supplies or drugs ♦ Home birth Abortion and abortion-related Services We cover the following Services: Services in Connection with a Clinical • Surgical abortion Trial • Prescription drugs,in accord with our drug formulary guidelines We cover Services you receive in connection with a • Abortion-related Services clinical trial if all of the following requirements are met: • We would have covered the Services if they were not For the following Services, refer to these related to a clinical trial sections • You are eligible to participate in the clinical trial • Fertility preservation Services for iatrogenic according to the trial protocol with respect to Infertility(refer to"Fertility Preservation Services for treatment of cancer or other life-threatening condition Iatrogenic Infertility") (a condition from which the likelihood of death is probable unless the course of the condition is • Services to diagnose or treat Infertility(refer to interrupted),as determined in one of the following "Fertility Services") ways: • Office visits related to injectable contraceptives, ♦ a Plan Provider makes this determination internally implanted time-release contraceptives or intrauterine devices("I[JDs")when provided for ♦ you provide us with medical and scientific medical reasons other than to prevent pregnancy information establishing this determination (refer to"Office Visits") • If any Plan Providers participate in the clinical trial • Outpatient administered drugs that are not and will accept you as a participant in the clinical contraceptives(refer to"Administered Drugs and trial,you must participate in the clinical trial through Products") a Plan Provider unless the clinical trial is outside the state where you live • Outpatient laboratory and imaging services associated . The clinical trial is an Approved Clinical Trial with family planning services(refer to"Outpatient Imaging,Laboratory,and Other Diagnostic and Treatment Services") "Approved Clinical Trial"means a phase I,phase II, phase Ill,or phase IV clinical trial related to the • Outpatient contraceptive drugs and devices(refer to prevention,detection,or treatment of cancer or other "Outpatient Prescription Drugs, Supplies,and life-threatening condition,and that meets one of the Supplements") following requirements: • Outpatient surgery and outpatient procedures when . The study or investigation is conducted under an provided for medical reasons other than to prevent investigational new drug application reviewed by the pregnancy(refer to"Outpatient Surgery and federal Food and Drug Administration Outpatient Procedures") • The study or investigation is a drug trial that is Reproductive health Services exclusions exempt from having an investigational new drug application • Reversal of surgical sterilization originally performed o The study or investigation is approved or funded by at for family planning purposes least one of the following: • Plan Doula services exclusions: ♦ the National Institutes of Health Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 62 ♦ the Centers for Disease Control and Prevention • Durable medical equipment if Skilled Nursing ♦ the Agency for Health Care Research and Quality Facilities ordinarily furnish the equipment(refer to ♦ the Centers for Medicare&Medicaid Services "Medical Group authorization procedure for certain referrals"under"Getting a Referral"in the"How to ♦ a cooperative group or center of any of the above Obtain Services"section) entities or of the Department of Defense or the Department of Veterans Affairs • Imaging and laboratory Services that Skilled Nursing ♦ a qualified non-governmental research entity Facilities ordinarily provide identified in the guidelines issued by the National • Medical social services Institutes of Health for center support grants • Whole blood,red blood cells,plasma,platelets,and ♦ the Department of Veterans Affairs or the their administration Department of Defense or the Department of • Medical supplies Energy,but only if the study or investigation has been reviewed and approved though a system of • Behavioral Health Treatment for Autism Spectrum peer review that the U.S. Secretary of Health and Disorder Human Services determines meets all of the • Physical,occupational,and speech therapy following requirements: (1)It is comparable to the . Respiratory therapy National Institutes of Health system of peer review of studies and investigations and(2)it assures For the following Services, refer to these unbiased review of the highest scientific standards by qualified people who have no interest in the sections outcome of the review • Outpatient imaging,laboratory,and other diagnostic and treatment Services(refer to"Outpatient Imaging, For covered Services related to a clinical trial,you will Laboratory,and Other Diagnostic and Treatment pay the Cost Share you would pay if the Services were Services") not related to a clinical trial.For example, see"Hospital • Outpatient physical,occupational,and speech therapy inpatient Services"in the"Cost Share Summary"section (refer to"Rehabilitative and Habilitative Services") of this EOC for the Cost Share that applies for hospital inpatient Services. Substance Use Disorder Treatment Services in connection with a clinical trial exclusions We cover Services specified in this"Substance Use • The investigational Service Disorder Treatment"section only when the Services are for the prevention,diagnosis,or treatment of Substance • Services that are provided solely to satisfy data Use Disorders.A"Substance Use Disorder"is a collection and analysis needs and are not used in your substance use disorder that falls under any of the clinical management diagnostic categories listed in the mental and behavioral disorders chapter of the most recent edition of the International Classification of Diseases or that is listed Skilled Nursing Facility Care in the most recent version of the Diagnostic and Inside our Service Area,we cover skilled inpatient Statistical Manual of Mental Disorders. Services in a Plan Skilled Nursing Facility. The skilled Outpatient substance use disorder treatment inpatient Services must be customarily provided by a Skilled Nursing Facility,and above the level of custodial We cover the following Services for treatment of substance use disorders: or intermediate care. • Day-treatment programs We cover the following Services: • Individual and group substance use disorder • Physician and nursing Services counseling • Room and board • Intensive outpatient programs • Drugs prescribed by a Plan Physician as part of your • Medical treatment for withdrawal symptoms plan of care in the Plan Skilled Nursing Facility in • Methadone maintenance treatment at a licensed accord with our drug formulary guidelines if they are treatment center approved by Medical Group administered to you in the Plan Skilled Nursing Facility by medical personnel Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 63 Residential treatment For these referral Services and 988 Services,you pay the Inside our Service Area,we cover the following Services Cost Share required for Services provided by a Plan when the Services are provided in a licensed residential Provider as described in this EOC. treatment facility that provides 24-hour individualized substance use disorder treatment,the Services are For the following Services, refer to these generally and customarily provided by a substance use sections disorder residential treatment program in a licensed • Outpatient laboratory,including drug testing(refer to residential treatment facility,and the Services are above "Outpatient Imaging,Laboratory,and Other the level of custodial care: Diagnostic and Treatment Services") • Individual and group substance use disorder • Outpatient self-administered drugs(refer to counseling "Outpatient Prescription Drugs, Supplies,and • Medical services Supplements") • Medication monitoring • Telehealth Visits(refer to"Telehealth Visits") • Room and board • Social services Telehealth Visits • Drugs prescribed by a Plan Provider as part of your Telehealth Visits are intended to make it more plan of care in the residential treatment facility in convenient for you to receive covered Services,when a accord with our drug formulary guidelines if they are Plan Provider determines it is medically appropriate for administered to you in the facility by medical your medical condition.You may receive covered personnel(for discharge drugs prescribed when you Services via Telehealth Visits,when available and if the are released from the residential treatment facility, Services would have been covered under this EOC if refer to"Outpatient Prescription Drugs, Supplies,and provided in person.You are not required to use Supplements"in this"Benefits"section) Telehealth Visits,and you may choose to receive in- • Discharge planning person Services from a Plan Provider instead. Some Plan Providers offer Services exclusively through a telehealth Inpatient detoxification technology platform and have no physical location at We cover hospitalization in a Plan Hospital only for which you can receive Services.If you receive covered medical management of withdrawal symptoms,including Services from these Plan Providers,you may access your room and board,Plan Physician Services,drugs, medical record of the Telehealth Visit and,unless you dependency recovery Services,education,and object,such information will be added to your Health counseling. Plan electronic medical record and shared with your Primary Care Physician. Services from Non-Plan Providers If we are not able to offer an appointment with a Plan We cover the following types of Telehealth Visits with Provider within required geographic and timely access Primary Care Physicians,Non-Physician Specialists,and standards,we will offer to refer you to a Non-Plan Physician Specialists: Provider(as described in"Medical Group authorization • Interactive video visits procedure for certain referrals"under"Getting a • Scheduled telephone visits Referral'in the"How to Obtain Services"section). Additionally,we cover Services provided by a 988 Transplant Services center,mobile crisis team,or other provider of behavioral health crisis services(collectively,"988 We cover transplants of organs,tissue,or bone marrow if Services")for medically necessary treatment of a mental the Medical Group provides a written referral for care to health or substance use disorder without prior a transplant facility as described in"Medical Group authorization until the condition is stabilized,as required authorization procedure for certain referrals"under by state law.After the mental health or substance use "Getting a Referral'in the"How to Obtain Services" disorder condition has been stabilized,post-stabilization section. care from Non-Plan Providers is subject to prior authorization as described under"Post-Stabilization Care"in the"Emergency Services"section. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 64 After the referral to a transplant facility,the following We cover the following for Adult Members: applies: • Routine eye exams with a Plan Optometrist to • If either the Medical Group or the referral facility determine the need for vision correction(including determines that you do not satisfy its respective dilation Services when Medically Necessary)and to criteria for a transplant,we will only cover Services provide a prescription for eyeglass lenses you receive before that determination is made • Physician Specialist Visits to diagnose and treat • Health Plan,Plan Hospitals,the Medical Group,and injuries or diseases of the eye Plan Physicians are not responsible for finding, • Non-Physician Specialist Visits to diagnose and treat furnishing,or ensuring the availability of an organ, injuries or diseases of the eye tissue,or bone marrow donor • In accord with our guidelines for Services for living Optical Services transplant donors,we provide certain donation-related We cover the Services described in this"Optical Services for a donor,or an individual identified by the Services"section when received from Plan Medical Medical Group as a potential donor,whether or not Offices or Plan Optical Sales Offices. the donor is a Member. These Services must be directly related to a covered transplant for you,which The date we provide an Allowance toward(or otherwise may include certain Services for harvesting the organ, cover)an item described in this"Optical Services" tissue,or bone marrow and for treatment of section is the date on which you order the item.For complications.Please call Member Services for example,if we last provided an Allowance toward an questions about donor Services item you ordered on May 1,2023,and if we provide an Allowance not more than once every 24 months for that For covered transplant Services that you receive,you type of item,then we would not provide another will pay the Cost Share you would pay if the Services Allowance toward that type of item until on or after May were not related to a transplant.For example,see 1,2025.You can use the Allowances under this"Optical "Hospital inpatient Services"in the"Cost Share Services"section only when you first order an item.If Summary"section of this EOC for the Cost Share that you use part but not all of an Allowance when you first applies for hospital inpatient Services.We provide or pay order an item,you cannot use the rest of that Allowance for donation-related Services for actual or potential later. donors(whether or not they are Members)in accord with our guidelines for donor Services at no charge. Special contact lenses For the following Services, refer to these We cover the following: sections • For aniridia(missing iris),we cover up to two Medically Necessary contact lenses per eye • Dental Services that are Medically Necessary to (including fitting and dispensing)in any 12-month prepare for a transplant(refer to"Dental and period when prescribed by a Plan Physician or Plan Orthodontic Services") Optometrist • Outpatient imaging and laboratory(refer to • For aphakia(absence of the crystalline lens of the "Outpatient Imaging,Laboratory,and Other eye),we cover up to six Medically Necessary aphakic Diagnostic and Treatment Services") contact lenses per eye(including fitting and • Outpatient prescription drugs(refer to"Outpatient dispensing)in any 12-month period when prescribed Prescription Drugs, Supplies,and Supplements") by a Plan Physician or Plan Optometrist • Outpatient administered drugs(refer to"Administered • For other specialty contact lenses that will provide a Drugs and Products") significant improvement in your vision not obtainable with eyeglass lenses,we cover either one pair of contact lenses(including fitting and dispensing)or an Vision Services for Adult Members initial supply of disposable contact lenses(up to six months,including fitting and dispensing)in any 24- For the purpose of this"Vision Services for Adult month period Members"section,an"Adult Member"is a Member who is age 19 or older and is not a Pediatric Member,as Eyeglasses and contact lenses defined under"Vision Services for Pediatric Members" We provide a single Allowance toward the purchase in this"Benefits"section.For example,if you turn 19 on price of any or all of the following not more than once June 25,you will be an Adult Member starting July 1. every 24 months when a physician or optometrist Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 65 prescribes an eyeglass lens(for eyeglass lenses and • Items that do not require a prescription by law(other frames)or contact lens(for contact lenses).Refer to than eyeglass frames),such as eyeglass holders, "Vision Services for Adult Members"in the"Cost Share eyeglass cases,and repair kits Summary"section of this EOC for your Allowance • Lenses and sunglasses without refractive value, amount. except as described in this"Vision Services for Adult • Eyeglass lenses when a Plan Provider puts the lenses Members"section into a frame • Low vision devices ♦ we cover a clear balance lens when only one eye o Replacement of lost,broken,or damaged contact needs correction ♦ we cover tinted lenses when Medically Necessary lenses,eyeglass lenses,and frames to treat macular degeneration or retinitis pigmentosa Vision Services for Pediatric Members • Eyeglass frames when a Plan Provider puts two lenses (at least one of which must have refractive value)into For the purpose of this"Vision Services for Pediatric the frame Members"section,a"Pediatric Member"is a Member • Contact lenses,fitting,and dispensing from birth through the end of the month of their 19th birthday.For example,if you turn 19 on June 25,you We will not provide the Allowance if we have provided will be an Adult Member starting July 1 and your last an Allowance toward(or otherwise covered)eyeglass minute as a Pediatric Member will be 11:59 p.m. on June lenses or frames within the previous 24 months. 30. Replacement lenses We cover the following for Pediatric Members: If you have a change in prescription of at least.50 • Routine eye exams with a Plan Optometrist to diopter in one or both eyes within 12 months of the determine the need for vision correction(including initial point of sale of an eyeglass lens or contact lens dilation Services when Medically Necessary)and to that we provided an Allowance toward(or otherwise provide a prescription for eyeglass lenses covered)we will provide an Allowance toward the • Physician Specialist Visits to diagnose and treat purchase price of a replacement item of the same type injuries or diseases of the eye (eyeglass lens,or contact lens,fitting,and dispensing) • Non-Physician Specialist Visits to diagnose and treat for the eye that had the .50 diopter change.Refer to "Vision Services for Adult Members"in the"Cost Share injuries or diseases of the eye Summary"section of this EOC for your Allowance Optical Services amount. We cover the Services described in this"Optical Low vision devices Services"section when received from Plan Medical Low vision devices(including fitting and dispensing)are Offices or Plan Optical Sales Offices. not covered under this EOC. Special contact lenses For the following Services, refer to these We cover the following: sections • For aniridia(missing iris),we cover up to two • Routine vision screenings when performed as part of Medically Necessary contact lenses per eye a routine physical exam(refer to"Preventive (including fitting and dispensing)in any 12-month Services") period when prescribed by a Plan Physician or Plan • Services related to the eye or vision other than Optometrist Services covered under this"Vision Services for • For aphakia(absence of the crystalline lens of the Adult Members"section,such as outpatient surgery eye),we cover up to six Medically Necessary aphakic and outpatient prescription drugs,supplies,and contact lenses per eye(including fitting and supplements(refer to the applicable heading in this dispensing)in any 12-month period when prescribed "Benefits"section) by a Plan Physician or Plan Optometrist • For other specialty contact lenses that will provide a Vision Services for Adult Members exclusions significant improvement in your vision not obtainable • Eyeglass or contact lens adornment,such as with eyeglass lenses,we cover either one pair of engraving,faceting,or jeweling contact lenses(including fitting and dispensing)or an Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 66 initial supply of disposable contact lenses(up to six Vision Services for Pediatric Members months,including fitting and dispensing)in any 24- exclusions month period e Eyeglass or contact lens adornment,such as Eyeglasses and contact lenses engraving,faceting,or jeweling We provide a single Allowance toward the purchase • Items that do not require a prescription by law(other price of any or all of the following not more than once than eyeglass frames),such as eyeglass holders, every 24 months when a physician or optometrist eyeglass cases,and repair kits prescribes an eyeglass lens(for eyeglass lenses and • Lenses and sunglasses without refractive value, frames)or contact lens(for contact lenses).Refer to except as described in this"Vision Services for "Vision Services for Pediatric Members"in the"Cost Pediatric Members"section Share Summary"section of this EOC for your • Low vision devices Allowance amount. • Replacement of lost,broken,or damaged contact • Eyeglass lenses when a Plan Provider puts the lenses lenses,eyeglass lenses,and frames into a frame ♦ we cover a clear balance lens when only one eye needs correction ♦ we cover tinted lenses when Medically Necessary EXC�USIOnS, Limitations, to treat macular degeneration or retinitis Coordination Of Benefits, and pigmentosa Reductions • Eyeglass frames when a Plan Provider puts two lenses (at least one of which must have refractive value)into Exclusions the frame • Contact lenses,fitting,and dispensing The items and services listed in this"Exclusions"section are excluded from coverage.These exclusions apply to We will not provide the Allowance if we have provided all Services that would otherwise be covered under this an Allowance toward(or otherwise covered)eyeglass EOC regardless of whether the services are within the lenses or frames within the previous 24 months. scope of a provider's license or certificate.These exclusions or limitations do not apply to Services that are Replacement lenses Medically Necessary to treat mental health conditions or substance use disorders that fall under any of the If you have a change in prescription of at least.50 diagnostic categories listed in the mental and behavioral diopter in one or both eyes at least 12 months after the disorders chapter of the most recent edition of the date we dispensed eyeglass lenses of the type described International Classification of Diseases or that are listed in this"Vision Services for Pediatric Members"section, in the most recent version of the Diagnostic and we will cover a replacement Regular Eyeglass Lens for Statistical Manual of Mental Disorders. the eye that had the .50 diopter change. Low vision devices Certain exams and Services Routine physical exams and other Services that are not Low vision devices(including fitting and dispensing)are Medically Necessary,such as when required(1)for not covered under this EOC. obtaining or maintaining employment or participation in For the following Services, refer to these employee programs,(2)for insurance,credentialing or sections licensing,(3)for travel,or(4)by court order or for parole or probation. • Routine vision screenings when performed as part of a routine physical exam(refer to"Preventive Chiropractic Services Services") Chiropractic Services and the Services of a chiropractor, • Services related to the eye or vision other than unless you have coverage for supplemental chiropractic Services covered under this"Vision Services for Services as described in an amendment to this EOC. Pediatric Members"section,such as outpatient surgery and outpatient prescription drugs,supplies, Cosmetic Services and supplements(refer to the applicable heading in Services that are intended primarily to change or this"Benefits"section) maintain your appearance,including cosmetic surgery (surgery that is performed to alter or reshape normal Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 67 structures of the body in order to improve appearance), Experimental or investigational Services except that this exclusion does not apply to any of the A Service is experimental or investigational if we,in following: consultation with the Medical Group,determine that one • Services covered under"Reconstructive Surgery"in of the following is true: the"Benefits"section • Generally accepted medical standards do not • The following devices covered under"Prosthetic and recognize it as safe and effective for treating the Orthotic Devices"in the`Benefits"section:testicular condition in question(even if it has been authorized implants implanted as part of a covered reconstructive by law for use in testing or other studies on human surgery,breast prostheses needed after removal of all patients) or part of a breast,and prostheses to replace all or part • It requires government approval that has not been of an external facial body part obtained when the Service is to be provided Custodial care This exclusion does not apply to any of the following: Assistance with activities of daily living(for example: . Experimental or investigational Services when an walking,getting in and out of bed,bathing,dressing, investigational application has been filed with the feeding,toileting,and taking medicine). federal Food and Drug Administration("FDA")and the manufacturer or other source makes the Services This exclusion does not apply to assistance with available to you or Kaiser Permanente through an activities of daily living that is provided as part of FDA-authorized procedure,except that we do not covered hospice, Skilled Nursing Facility,or hospital cover Services that are customarily provided by inpatient Services. research sponsors free of charge to enrollees in a Dental and orthodontic Services clinical trial or other investigational treatment protocol Dental and orthodontic Services such as X-rays, appliances,implants, Services provided by dentists or • Services covered under Services in Connection with orthodontists,dental Services following accidental injury a Clinical Trial"in the"Benefits"section to teeth,and dental Services resulting from medical treatment such as surgery on the jawbone and radiation Refer to the"Dispute Resolution"section for information treatment. about Independent Medical Review related to denied requests for experimental or investigational Services. This exclusion does not apply to the following Services: Hair loss or growth treatment • Services covered under"Dental and Orthodontic Items and services for the promotion,prevention or Services"in the"Benefits"section other treatment of hair loss or hair growth. • Service described under"Injury to Teeth"in the "Benefits"section Intermediate care • Pediatric dental Services described in a Pediatric Care in a licensed intermediate care facility.This Dental Services Amendment to this EOC,if any.If exclusion does not apply to Services covered under your plan has a Pediatric Dental Services "Durable Medical Equipment("DME")for Home Use," Amendment,it will be attached to this EOC,and it "Home Health Care,"and"Hospice Care"in the will be listed in the EOC's Table of Contents "Benefits"section. Disposable supplies Items and services that are not health care items Disposable supplies for home use,such as bandages, and services gauze,tape,antiseptics,dressings,Ace-type bandages, For example,we do not cover: and diapers,underpads,and other incontinence supplies. • Teaching manners and etiquette • Teaching and support services to develop planning This exclusion does not apply to disposable supplies skills such as daily activity planning and project or covered under"Durable Medical Equipment("DME") for Home Use,""Home Health Care,""Hospice Care," task planning "Ostomy and Urological Supplies,"and"Outpatient • Items and services for the purpose of increasing Prescription Drugs, Supplies,and Supplements"in the academic knowledge or skills "Benefits"section. • Teaching and support services to increase intelligence Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 68 • Academic coaching or tutoring for skills such as Routine foot care items and services grammar,math,and time management Routine foot care items and services that are not • Teaching you how to read,whether or not you have Medically Necessary. dyslexia Services not approved by the federal Food and • Educational testing Drug Administration • Teaching art,dance,horse riding,music,play or Drugs,supplements,tests,vaccines,devices,radioactive swimming materials,and any other Services that by law require • Teaching skills for employment or vocational federal Food and Drug Administration("FDA")approval purposes in order to be sold in the U.S.but are not approved by the FDA.This exclusion applies to Services provided • Vocational training or teaching vocational skills anywhere,even outside the U.S. • Professional growth courses • Training for a specific job or employment counseling This exclusion does not apply to any of the following: • Aquatic therapy and other water therapy,except that • Services covered under the"Emergency Services and this exclusion for aquatic therapy and other water Urgent Care"section that you receive outside the U.S. therapy does not apply to therapy Services that are • Experimental or investigational Services when an part of a physical therapy treatment plan and covered investigational application has been filed with the under"Home Health Care,""Hospice Services," FDA and the manufacturer or other source makes the "Hospital Inpatient Services,""Rehabilitative and Services available to you or Kaiser Permanente Habilitative Services,"or"Skilled Nursing Facility through an FDA-authorized procedure,except that we Care"in the"Benefits"section do not cover Services that are customarily provided by research sponsors free of charge to enrollees in a Items and services to correct refractive defects clinical trial or other investigational treatment of the eye protocol Items and services(such as eye surgery or contact lenses • Services covered under"Services in Connection with to reshape the eye)for the purpose of correcting a Clinical Trial"in the`Benefits"section refractive defects of the eye such as myopia,hyperopia, or astigmatism. • COVID-19 Services granted emergency use authorization by the FDA(COVID-19 laboratory Massage therapy tests,therapeutics,and immunizations must be Massage therapy,and services of massage therapists. prescribed or furnished by a licensed health care provider acting within their scope of practice and the Oral nutrition and weight loss aids standard of care) Outpatient oral nutrition, such as dietary supplements, Refer to the"Dispute Resolution"section for information herbal supplements,formulas,food,and weight loss aids. about Independent Medical Review related to denied This exclusion does not apply to any of the following: requests for experimental or investigational Services. • Amino acid—modified products and elemental dietary Services performed by unlicensed people enteral formula covered under"Outpatient Services that are performed safely and effectively by Prescription Drugs, Supplies,and Supplements"in people who do not require licenses or certificates by the the"Benefits"section state to provide health care services and where the • Enteral formula covered under"Prosthetic and Member's condition does not require that the services be Orthotic Devices"in the"Benefits"section provided by a licensed health care provider. Residential care This exclusion does not apply to covered Plan Doula Care in a facility where you stay overnight,except that services. this exclusion does not apply when the overnight stay is part of covered care in a hospital,a Skilled Nursing Services related to a noncovered Service Facility,or inpatient respite care covered in the"Hospice When a Service is not covered,all Services related to the Care"section. noncovered Service are excluded, except for Services we would otherwise cover to treat complications of the noncovered Service.For example,if you have a Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 69 noncovered cosmetic surgery,we would not cover Department of Managed Health Care.Those rules are Services you receive in preparation for the surgery or for incorporated into this EOC. follow-up care. If you later suffer a life-threatening complication such as a serious infection,this exclusion If both the other coverage and we cover the same would not apply and we would cover any Services that Service,the other coverage and we will see that up to we would otherwise cover to treat that complication. 100 percent of your covered medical expenses are paid for that Service.The coordination of benefits rules Surrogacy determine which coverage pays first,or is"primary,"and Services for anyone in connection with a Surrogacy which coverage pays second,or is"secondary."The Arrangement,except for otherwise-covered Services secondary coverage may reduce its payment to take into provided to a Member who is a surrogate.Refer to account payment by the primary coverage.You must "Surrogacy Arrangements"under"Reductions"in this give us any information we request to help us coordinate "Exclusions,Limitations,Coordination of Benefits,and benefits. Reductions"section for information about your obligations to us in connection with a Surrogacy If your coverage under this EOC is secondary,we may Arrangement,including your obligations to reimburse us be able to establish a Benefit Reserve Account for you. for any Services we cover and to provide information You may draw on the Benefit Reserve Account during a about anyone who may be financially responsible for calendar year to pay for your out-of-pocket expenses for Services the baby(or babies)receive. Services that are partially covered by either your other coverage or us during that calendar year.If you are Travel and lodging expenses entitled to a Benefit Reserve Account,we will provide Travel and lodging expenses,except as described in our you with detailed information about this account. Travel and Lodging Program Description.The Travel and Lodging Program Description is available online at If you have any questions about coordination of benefits, ko.or2/specialty-care/travel-reimbursements or by please call Member Services. calling Member Services. Medicare coverage If you have Medicare coverage,we will coordinate Limitations benefits with the Medicare coverage under Medicare We will make a good faith effort to provide or arrange rules.Medicare rules determine which coverage pays for covered Services within the remaining availability of first or is"primary,"and which coverage pays second, or is"secondary."You must give us any information we facilities or personnel in the event of unusual request to help us coordinate benefits.Please call circumstances that delay or render impractical the Member Services to find out which Medicare rules apply provision of Services under this EOC,such as a major to your situation,and how payment will be handled. disaster,epidemic,war,riot,civil insurrection,disability of a large share of personnel at a Plan Facility,complete or partial destruction of facilities,and labor dispute. Reductions Under these circumstances,if you have an Emergency Medical Condition,call 911 or go to the nearest Employer responsibility emergency department as described under"Emergency For any Services that the law requires an employer to Services"in the"Emergency Services and Urgent Care" provide,we will not pay the employer,and when we section,and we will provide coverage and cover any such Services we may recover the value of the reimbursement as described in that section. Services from the employer. Government agency responsibility Coordination of Benefits For any Services that the law requires be provided only The Services covered under this EOC are subject to by or received only from a government agency,we will coordination of benefits rules. not pay the government agency,and when we cover any such Services we may recover the value of the Services Coverage other than Medicare coverage from the government agency. If you have medical or dental coverage under another Injuries or illnesses alleged to be caused by plan that is subject to coordination of benefits,we will coordinate benefits with the other coverage under the other parties coordination of benefits rules of the California If you obtain a judgment or settlement from or on behalf of another party who allegedly caused an injury or illness Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 70 for which you received covered Services,you must If your estate,parent,guardian,or conservator asserts a reimburse us to the maximum extent allowed under claim against another party based on your injury or California Civil Code Section 3040.The reimbursement illness,your estate,parent,guardian,or conservator and due to us is not limited by or subject to the Plan Out-of- any settlement or judgment recovered by the estate, Pocket Maximum.Note: This"Injuries or illnesses parent,guardian,or conservator shall be subject to our alleged to be caused by other parties"section does not liens and other rights to the same extent as if you had affect your obligation to pay your Cost Share for these asserted the claim against the other party.We may assign Services. our rights to enforce our liens and other rights. To the extent permitted or required by law,we have the If you have Medicare,Medicare law may apply with option of becoming subrogated to all claims,causes of respect to Services covered by Medicare. action,and other rights you may have against another party or an insurer,government program,or other source Surrogacy Arrangements of coverage for monetary damages,compensation,or If you enter into a Surrogacy Arrangement and you or indemnification on account of the injury or illness any other payee are entitled to receive monetary allegedly caused by the other party.We will be so compensation under the Surrogacy Arrangement,you subrogated as of the time we mail or deliver a written must reimburse us for covered Services you receive notice of our exercise of this option to you or your related to conception,pregnancy,delivery,or postpartum attorney. care in connection with that arrangement("Surrogacy Health Services")to the maximum extent allowed under To secure our rights,we will have a lien and California Civil Code Section 3040.Note:This reimbursement rights to the proceeds of any judgment or "Surrogacy Arrangements"section does not affect your settlement you or we obtain(1)against another party, obligation to pay your Cost Share for these Services. and/or(2)from other types of coverage or sources of After you surrender a baby to the legal parents,you are payment that include but are not limited to: liability, not obligated to reimburse us for any Services that the uninsured motorist,underinsured motorist,personal baby receives(the legal parents are financially umbrella,workers' compensation,and/or personal injury responsible for any Services that the baby receives). coverages,any other types of medical payments and all other first party types of coverages or sources of By accepting Surrogacy Health Services,you payment.The proceeds of any judgment or settlement automatically assign to us your right to receive payments that you or we obtain and/or payments that you receive that are payable to you or any other payee under the shall first be applied to satisfy our lien,regardless of Surrogacy Arrangement,regardless of whether those whether you are made whole and regardless of whether payments are characterized as being for medical the total amount of the proceeds is less than the actual expenses.To secure our rights,we will also have a lien losses and damages you incurred. on those payments and on any escrow account,trust,or any other account that holds those payments. Those Within 30 days after submitting or filing a claim or legal payments(and amounts in any escrow account,trust,or action against another party,you must send written other account that holds those payments)shall first be notice of the claim or legal action to: applied to satisfy our lien. The assignment and our lien will not exceed the total amount of your obligation to us The Rawlings Company under the preceding paragraph. One Eden Parkway P.O.Box 2000 Within 30 days after entering into a Surrogacy LaGrange,KY 40031-2000 Arrangement,you must send written notice of the Fax: 502-214-1137 arrangement,including all of the following information: • Names,addresses,and phone numbers of the other In order for us to determine the existence of any rights parties to the arrangement we may have and to satisfy those rights,you must complete and send us all consents,releases, • Names,addresses,and phone numbers of any escrow authorizations,assignments,and other documents, agent or trustee including lien forms directing your attorney,the other • Names,addresses,and phone numbers of the intended party,and the other party's liability insurer to pay us parents and any other parties who are financially directly.You may not agree to waive,release,or reduce responsible for Services the baby(or babies)receive, our rights under this provision without our prior,written including names,addresses,and phone numbers for consent. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 71 any health insurance that will cover Services that the recover the value of any covered Services from the baby(or babies)receive following sources: • A signed copy of any contracts and other documents • From any source providing a Financial Benefit or explaining the arrangement from whom a Financial Benefit is due • Any other information we request in order to satisfy • From you,to the extent that a Financial Benefit is our rights provided or payable or would have been required to be provided or payable if you had diligently sought to You must send this information to: establish your rights to the Financial Benefit under any workers' compensation or employer's liability The Rawlings Company law One Eden Parkway P.O.Box 2000 LaGrange,KY 40031-2000 Post-Service Claims and Appeals Fax: 502-214-1137 You must complete and send us all consents,releases, This"Post-Service Claims and Appeals"section explains authorizations,lien forms,and other documents that are how to file a claim for payment or reimbursement for reasonably necessary for us to determine the existence of Services that you have already received.Please use the any rights we may have under this"Surrogacy procedures in this section in the following situations: Arrangements"section and to satisfy those rights.You • You have received Emergency Services,Post- may not agree to waive,release,or reduce our rights Stabilization Care,Out-of-Area Urgent Care, under this"Surrogacy Arrangements"section without emergency ambulance Services,or COVID-19 our prior,written consent. testing,therapeutics,or immunization Services from a Non—Plan Provider and you want us to pay for the If your estate,parent,guardian,or conservator asserts a Services claim against another party based on the Surrogacy • You have received Services from a Non—Plan Arrangement,your estate,parent,guardian,or Provider that we did not authorize(other than conservator and any settlement or judgment recovered by Emergency Services,Post-Stabilization Care,Out-of- the estate,parent,guardian,or conservator shall be Area Urgent Care,emergency ambulance Services,or subject to our liens and other rights to the same extent as COVID-19 testing,therapeutics,or immunization if you had asserted the claim against the other party.We Services)and you want us to pay for the Services may assign our rights to enforce our liens and other . You want to appeal a denial of an initial claim for rights. payment If you have questions about your obligations under this provision please call Member Services. Please follow the procedures under"Grievances"in the "Dispute Resolution"section in the following situations: U.S. Department of Veterans Affairs • You want us to cover Services that you have not yet For any Services for conditions arising from military received service that the law requires the Department of Veterans • You want us to continue to cover an ongoing course Affairs to provide,we will not pay the Department of of covered treatment Veterans Affairs,and when we cover any such Services • You want to appeal a written denial of a request for we may recover the value of the Services from the Department of Veterans Affairs. Services that require prior authorization(as described under"Medical Group authorization procedure for Workers' compensation or employer's liability certain referrals") benefits You may be eligible for payments or other benefits, Who May File including amounts received as a settlement(collectively referred to as"Financial Benefit"),under workers' The following people may file claims: compensation or employer's liability law.We will • You may file for yourself provide covered Services even if it is unclear whether you are entitled to a Financial Benefit,but we may • You can ask a friend,relative,attorney,or any other individual to file a claim for you by appointing them in writing as your authorized representative Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 72 • A parent may file for their child under age 18,except • In person from any Member Services office at a Plan that the child must appoint the parent as authorized Facility and from Plan Providers(for addresses,refer representative if the child has the legal right to control to our Provider Directory or call Member Services) release of information that is relevant to the claim • By calling Member Services at 1-800-464-4000(TTY • A court-appointed guardian may file for their ward, users call 711) except that the ward must appoint the court-appointed guardian as authorized representative if the ward has Other supporting information the legal right to control release of information that is When you file a claim,please include any information relevant to the claim that clarifies or supports your position.For example,if • A court-appointed conservator may file for their you have paid for Services,please include any bills and conservatee receipts that support your claim.To request that we pay a Non—Plan Provider for Services,include any bills from • An agent under a currently effective health care the Non—Plan Provider.If the Non—Plan Provider states proxy,to the extent provided under state law,may file that they will file the claim,you are still responsible for for their principal making sure that we receive everything we need to process the request for payment.When appropriate,we Authorized representatives must be appointed in writing will request medical records from Plan Providers on your using either our authorization form or some other form of behalf.If you tell us that you have consulted with a Non— written notification. The authorization form is available Plan Provider and are unable to provide copies of from the Member Services office at a Plan Facility,on relevant medical records,we will contact the provider to our website at kp.org,or by calling Member Services. request a copy of your relevant medical records.We will Your written authorization must accompany the claim. ask you to provide us a written authorization so that we You must pay the cost of anyone you hire to represent or can request your records. help you. If you want to review the information that we have Supporting Documents collected regarding your claim,you may request,and we will provide without charge,copies of all relevant You can request payment or reimbursement orally or in documents,records,and other information.You also writing.Your request for payment or reimbursement,and have the right to request any diagnosis and treatment any related documents that you give us,constitute your codes and their meanings that are the subject of your claim. claim.To make a request,you should follow the steps in the written notice sent to you about your claim. Claim forms for Emergency Services, Post- Stabilization Care, Out-of-Area Urgent Care, emergency ambulance Services, and COVID-19 Initial Claims Services To request that we pay a provider(or reimburse you)for To file a claim in writing for Emergency Services,Post- Services that you have already received,you must file a Stabilization Care,Out-of-Area Urgent Care,emergency claim.If you have any questions about the claims ambulance Services,or COVID-19 testing,therapeutics, process,please call Member Services. or immunization Services,please use our claim form. You can obtain a claim form in the following ways: Submitting a claim for Emergency Services, • By visiting our website at kp.org Post-Stabilization Care, Out-of-Area Urgent • In person from any Member Services office at a Plan Care, emergency ambulance Services, andCOVID-19 Services Facility and from Plan Providers(for addresses,refer to our Provider Directory or call Member Services) You may file a claim(request for payment/reimbursement): • By calling Member Services at 1-800-464-4000(TTY • By visiting kp•org,completing an electronic form users call 711) and uploading supporting documentation; Claims forms for all other Services • By mailing a paper form that can be obtained by To file a claim in writing for all other Services,you may visiting kp•org or calling Member Services;or use our grievance form.You can obtain this form in the • If you are unable access the electronic form(or obtain following ways: the paper form),by mailing the minimum amount of • By visiting our website at kp•org information we need to process your claim: Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 73 ♦ Member/Patient Name and Medical/Health Record decision period.We will send our written decision no Number later than 15 days after the date we receive the ♦ The date you received the Services additional information.If we do not receive the ♦ Where you received the Services necessary information within the timeframe specified in our letter,we will make our decision based on the ♦ Who provided the Services information we have within 15 days after the end of ♦ Why you think we should pay for the Services that timeframe ♦ A copy of the bill,your medical record(s)for these Services,and your receipt if you paid for the If we pay any part of your claim,we will subtract Services applicable Cost Share from any payment we make to you or the Non—Plan Provider.You are not responsible for Mailing address to submit your claim to Kaiser any amounts beyond your Cost Share for covered Permanente: Emergency Services.If we deny your claim(if we do not agree to pay for all the Services you requested other than Kaiser Permanente the applicable Cost Share),our letter will explain why Claims Administration-NCAL we denied your claim and how you can appeal. P.O.Box 12923 Oakland,CA 94604-2923 If you later receive any bills from the Non—Plan Provider for covered Services(other than bills for your Cost Please call Member Services if you need help filing your Share),please call Member Services for assistance. claim. Submitting a claim for all other Services Appeals If you have received any other Services from a Non—Plan Claims for Emergency Services, Post- Provider that we did not authorize,then as soon as Stabilization Care, Out-of-Area Urgent Care, possible after you receive the Services,you must file emergency ambulance Services, or COVID-19 your claim in one of the following ways: Services from a Non—Plan Provider • By delivering your claim to a Member Services office If we did not decide fully in your favor and you want to at a Plan Facility(for addresses,refer to our Provider appeal our decision,you may submit your appeal in one Directory or call Member Services) of the following ways: • By mailing your claim to a Member Services office at • By mailing your appeal to the Claims Department at a Plan Facility(for addresses,refer to our Provider the following address: Directory or call Member Services) Kaiser Foundation Health Plan,Inc. • By calling Member Services at 1-800-464-4000(TTY Special Services Unit users call 711) P.O.Box 23280 Oakland,CA 94623 • By visiting our website at kp.org • By calling Member Services at 1-800-464-4000(TTY Please call Member Services if you need help filing your users call 711) claim. By visiting our website at k1p.org After we receive your claim Claims for all other Services from a Non-Plan Provider that we did not authorize We will send you an acknowledgment letter within five days after we receive your claim. If we did not decide fully in your favor and you want to appeal our decision,you may submit your appeal in one After we review your claim,we will respond as follows: of the following ways: • If we have all the information we need we will send • By visiting our website at kp.org you a written decision within 30 days after we receive • By mailing your appeal to any Member Services your claim.We may extend the time for making a office at a Plan Facility(for addresses,refer to our decision for an additional 15 days if circumstances Provider Directory or call Member Services) beyond our control delay our decision,if we notify • In person at any Member Services office at a Plan you within 30 days after we receive your claim Facility or any Plan Provider(for addresses,refer to • If we need more information,we will ask you for the our Provider Directory or call Member Services) information before the end of the initial 30-day Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 74 • By calling Member Services at 1-800-464-4000(TTY We will send you a resolution letter within 30 days after users call 711) we receive your appeal.If we do not decide in your favor,our letter will explain why and describe your When you file an appeal,please include any information further appeal rights. that clarifies or supports your position.If you want to review the information that we have collected regarding your claim,you may request,and we will provide External Review without charge,copies of all relevant documents, You must exhaust our internal claims and appeals records,and other information.To make a request,you procedures before you may request external review should call Member Services. unless we have failed to comply with the claims and Additional information regarding claims for all appeals procedures described in this"Post-Service other Services from a Non—Plan Provider that Claims and Appeals"section.For information about the we did not authorize external review process,see"Independent Medical Review("IMR")"in the"Dispute Resolution"section. If we initially denied your request,you must file your appeal within 180 days after the date you received our denial letter.You may send us information including Additional Review comments,documents,and medical records that you believe support your claim. If we asked for additional You may have certain additional rights if you remain information and you did not provide it before we made dissatisfied after you have exhausted our internal claims our initial decision about your claim,then you may still and appeals procedure,and if applicable,external send us the additional information so that we may review: include it as part of our review of your appeal.Please • If your Group's benefit plan is subject to the send all additional information to the address or fax Employee Retirement Income Security Act mentioned in your denial letter. ("ERISA"),you may file a civil action under section 502(a)of ERISA. To understand these rights,you Also,you may give testimony in writing or by phone. should check with your Group or contact the Please send your written testimony to the address Employee Benefits Security Administration(part of mentioned in our acknowledgment letter,sent to you the U.S.Department of Labor)at 1-866-444-EBSA within five days after we receive your appeal.To arrange (1-866-444-3272) to give testimony by phone,you should call the phone . If your Group's benefit plan is not subject to ERISA number mentioned in our acknowledgment letter. (for example,most state or local government plans We will add the information that you provide through and church plans),you may have a right to request testimony or other means to your appeal file and we will review in state court review it without regard to whether this information was filed or considered in our initial decision regarding your request for Services.You have the right to request any Dispute Resolution diagnosis and treatment codes and their meanings that are the subject of your claim. We are committed to providing you with quality care and with a timely response to your concerns.You can discuss We will share any additional information that we collect your concerns with our Member Services representatives in the course of our review and we will send it to you.If at most Plan Facilities,or you can call Member Services. we believe that your request should not be granted, before we issue our final decision letter,we will also share with you any new or additional reasons for that Grievances decision.We will send you a letter explaining the additional information and/or reasons. Our letters about This"Grievances"section describes our grievance additional information and new or additional rationales procedure.A grievance is any expression of will tell you how you can respond to the information dissatisfaction expressed by you or your authorized provided if you choose to do so.If you do not respond representative through the grievance process.If you want before we must issue our final decision letter,that to make a claim for payment or reimbursement for decision will be based on the information in your appeal Services that you have already received from a Non—Plan file. Provider,please follow the procedure in the"Post- Service Claims and Appeals"section. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 75 Here are some examples of reasons you might file a • Your physician may act as your authorized grievance: representative with your verbal consent to request an • You are not satisfied with the quality of care you urgent grievance as described under"Urgent received procedure"in this"Grievances"section • You received a written denial of Services that require Authorized representatives must be appointed in writing prior authorization from the Medical Group and you using either our authorization form or some other form of want us to cover the Services written notification.The authorization form is available • You received a written denial for a second opinion or from the Member Services office at a Plan Facility,on we did not respond to your request for a second our website at kp.org,or by calling Member Services. opinion in an expeditious manner,as appropriate for Your written authorization must accompany the your condition grievance.You must pay the cost of anyone you hire to • Your treating physician has said that Services are not represent or help you. Medically Necessary and you want us to cover the How to file Services You can file a grievance orally or in writing.Your • You were told that Services are not covered and you grievance must explain your issue,such as the reasons believe that the Services should be covered why you believe a decision was in error or why you are • You want us to continue to cover an ongoing course dissatisfied with the Services you received. of covered treatment • You are dissatisfied with how long it took to get Standard Procedure Services,including getting an appointment,in the To file a grievance electronically,use the grievance form waiting room,or in the exam room on kp.org. • You want to report unsatisfactory behavior by To file a grievance orally,call Member Services toll free providers or staff,or dissatisfaction with the condition at 1-800-464-4000(TTY users call 711). of a facility • You believe you have faced discrimination from To file a grievance in writing,please use our grievance providers,staff,or Health Plan form,which is available on kp•org under"Forms& • We terminated your membership and you disagree Publications,"in person from any Member Services with that termination office at a Plan Facility,or from Plan Providers(for addresses,refer to our Provider Directory or call Member Who may file Services).You can submit the form in the following The following people may file a grievance: ways: You may file for yourself • In person at any Member Services office at a Plan •• You can ask a friend,relative,attorney,or any other Facility individual to file a grievance for you by appointing • By mail to any Member Services office at a Plan them in writing as your authorized representative Facility • A parent may file for their child under age 18,except You must file your grievance within 180 days following that the child must appoint the parent as authorized the incident or action that is subject to your representative if the child has the legal right to control dissatisfaction.You may send us information including release of information that is relevant to the grievance comments,documents,and medical records that you • A court-appointed guardian may file for their ward, believe support your grievance. except that the ward must appoint the court-appointed guardian as authorized representative if the ward has Please call Member Services if you need help filing a the legal right to control release of information that is grievance. relevant to the grievance • A court-appointed conservator may file for their If your grievance involves a request to obtain a non- conservatee formulary prescription drug,we will notify you of our decision within 72 hours.If we do not decide in your • An agent under a currently effective health care favor,our letter will explain why and describe your proxy,to the extent provided under state law,may file further appeal rights.For information on how to request for their principal a review by an independent review organization,see Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 76 "Independent Review Organization for Non-Formulary • Using the standard procedure would,in the opinion of Prescription Drug Requests"in this"Dispute Resolution" a physician with knowledge of your medical section. condition,subject you to severe pain that cannot be adequately managed without extending your course of For all other grievances,we will send you an covered treatment acknowledgment letter within five days after we receive . A physician with knowledge of your medical your grievance.We will send you a resolution letter condition determines that your grievance is urgent within 30 days after we receive your grievance.If you are requesting Services,and we do not decide in your • You have received Emergency Services but have not favor,our letter will explain why and describe your been discharged from a facility and your request further appeal rights. involves admissions,continued stay,or other health care Services If you want to review the information that we have • You are undergoing a current course of treatment collected regarding your grievance,you may request,and using a non-formulary prescription drug and your we will provide without charge,copies of all relevant grievance involves a request to refill a non-formulary documents,records,and other information. To make a prescription drug request,you should call Member Services. For most grievances that we respond to on an urgent Urgent procedure basis,we will give you oral notice of our decision as If you want us to consider your grievance on an urgent soon as your clinical condition requires,but no later than basis,please tell us that when you file your grievance. 72 hours after we received your grievance.We will send Note:Urgent is sometimes referred to as"exigent."If you a written confirmation of our decision within three exigent circumstances exist,your grievance may be days after we received your grievance. reviewed using the urgent procedure described in this section. If your grievance involves a request to obtain a non- formulary prescription drug and we respond to your You must file your urgent grievance in one of the request on an urgent basis,we will notify you of our following ways: decision within 24 hours of your request.For information • By calling our Expedited Review Unit toll free at on how to request a review by an independent review 1-888-987-7247(TTY users call 711) organization,see"Independent Review Organization for Non-Formulary Prescription Drug Requests"in this • By mailing a written request to: "Dispute Resolution"section. Kaiser Foundation Health Plan,Inc. Expedited Review Unit If we do not decide in your favor,our letter will explain P.O.Box 1809 why and describe your further appeal rights. Pleasanton,CA 94566 • By faxing a written request to our Expedited Review Note:If you have an issue that involves an imminent and Unit toll free at 1-888-987-2252 serious threat to your health(such as severe pain or potential loss of life,limb,or major bodily function),you • By visiting a Member Services office at a Plan can contact the California Department of Managed Facility(for addresses,refer to our Provider Directory Health Care at any time at 1-888-466-2219(TDD 1-877- or call Member Services) 688-9891)without first filing a grievance with us. • By completing the grievance form on our website at ky.om If you want to review the information that we have collected regarding your grievance,you may request,and We will decide whether your grievance is urgent or non- we will provide without charge,copies of all relevant urgent unless your attending health care provider tells us documents,records,and other information. To make a your grievance is urgent.If we determine that your request,you should call Member Services. grievance is not urgent,we will use the procedure described under"Standard procedure"in this Additional information regarding pre-service requests "Grievances"section.Generally,a grievance is urgent for Medically Necessary Services only if one of the following is true: You may give testimony in writing or by phone.Please • Using the standard procedure could seriously send your written testimony to the address mentioned in jeopardize your life,health,or ability to regain our acknowledgment letter.To arrange to give testimony maximum function Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 77 by phone,you should call the phone number mentioned decision letter,that decision will be based on the in our acknowledgment letter. information in your appeal file. We will add the information that you provide through Additional information about utilization review testimony or other means to your grievance file and we determination criteria for mental health Services or will consider it in our decision regarding your pre- substance use disorder treatment service request for Medically Necessary Services. Utilization review determination criteria and any education program materials for individuals making We will share any additional information that we collect authorization decisions related to mental health Services in the course of our review and we will send it to you.If or substance use disorder treatment are available at we believe that your request should not be granted, kp•or2 at no cost. before we issue our decision letter,we will also share with you any new or additional reasons for that decision. We will send you a letter explaining the additional Independent Review Organization for information and/or reasons. Our letters about additional Non-Formulary Prescription Drug information and new or additional rationales will tell you Requests how you can respond to the information provided if you choose to do so.If your grievance is urgent,the If you filed a grievance to obtain a non-formulary information will be provided to you orally and followed prescription drug and we did not decide in your favor, in writing.If you do not respond before we must issue you may submit a request for a review of your grievance our final decision letter,that decision will be based on by an independent review organization("IRO").You the information in your grievance file. must submit your request for IRO review within 180 days of the receipt of our decision letter. Additional information regarding appeals of written denials for Services that require prior authorization You must file your request for IRO review in one of the You must file your appeal within 180 days after the date following ways: you received our denial letter. • By calling our Expedited Review Unit toll free at 1-888-987-7247(TTY users call 711) You have the right to request any diagnosis and treatment codes and their meanings that are the subject of • By mailing a written request to: your appeal. Kaiser Foundation Health Plan,Inc. Expedited Review Unit Also,you may give testimony in writing or by phone. P.O.Box 1809 Please send your written testimony to the address Pleasanton,CA 94566 mentioned in our acknowledgment letter.To arrange to o By faxing a written request to our Expedited Review give testimony by phone,you should call the phone Unit toll free at 1-888-987-2252 number mentioned in our acknowledgment letter. . By visiting a Member Services office at a Plan We will add the information that you provide through Facility(for addresses,refer to our Provider Directory testimony or other means to your appeal file and we will or call Member Services) consider it in our decision regarding your appeal. • By completing the grievance form on our website at kp•or2 We will share any additional information that we collect in the course of our review and we will send it to you.If For urgent IRO reviews,we will forward to you the we believe that your request should not be granted, independent reviewer's decision within 24 hours.For before we issue our decision letter,we will also share non-urgent requests,we will forward the independent with you any new or additional reasons for that decision. reviewer's decision to you within 72 hours.If the We will send you a letter explaining the additional independent reviewer does not decide in your favor,you information and/or reasons. Our letters about additional may submit a complaint to the Department of Managed information and new or additional rationales will tell you Health Care,as described under"Department of how you can respond to the information provided if you Managed Health Care Complaints"in this"Dispute choose to do so.If your appeal is urgent,the information Resolution"section.You may also submit a request for will be provided to you orally and followed in writing.If an Independent Medical Review as described under you do not respond before we must issue our final "Independent Medical Review"in this"Dispute Resolution"section. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 78 Department of Managed Health Care from a provider who determined the Services to be Complaints Medically Necessary ♦ you have been seen by a Plan Provider for the The California Department of Managed Health Care is diagnosis or treatment of your medical condition responsible for regulating health care service plans.If . Your request for payment or Services has been you have a grievance against your health plan,you denied,modified,or delayed based in whole or in part should first telephone your health plan toll free at 1-800-464-4000 (TTY users call 711)and use your N a decision that the Services are not Medically Necessary health plan's grievance process before contacting the department.Utilizing this grievance procedure does not • You have filed a grievance and we have denied it or prohibit any potential legal rights or remedies that may we haven't made a decision about your grievance be available to you.If you need help with a grievance within 30 days(or three days for urgent grievances). involving an emergency,a grievance that has not been The DMHC may waive the requirement that you first satisfactorily resolved by your health plan,or a grievance file a grievance with us in extraordinary and that has remained unresolved for more than 30 days,you compelling cases,such as severe pain or potential loss may call the department for assistance.You may also be of life,limb,or major bodily function.If we have eligible for an Independent Medical Review(IMR).If denied your grievance,you must submit your request you are eligible for IMR,the IMR process will provide for an IMR within six months of the date of our an impartial review of medical decisions made by a written denial.However,the DMHC may accept your health plan related to the medical necessity of a proposed request after six months if they determine that service or treatment,coverage decisions for treatments circumstances prevented timely submission that are experimental or investigational in nature and payment disputes for emergency or urgent medical You may also qualify for IMR if the Service you services.The department also has a toll-free telephone requested has been denied on the basis that it is number(1-888-466-2219)and a TDD line experimental or investigational as described under (1-877-688-9891)for the hearing and speech "Experimental or investigational denials." impaired.The department's Internet website If the DMHC determines that your case is eligible for www.dmhC.Ca.gOV has complaint forms,IMR IMR,it will ask us to send your case to the DMHC's application forms and instructions online. IMR organization.The DMHC will promptly notify you of its decision after it receives the IMR organization's Independent Medical Review ("IMR") determination.If the decision is in your favor,we will contact you to arrange for the Service or payment. Except as described in this"Independent Medical Review("IMR")"section,you must exhaust our internal Experimental or investigational denials grievance procedure before you may request independent If we deny a Service because it is experimental or medical review unless we have failed to comply with the investigational,we will send you our written explanation grievance procedure described under"Grievances"in within three days after we received your request.We will this"Dispute Resolution"section.If you qualify,you or explain why we denied the Service and provide your authorized representative may have your issue additional dispute resolution options.Also,we will reviewed through the IMR process managed by the provide information about your right to request California Department of Managed Health Care Independent Medical Review if we had the following ("DMHC").The DMHC determines which cases qualify information when we made our decision: for IMR.This review is at no cost to you.If you decide . Your treating physician provided us a written not to request an IMR,you may give up the right to statement that you have a life-threatening or seriously pursue some legal actions against us. debilitating condition and that standard therapies have not been effective in improving your condition,or You may qualify for IMR if all of the following are true: that standard therapies would not be appropriate,or • One of these situations applies to you: that there is no more beneficial standard therapy we cover than the therapy being requested."Life- requesting you have a recommendation from a provider threatening"means diseases or conditions where the requesting Medically Necessary Services likelihood of death is high unless the course of the ♦ you have received Emergency Services, disease is interrupted,or diseases or conditions with emergency ambulance Services,or Urgent Care potentially fatal outcomes where the end point of clinical intervention is survival."Seriously Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 79 debilitating"means diseases or conditions that cause 502(a)of ERISA. To understand these rights,you major irreversible morbidity should check with your Group or contact the • If your treating physician is a Plan Physician,they Employee Benefits Security Administration(part of recommended a treatment,drug,device,procedure,or the U.S.Department of Labor)at 1-866-444-EBSA other therapy and certified that the requested therapy (1-866-444-3272) is likely to be more beneficial to you than any • If your Group's benefit plan is not subject to ERISA available standard therapies and included a statement (for example,most state or local government plans of the evidence relied upon by the Plan Physician in and church plans),you may have a right to request certifying their recommendation review in state court • You(or your Non—Plan Physician who is a licensed, and either a board-certified or board-eligible, Binding Arbitration physician qualified in the area of practice appropriate to treat your condition)requested a therapy that, For all claims subject to this`Binding Arbitration" based on two documents from the medical and section,both Claimants and Respondents give up the scientific evidence,as defined in California Health right to a jury or court trial and accept the use of binding and Safety Code Section 1370.4(d),is likely to be arbitration.Insofar as this"Binding Arbitration"section more beneficial for you than any available standard applies to claims asserted by Kaiser Permanente Parties, therapy. The physician's certification included a it shall apply retroactively to all unresolved claims that statement of the evidence relied upon by the accrued before the effective date of this EOC. Such physician in certifying their recommendation.We do retroactive application shall be binding only on the not cover the Services of the Non—Plan Provider Kaiser Permanente Parties. Note:You can request IMR for experimental or Scope of arbitration investigational denials at any time without first filing a Any dispute shall be submitted to binding arbitration if grievance with us. all of the following requirements are met: • The claim arises from or is related to an alleged Office of Civil Rights Complaints violation of any duty incident to or arising out of or relating to this EOC or a Member Party's relationship If you believe that you have been discriminated against to Kaiser Foundation Health Plan,Inc.("Health by a Plan Provider or by us because of your race,color, Plan"),including any claim for medical or hospital national origin,disability,age,sex(including sex malpractice(a claim that medical services or items stereotyping and gender identity),or religion,you may were unnecessary or unauthorized or were file a complaint with the Office of Civil Rights in the improperly,negligently,or incompetently rendered), United States Department of Health and Human Services for premises liability,or relating to the coverage for, ("OCR"). or delivery of,services or items,irrespective of the legal theories upon which the claim is asserted You may file your complaint with the OCR within 180 . The claim is asserted by one or more Member Parties days of when you believe the act of discrimination against one or more Kaiser Permanente Parties or by occurred.However,the OCR may accept your request one or more Kaiser Permanente Parties against one or after six months if they determine that circumstances more Member Parties prevented timely submission.For more information on the OCR and how to file a complaint with the OCR,go • Governing law does not prevent the use of binding to hhs.gov/civil-rights. arbitration to resolve the claim Members enrolled under this EOC thus give up their Additional Review right to a court or jury trial,and instead accept the use of binding arbitration except that the following types of You may have certain additional rights if you remain claims are not subject to binding arbitration: dissatisfied after you have exhausted our internal claims and appeals procedure,and if applicable,external • Claims within the jurisdiction of the Small Claims review: Court • If your Group's benefit plan is subject to the • Claims subject to a Medicare appeal procedure as Employee Retirement Income Security Act applicable to Kaiser Permanente Senior Advantage ("ERISA"),you may file a civil action under section Members Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 80 • Claims that cannot be subject to binding arbitration on the same incident,transaction,or related under governing law circumstances. As referred to in this"Binding Arbitration"section, Serving Demand for Arbitration "Member Parties"include: Health Plan,Kaiser Foundation Hospitals,The • A Member Permanente Medical Group,Inc., Southern California Permanente Medical Group,The Permanente Federation, • A Member's heir,relative,or personal representative LLC,and The Permanente Company,LLC,shall be • Any person claiming that a duty to them arises from a served with a Demand for Arbitration by mailing the Member's relationship to one or more Kaiser Demand for Arbitration addressed to that Respondent in Permanente Parties care of: Kaiser Foundation Health Plan,Inc. "Kaiser Permanente Parties"include: Legal Department,Professional&Public Liability • Kaiser Foundation Health Plan,Inc. 1 Kaiser Plaza, 191h Floor • Kaiser Foundation Hospitals Oakland,CA 94612 • The Permanente Medical Group,Inc. Service on that Respondent shall be deemed completed • Southern California Permanente Medical Group when received.All other Respondents,including individuals,must be served as required by the California • The Permanente Federation,LLC Code of Civil Procedure for a civil action. • The Permanente Company,LLC • Any Southern California Permanente Medical Group Filing fee or The Permanente Medical Group physician The Claimants shall pay a single,nonrefundable filing fee of$150 per arbitration payable to"Arbitration • Any individual or organization whose contract with Account"regardless of the number of claims asserted in any of the organizations identified above requires the Demand for Arbitration or the number of Claimants arbitration of claims brought by one or more Member or Respondents named in the Demand for Arbitration. Parties • Any employee or agent of any of the foregoing Any Claimant who claims extreme hardship may request that the Office of the Independent Administrator waive "Claimant"refers to a Member Party or a Kaiser the filing fee and the neutral arbitrator's fees and Permanente Party who asserts a claim as described expenses.A Claimant who seeks such waivers shall above."Respondent"refers to a Member Party or a complete the Fee Waiver Form and submit it to the Kaiser Permanente Party against whom a claim is Office of the Independent Administrator and asserted. simultaneously serve it upon the Respondents.The Fee Waiver Form sets forth the criteria for waiving fees and Rules of Procedure is available by calling Member Services. Arbitrations shall be conducted according to the Rules for Kaiser Permanente Member Arbitrations Overseen Number of arbitrators by the Office of the Independent Administrator("Rules The number of arbitrators may affect the Claimants' of Procedure")developed by the Office of the responsibility for paying the neutral arbitrator's fees and Independent Administrator in consultation with Kaiser expenses(see the Rules of Procedure). Permanente and the Arbitration Oversight Board. Copies of the Rules of Procedure may be obtained from Member If the Demand for Arbitration seeks total damages of Services. $200,000 or less,the dispute shall be heard and determined by one neutral arbitrator,unless the parties Initiating arbitration otherwise agree in writing after a dispute has arisen and a Claimants shall initiate arbitration by serving a Demand request for binding arbitration has been submitted that for Arbitration. The Demand for Arbitration shall include the arbitration shall be heard by two party arbitrators and the basis of the claim against the Respondents;the one neutral arbitrator.The neutral arbitrator shall not amount of damages the Claimants seek in the arbitration; have authority to award monetary damages that are the names,addresses,and phone numbers of the greater than$200,000. Claimants and their attorney,if any;and the names of all Respondents. Claimants shall include in the Demand for If the Demand for Arbitration seeks total damages of Arbitration all claims against Respondents that are based more than$200,000,the dispute shall be heard and Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 81 determined by one neutral arbitrator and two party future damages conformed to periodic payments,shall arbitrators,one jointly appointed by all Claimants and apply to any claims for professional negligence or any one jointly appointed by all Respondents.Parties who are other claims as permitted or required by law. entitled to select a party arbitrator may agree to waive this right.If all parties agree,these arbitrations will be Arbitrations shall be governed by this"Binding heard by a single neutral arbitrator. Arbitration"section, Section 2 of the Federal Arbitration Act,and the California Code of Civil Procedure Payment of arbitrators'fees and expenses provisions relating to arbitration that are in effect at the Health Plan will pay the fees and expenses of the neutral time the statute is applied,together with the Rules of arbitrator under certain conditions as set forth in the Procedure,to the extent not inconsistent with this Rules of Procedure.In all other arbitrations,the fees and "Binding Arbitration"section.In accord with the rule expenses of the neutral arbitrator shall be paid one-half that applies under Sections 3 and 4 of the Federal by the Claimants and one-half by the Respondents. Arbitration Act,the right to arbitration under this "Binding Arbitration"section shall not be denied,stayed, If the parties select party arbitrators,Claimants shall be or otherwise impeded because a dispute between a responsible for paying the fees and expenses of their Member Party and a Kaiser Permanente Party involves party arbitrator and Respondents shall be responsible for both arbitrable and nonarbitrable claims or because one paying the fees and expenses of their party arbitrator. or more parties to the arbitration is also a party to a pending court action with another party that arises out of Costs the same or related transactions and presents a possibility Except for the aforementioned fees and expenses of the of conflicting rulings or findings. neutral arbitrator,and except as otherwise mandated by laws that apply to arbitrations under this"Binding Arbitration"section,each party shall bear the party's Termination of Membership own attorneys' fees,witness fees,and other expenses incurred in prosecuting or defending against a claim Your Group is required to inform the Subscriber of the regardless of the nature of the claim or outcome of the date your membership terminates.Your membership arbitration. termination date is the first day you are not covered(for General provisions example,if your termination date is January 1,2026, your last minute of coverage was at 11:59 p.m.on A claim shall be waived and forever barred if(1)on the December 31,2025).When a Subscriber's membership date the Demand for Arbitration of the claim is served, ends,the memberships of any Dependents end at the the claim,if asserted in a civil action,would be barred as same time.You will be billed as a non-Member for any to the Respondent served by the applicable statute of Services you receive after your membership terminates. limitations,(2)Claimants fail to pursue the arbitration Health Plan and Plan Providers have no further liability claim in accord with the Rules of Procedure with or responsibility under this EOC after your membership reasonable diligence,or(3)the arbitration hearing is not terminates,except as provided under"Payments after commenced within five years after the earlier of(a)the Termination"in this"Termination of Membership" date the Demand for Arbitration was served in accord section. with the procedures prescribed herein,or(b)the date of filing of a civil action based upon the same incident, transaction,or related circumstances involved in the Termination Due to Loss of Eligibility claim.A claim may be dismissed on other grounds by the neutral arbitrator based on a showing of a good cause.If If you no longer meet the eligibility requirements a party fails to attend the arbitration hearing after being described under"Who Is Eligible"in the"Premiums, given due notice thereof,the neutral arbitrator may Eligibility,and Enrollment"section,your Group will proceed to determine the controversy in the party's notify you of the date that your membership will end. absence. Your membership termination date is the first day you are not covered.For example,if your termination date is The California Medical Injury Compensation Reform January 1,2026,your last minute of coverage was at Act of 1975 (including any amendments thereto), 11:59 p.m. on December 31,2025. including sections establishing the right to introduce evidence of any insurance or disability benefit payment to the patient,the limitation on recovery for non- economic losses,and the right to have an award for Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 82 Termination of Agreement Payments after Termination If your Group's Agreement with us terminates for any If we terminate your membership for cause or for reason,your membership ends on the same date.Your nonpayment,we will: Group is required to notify Subscribers in writing if its • Refund any amounts we owe your Group for Agreement with us terminates. Premiums paid after the termination date • Pay you any amounts we have determined that we Termination for Cause owe you for claims during your membership in accord with the"Emergency Services and Urgent If you intentionally commit fraud in connection with Care"and"Dispute Resolution"sections membership,Health Plan,or a Plan Provider,we may terminate your membership by sending written notice to We will deduct any amounts you owe Health Plan or the Subscriber;termination will be effective 30 days Plan Providers from any payment we make to you. from the date we send the notice. Some examples of fraud include: • Misrepresenting eligibility information about you or a State Review of Membership Dependent Termination • Presenting an invalid prescription or physician order If you believe that we have terminated your membership • Misusing a Kaiser Permanente ID card(or letting because of your ill health or your need for care,you may someone else use it) request a review of the termination by the California • Giving us incorrect or incomplete material Department of Managed Health Care(please see information.For example,you have entered into a "Department of Managed Health Care Complaints"in Surrogacy Arrangement and you fail to send us the the"Dispute Resolution"section). information we require under"Surrogacy Arrangements"under"Reductions"in the "Exclusions,Limitations,Coordination of Benefits, Continuation Of Membership and Reductions"section • Failing to notify us of changes in family status or If your membership under this EOC ends,you may be Medicare coverage that may affect your eligibility or eligible to continue Health Plan membership without a benefits break in coverage.You may be able to continue Group coverage under this EOC as described under If we terminate your membership for cause,you will not "Continuation of Group Coverage."Also,you may be be allowed to enroll in Health Plan in the future.We may able to continue membership under an individual plan as also report criminal fraud and other illegal acts to the described under"Continuation of Coverage under an authorities for prosecution. Individual Plan."If at any time you become entitled to continuation of Group coverage,please examine your coverage options carefully before declining this Termination of a Product or all Products coverage.Individual plan premiums and coverage will be different from the premiums and coverage under your We may terminate a particular product or all products Group plan. offered in the group market as permitted or required by law.If we discontinue offering a particular product in the group market,we will terminate just the particular Continuation of Group Coverage product by sending you written notice at least 90 days before the product terminates.If we discontinue offering COBRA all products in the group market,we may terminate your You may be able to continue your coverage under this Group's Agreement by sending you written notice at EOC for a limited time after you would otherwise lose least 180 days before the Agreement terminates. eligibility,if required by the federal Consolidated Omnibus Budget Reconciliation Act("COBRA"). COBRA applies to most employees(and most of their covered family Dependents)of most employers with 20 or more employees. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 83 If your Group is subject to COBRA and you are eligible must send us the Premium payment by the due date on for COBRA coverage,in order to enroll you must submit the bill to be enrolled in Cal-COBRA. a COBRA election form to your Group within the COBRA election period.Please ask your Group for After that first payment,your Premium payment for the details about COBRA coverage,such as how to elect upcoming coverage month is due on the last day of the coverage,how much you must pay for coverage,when preceding month. The Premiums will not exceed 110 coverage and Premiums may change,and where to send percent of the applicable Premiums charged to a your Premium payments. similarly situated individual under the Group benefit plan except that Premiums for disabled individuals after 18 If you enroll in COBRA and exhaust the time limit for months of COBRA coverage will not exceed 150 percent COBRA coverage,you may be able to continue Group instead of 110 percent.Returned checks or insufficient coverage under state law as described under"Cal- funds on electronic payments may be subject to a fee. COBRA"in this"Continuation of Group Coverage" section. If you have selected Ancillary Coverage provided under any other program,the Premium for that Ancillary Cal-COBRA Coverage will be billed together with required Premiums If you are eligible for coverage under the California for coverage under this EOC.Full Premiums will then Continuation Benefits Replacement Act("Cal- also include Premium for Ancillary Coverage. This COBRA"),you can continue coverage as described in means if you do not pay the Full Premiums owed by the this"Cal-COBRA"section if you apply for coverage in due date,we may terminate your membership under this compliance with Cal-COBRA law and pay applicable EOC and any Ancillary Coverage,as described in the Premiums. "Termination for nonpayment of Cal-COBRA Premiums"section. Eligibility and effective date of coverage for Cal- COBRA after COBRA Changes to Cal-COBRA coverage and Premiums If your group is subject to COBRA and your COBRA Your Cal-COBRA coverage is the same as for any coverage ends,you may be able to continue Group similarly situated individual under your Group's coverage effective the date your COBRA coverage ends Agreement,and your Cal-COBRA coverage and if all of the following are true: Premiums will change at the same time that coverage or Premiums change in your Group's Agreement.Your • Your effective date of COBRA coverage was on or Group's coverage and Premiums will change on the after January 1,2003 renewal date of its Agreement(January 1),and may also • You have exhausted the time limit for COBRA change at other times if your Group's Agreement is coverage and that time limit was 18 or 29 months amended.Your monthly invoice will reflect the current • You do not have Medicare Premiums that are due for Cal-COBRA coverage, including any changes.For example,if your Group You must request an enrollment application by calling makes a change that affects Premiums retroactively,the Member Services within 60 days of the date of when amount we bill you will be adjusted to reflect the your COBRA coverage ends. retroactive adjustment in Premiums.Your Group can tell you whether this EOC is still in effect and give you a Cal-COBRA enrollment and Premiums current one if this EOC has expired or been amended. Within 10 days of your request for an enrollment You can also request one from Member Services. application,we will send you our application,which will include Premium and billing information.You must Cal-COBRA open enrollment or termination of another return your completed application within 63 days of the health plan date of our termination letter or of your membership If you previously elected Cal-COBRA coverage through termination date(whichever date is later). another health plan available through your Group,you may be eligible to enroll in Kaiser Permanente during If we approve your enrollment application,we will send your Group's annual open enrollment period,or if your you billing information within 30 days after we receive Group terminates its agreement with the health plan you your application.You must pay Full Premiums within 45 are enrolled in.You will be entitled to Cal-COBRA days after the date we issue the bill. The first Premium coverage only for the remainder,if any,of the coverage payment will include coverage from your Cal-COBRA period prescribed by Cal-COBRA.Please ask your effective date through our current billing cycle.You Group for information about health plans available to Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 84 you either at open enrollment or if your Group terminates when the memberships of the Subscriber and all a health plan's agreement. Dependents will terminate if the required Premiums are not paid.Your coverage will continue during this grace In order for you to switch from another health plan and period.If we do not receive Full Premium payment by continue your Cal-COBRA coverage with us,we must the end of the grace period,we will mail a termination receive your enrollment application during your Group's notice to the Subscriber's address of record.After open enrollment period,or within 63 days of receiving termination of your membership for nonpayment of Cal- the Group's termination notice described under"Group COBRA Premiums,you are still responsible for paying responsibilities."To request an application,please call all amounts due,including Premiums for the grace Member Services.We will send you our enrollment period. application and you must return your completed application before open enrollment ends or within 63 Reinstatement of your membership after termination days of receiving the termination notice described under for nonpayment of Cal-COBRA Premiums "Group responsibilities."If we approve your enrollment If we terminate your membership for nonpayment of application,we will send you billing information within Premiums,we will permit reinstatement of your 30 days after we receive your application.You must pay membership three times during any 12-month period if the bill within 45 days after the date we issue the bill. we receive the amounts owed within 15 days of the date You must send us the Premium payment by the due date of the Termination Notice.We will not reinstate your on the bill to be enrolled in Cal-COBRA_ membership if you do not obtain reinstatement of your terminated membership within the required 15 days,or if How you may terminate your Cal-COBRA coverage we terminate your membership for nonpayment of You may terminate your Cal-COBRA coverage by Premiums more than three times in a 12-month period. sending written notice,signed by the Subscriber,to the address below.Your membership will terminate at 11:59 Termination of Cal-COBRA coverage p.m.on the last day of the month in which we receive Cal-COBRA coverage continues only upon payment of your notice.Also,you must include with your notice all applicable monthly Premiums to us at the time we amounts payable related to your Cal-COBRA coverage, specify,and terminates on the earliest of- including Premiums,for the period prior to your . The date your Group's Agreement with us terminates termination date. (you may still be eligible for Cal-COBRA through Kaiser Foundation Health Plan,Inc. another Group health plan) California Service Center • The date you get Medicare P.O.Box 23127 • The date your coverage begins under any other group San Diego,CA 92193-3127 health plan that does not contain any exclusion or limitation with respect to any pre-existing condition Termination for nonpayment of Cal-COBRA Premiums you may have(or that does contain such an exclusion If you do not pay Full Premiums by the due date,we may or limitation,but it has been satisfied) terminate your membership as described in this • The date that is 36 months after your original "Termination for nonpayment of Cal-COBRA COBRA effective date(under this or any other plan) Premiums"section.If you intend to terminate your membership,be sure to notify us as described under • The date your membership is terminated for "How you may terminate your Cal-COBRA coverage"in nonpayment of Premiums as described under this"Cal-COBRA"section,as you will be responsible "Termination for nonpayment of Cal-COBRA for any Premiums billed to you unless you let us know Premiums"in this"Continuation of Membership" before the first of the coverage month that you want us to section terminate your coverage. Note:If the Social Security Administration determined Your Premium payment for the upcoming coverage that you were disabled at any time during the first 60 month is due on the last day of the preceding month.If days of COBRA coverage,you must notify your Group we do not receive Full Premium payment by the due within 60 days of receiving the determination from date,we will send a notice of nonreceipt of payment to Social Security.Also,if Social Security issues a final the Subscriber's address of record.You will have a 30- determination that you are no longer disabled in the 35th day grace period to pay the required Premiums before we or 36th month of Group continuation coverage,your Cal- terminate your Cal-COBRA coverage for nonpayment. COBRA coverage will end the later of. (1)expiration of The notice will state when the grace period begins and 36 months after your original COBRA effective date,or (2)the first day of the first month following 31 days after Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 85 Social Security issued its final determination.You must Your coverage will be subject to the terms of this EOC, notify us within 30 days after you receive Social including Cost Share,but we will not cover Services for Security's final determination that you are no longer any condition other than your totally disabling condition. disabled. For Subscribers and adult Dependents,"Totally Group responsibilities Disabled"means that,in the judgment of a Medical If your Group's agreement with a health plan is Group physician,an illness or injury is expected to result terminated,your Group is required to provide written in death or has lasted or is expected to last for a notice at least 30 days before the termination date to the continuous period of at least 12 months,and makes the persons whose Cal-COBRA coverage is terminating. person unable to engage in any employment or This notice must inform Cal-COBRA beneficiaries that occupation,even with training,education,and they can continue Cal-COBRA coverage by enrolling in experience. any health benefit plan offered by your Group.It must also include information about benefits,premiums, For Dependent children,"Totally Disabled"means that, payment instructions,and enrollment forms(including in the judgment of a Medical Group physician,an illness instructions on how to continue Cal-COBRA coverage or injury is expected to result in death or has lasted or is under the new health plan).Your Group is required to expected to last for a continuous period of at least 12 send this information to the person's last known address, months and the illness or injury makes the child unable as provided by the prior health plan.Health Plan is not to substantially engage in any of the normal activities of obligated to provide this information to qualified children in good health of like age. beneficiaries if your Group fails to provide the notice. These persons will be entitled to Cal-COBRA coverage To request continuation of coverage for your disabling only for the remainder,if any,of the coverage period condition,you must call Member Services within 30 prescribed by Cal-COBRA. days after your Group's Agreement with us terminates. USERRA If you are called to active duty in the uniformed services, Continuation of Coverage under an you may be able to continue your coverage under this Individual Plan EOC for a limited time after you would otherwise lose eligibility,if required by the federal Uniformed Services If you want to remain a Health Plan member when your Employment and Reemployment Rights Act Group coverage ends,you might be able to enroll in one ("USERRA").You must submit a USERRA election of our Kaiser Permanente for Individuals and Families form to your Group within 60 days after your call to plans. The premiums and coverage under our individual active duty.Please contact your Group to find out how to plan coverage are different from those under this EOC. elect USERRA coverage and how much you must pay your Group. If you want your individual plan coverage to be effective when your Group coverage ends,you must submit your Coverage for a Disabling Condition application within the special enrollment period for If you became Totally Disabled while you were a enrolling in an individual plan due to loss of other Member under your Group's Agreement with us and coverage.Otherwise,you will have to wait until the next while the Subscriber was employed by your Group,and annual open enrollment period. your Group's Agreement with us terminates and is not renewed,we will cover Services for your totally To request an application to enroll directly with us, disabling condition until the earliest of the following please go to buyky.org or call Member Services.For events occurs: information about plans that are available through Covered California,see"Covered California"below. • 12 months have elapsed since your Group's Agreement with us terminated Covered California • You are no longer Totally Disabled U.S.citizens or legal residents of the U.S.can buy health • Your Group's Agreement with us is replaced by care coverage from Covered California. This is another group health plan without limitation as to the California's health benefit exchange("the Exchange"). disabling condition You may apply for help to pay for premiums and copayments but only if you buy coverage through Covered California.This financial assistance may be available if you meet certain income guidelines. To learn more about coverage that is available through Covered Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 86 California,visit CoveredCA.com or call Covered Assignment California at 1-800-300-1506(TTY users call 711). You may not assign this EOC or any of the rights, interests,claims for money due,benefits,or obligations Miscellaneous Provisions ■ hereunder without our prior written consent. Attorney and Advocate Fees and Administration of Agreement Expenses We may adopt reasonable policies,procedures,and In any dispute between a Member and Health Plan,the interpretations to promote orderly and efficient Medical Group,or Kaiser Foundation Hospitals,each administration of your Group's Agreement, including this EOC. party will bear its own fees and expenses,including attorneys' fees,advocates' fees,and other expenses. Advance Directives Claims Review Authority The California Health Care Decision Law offers several We are responsible for determining whether you are ways for you to control the kind of health care you will entitled to benefits under this EOC and we have the receive if you become very ill or unconscious,including the following: discretionary authority to review and evaluate claims that arise under this EOC.We conduct this evaluation • A Power of Attorney for Health Care lets you name independently by interpreting the provisions of this EOC. someone to make health care decisions for you when We may use medical experts to help us review claims.If you cannot speak for yourself.It also lets you write coverage under this EOC is subject to the Employee down your own views on life support and other Retirement Income Security Act("ERISA")claims treatments procedure regulation(29 CFR 2560.503-1),then we are a • Individual health care instructions let you express "named claims fiduciary"to review claims under this your wishes about receiving life support and other EOC. treatment.You can express these wishes to your doctor and have them documented in your medical chart,or you can put them in writing and have that EOC Binding o n Members included in your medical chart By electing coverage or accepting benefits under this EOC,all Members legally capable of contracting,and To learn more about advance directives,including how the legal representatives of all Members incapable of to obtain forms and instructions,contact the Member contracting,agree to all provisions of this EOC. Services office at a Plan Facility.For more information about advance directives,refer to our website at kp.org or call Member Services. ERISA Notices This"ERISA Notices"section applies only if your Amendment of Agreement Group's health benefit plan is subject to the Employee Retirement Income Security Act("ERISA").We provide Your Group's Agreement with us will change these notices to assist ERISA-covered groups in periodically.If these changes affect this EOC,your complying with ERISA.Coverage for Services described Group is required to inform you in accord with in these notices is subject to all provisions of this EOC. applicable law and your Group's Agreement. Newborns' and Mothers' Health Protection Act Applications and Statements Group health plans and health insurance issuers generally may not,under Federal law,restrict benefits for any You must complete any applications,forms,or hospital length of stay in connection with childbirth for statements that we request in our normal course of the birthing person or newborn child to less than 48 business or as specified in this EOC. hours following a vaginal delivery,or less than 96 hours following a cesarean section.However,Federal law generally does not prohibit the birthing person's or newborn's attending provider,after consulting with the Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 87 birthing person,from discharging the birthing person or Subscriber's address,they should call Member Services their newborn earlier than 48 hours(or 96 hours as to discuss alternate delivery options. applicable).In any case,plans and issuers may not,under Federal law,require that a provider obtain authorization Note:When we tell your Group about changes to this from the plan or the insurance issuer for prescribing a EOC or provide your Group other information that length of stay not in excess of 48 hours(or 96 hours). affects you,your Group is required to notify the Subscriber within 30 days(or five days if we terminate Women's Health and Cancer Rights Act your Group's Agreement)after receiving the information If you have had or are going to have a mastectomy,you from us.The Subscriber is also responsible for notifying may be entitled to certain benefits under the Women's Group of any change in contact information. Health and Cancer Rights Act.For individuals receiving mastectomy-related benefits,coverage will be provided in a manner determined in consultation with the Overpayment Recovery attending physician and the patient,for all stages of We may recover any overpayment we make for Services reconstruction of the breast on which the mastectomy was performed,surgery and reconstruction of the other from anyone who receives such an overpayment or from breast to produce a symmetrical appearance,prostheses, any person or organization obligated to pay for the and treatment of physical complications of the Services. mastectomy,including lymphedemas.These benefits will be provided subject to the same Cost Share applicable to Privacy Practices other medical and surgical benefits provided under this plan. Kaiser Permanente will protect the privacy of your protected health information. We also Governing Law require contracting providers to protect your protected health information. Your protected Except as preempted by federal law,this EOC will be health information is individually-identifiable governed in accord with California law and any provision that is required to be in this EOC by state or information (oral, written, or electronic) about federal law shall bind Members and Health Plan whether your health, health care services you receive, or or not set forth in this EOC. payment for your health care. You may generally see and receive copies of your Group and Members Not Our Agents protected health information, correct or update your protected health information, and ask us Neither your Group nor any Member is the agent or for an accounting of certain disclosures of your representative of Health Plan. protected health information. No Waiver You can request delivery of confidential Our failure to enforce any provision of this EOC will not communication to a location other than your constitute a waiver of that or any other provision,or usual address or by a means of delivery other impair our right thereafter to require your strict than the usual means. You may request performance of any provision. confidential communication by completing a confidential communication request form, Notices Regarding Your Coverage which is available on kmom under"Request for confidential communications forms."Your Our notices to you will be sent to the most recent address request for confidential communication will be we have for the Subscriber.The Subscriber is responsible valid until you submit a revocation or a new for notifying us of any change in address. Subscribers w request for confidential communication. If you who move should call Member Services as soon as possible to give us their new address.If a Member does have questions,please call Member Services. not reside with the Subscriber,or needs to have confidential information sent to an address other than the We may use or disclose your protected health information for treatment, health research, Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 88 payment, and health care operations purposes, Helpful Information such as measuring the quality of Services. We are sometimes required by law to give How to Obtain this EOC in Other protected health information to others, such as Formats government agencies or in judicial actions. In addition,protected health information is shared You can request a copy of this EOC in an alternate format(Braille,audio,electronic text file,or large print) with your Group only with your authorization by calling Member Services. or as otherwise permitted by law. We will not use or disclose your protected Provider Directory health information for any other purpose Refer to the Provider Directory for your Home Region without your(or your representative's) written for the following information: authorization, except as described in our Notice . A list of Plan Physicians Of Privacy Practices (see below). Giving us . The location of Plan Facilities and the types of authorization is at your discretion. covered Services that are available from each facility • Hours of operation This is only a brief summary of some of our Appointments and advice phone numbers key privacy practices. OUR NOTICE OF PRIVACYPRACTICES, WHICH PROVIDES This directory is available on our website at ku.ora.To ADDITIONAL INFORMATION ABOUT obtain a printed copy,call Member Services. The OUR PRIVACY PRACTICES AND YOUR directory is updated periodically.The availability of Plan RIGHTS REGARDING YOUR PROTECTED Physicians and Plan Facilities may change.If you have HEALTH INFORMATION, IS AVAILABLE questions,please call Member Services. AND WILL BE FURNISHED TO YOU UPON REQUEST. To request a copy, please Online Tools and Resources call Member Services. You can also find the Here are some tools and resources available on our notice at a Plan Facility or on our website at website at kp.ore: kp.om. • How to use our Services and make appointments • Tools you can use to email your doctor's office,view Public Policy Participation test results,refill prescriptions,and schedule routine The Kaiser Foundation Health Plan,Inc.,Board of appointments Directors establishes public policy for Health Plan.A list • Health education resources of the Board of Directors is available on our website at • Preventive care guidelines about.kp.ora or from Member Services.If you would . Member rights and responsibilities like to provide input about Health Plan public policy for consideration by the Board,please send written You can also access tools and resources using the KP comments to: app on your smartphone or other mobile device. Kaiser Foundation Health Plan,Inc. Office of Board and Corporate Governance Services Document Delivery Preferences One Kaiser Plaza, 19th Floor Oakland,CA 94612 Many Health Plan documents are available electronically,such as bills,statements,and notices.If you prefer to get documents in electronic format,go to ky.om or call Member Services.You can change delivery preference at any time. To get a copy of a specific Heath Plan document in printed format,call Member Services. Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 89 How to Reach Us Call 1-800-464-4000(TTY users call 711) Appointments 24 hours a day,seven days a week(closed If you need to make an appointment,please call us or holidays) visit our website: Website ku.ora Call The appointment phone number at a Plan Away from Home Travel Line Facility(for phone numbers,refer to our Provider Directory or call Member Services) If you have questions about your coverage when you are away from home: Website ky.ore for routine(non-urgent)appointments with your personal Plan Physician or another Call 1-951-268-3900 Primary Care Physician 24 hours a day,seven days a week(closed holidays) Not sure what kind of care you need? Website kn.org/travel If you need advice on whether to get medical care,or how and when to get care,we have licensed health care Authorization for Post-Stabilization Care professionals available to assist you by phone 24 hours a day,seven days a week: To request prior authorization for Post-Stabilization Care as described under"Emergency Services"in the Call The appointment or advice phone number at a "Emergency Services and Urgent Care"section: Plan Facility(for phone numbers,refer to our Provider Directory or call Member Services) Call 1-800-225-8883 or the notification phone number on your Kaiser Permanente ID card Member Services (TTY users call 711) If you have questions or concerns about your coverage, 24 hours a day,seven days a week how to obtain Services,or the facilities where you can receive care,you can reach us in the following ways: Help with claim forms for Emergency Services, Call 1-800-464-4000(English and more than 150 Post-Stabilization Care, Out-of-Area Urgent languages using interpreter services) Care, emergency ambulance Services, and 1-800-788-0616(Spanish) COVID-19 Services 1-800-757-7585(Chinese dialects) If you need a claim form to request payment or TTY users call 711 reimbursement for Services described in the"Emergency Services and Urgent Care"section under"Ambulance 24 hours a day,seven days a week(closed Services"in the"Benefits"section,or COVID-19 holidays) Services under"Outpatient Imaging,Laboratory,and Visit Member Services office at a Plan Facility(for Other Diagnostic and Treatment Services,""Outpatient addresses,refer to our Provider Directory or Prescription Drugs, Supplies,and Supplements,"and call Member Services) "Preventive Services"in the"Benefits"section,or if you need help completing the form,you can reach us by Write Member Services office at a Plan Facility(for calling or by visiting our website. addresses,refer to our Provider Directory or Call 1-800-464-4000(TTY users call 711) call Member Services) Website kU.ore 24 hours a day,seven days a week(closed holidays) Estimates, bills, and statements Website ku.or2 For the following concerns,please call us at the number below: Submitting claims for Emergency Services, • If you have questions about a bill Post-Stabilization Care, Out-of-Area Urgent Care, emergency ambulance Services, and • To find out how much you have paid toward your COVID-19 Services Plan Deductible(if applicable)or Plan Out-of-Pocket If you need to submit a completed claim form for Maximum Services described in the"Emergency Services and • To get an estimate of Charges for Services that are Urgent Care"section,under"Ambulance Services"in subject to the Plan Deductible(if applicable) the"Benefits"section,or COVID-19 Services under "Outpatient Imaging,Laboratory,and Other Diagnostic Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 90 and Treatment Services,""Outpatient Prescription • If you receive Services from Non—Plan Providers that Drugs,Supplies,and Supplements,"and"Preventive we did not authorize(other than Emergency Services, Services"in the"Benefits"section,or if you need to Post-Stabilization Care,Out-of-Area Urgent Care, submit other information that we request about your emergency ambulance Services,or COVID-19 claim,send it to our Claims Department: Services)and you want us to pay for the care,you Write Kaiser Permanente must submit a grievance(refer to"Grievances"in the Claims Administration-NCAL "Dispute Resolution"section) P.O.Box 12923 • If you have coverage with another plan or with Oakland,CA 94604-2923 Medicare,we will coordinate benefits with the other coverage(refer to"Coordination of Benefits"in the Text telephone access ("TTY") "Exclusions,Limitations,Coordination of Benefits, If you use a text telephone device("TTY,"also known as and Reductions"section) "TDD")to communicate by phone,you can use the • In some situations,you or another party may be California Relay Service by calling 711. responsible for reimbursing us for covered Services (refer to"Reductions"in the"Exclusions, Interpreter services Limitations,Coordination of Benefits,and If you need interpreter services when you call us or when Reductions"section) you get covered Services,please let us know.Interpreter . You must pay the full price for noncovered Services services,including sign language,are available during all business hours at no cost to you.For more information on the interpreter services we offer,please call Member Services. Payment Responsibility This"Payment Responsibility"section briefly explains who is responsible for payments related to the health care coverage described in this EOC.Payment responsibility is more fully described in other sections of the EOC as described below: • Your Group is responsible for paying Premiums, except that you are responsible for paying Premiums if you have COBRA or Cal-COBRA(refer to "Premiums"in the"Premiums,Eligibility,and Enrollment"section and"COBRA"and "Cal-COBRA"under"Continuation of Group Coverage"in the"Continuation of Membership" section) • Your Group may require you to contribute to Premiums(your Group will tell you the amount and how to pay) • You are responsible for paying your Cost Share for covered Services(refer to the"Cost Share Summary" section) • If you receive Emergency Services,Post-Stabilization Care,Out-of-Area Urgent Care,or COVID-19 Services from a Non—Plan Provider,or if you receive emergency ambulance Services,you must pay the provider and file a claim for reimbursement unless the provider agrees to bill us(refer to"Payment and Reimbursement"in the"Emergency Services and Urgent Care"section) Group ID:604334 Kaiser Permanente Traditional HMO Plan Contract: 1 Version:36 EOC#5 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 91 Important Notices Language Assistance Services English: Language assistance is available at no cost to you, 24 hours a day, 7 days a week. You can request interpreter services, or materials translated into your language or alternative formats. You can also request auxiliary aids and devices at our facilities. Call our Member Service Contact Center for help, 24 hours a day, 7 days a week (closed holidays). • Medi-Cal: 1-855-839-7613 (TTY 711) • All others: 1-800-464-4000 (TTY 711) jl a,��sll a�y,11 a oy J�LSAL, j��I�L,I aetS aLL"JI �I i a L�. liter JI o,9 j w a,,jell a.4-%.jilI c,LQ. :Arabic aA I � J.a,l ,L,s�lyo cal j apL.ol c=,IscL. 15t;< ".s yl -9 1,x11 li j a,�y, t�T Lgi et,i 7 9�j4Il 24 J� 4Lv4 sl .;=cT (TTY 711) 1-855-839-7613 :Medi-Cal • (TTY 711) 1-800-464-4000 :w Y''► �7.— • Armenian: Qhg 4wpnrl t wbg6wp lhgquz4wh u pw4gnLlajnLh ulpuidwilp4til opp 24 dLud, 2urpwlap 7 op: `1nLp llurpnrl hp ujurhw[t2hl pwhwgnp raurpgiiwli}h burnurjnLla Ithhp, till lhgtjnq lauzpgdLu5quub 4wd uzjlphuipuzhpuzjhh &tLui�Lu4inq 4wulpwuurquzb hjnLlahp: `1nLp hurlL llurpnrl lap luhrlphl odurhrlurll oghnLlajnLhhhp tL uurpphp r£lap huruulurulnLlajnLhhhpnLr£: OghnLlajuzh hLudwp guzhguzhwphp dtip Uhrjwdhhph uujuzuuzp4dLU5 4wu&llhhtnpnh opp 24 dLud, 2uzpuzlap 7 op (uinh ophphh giurll t): • Medi-Cal' 1-855-839-7613 (TTY 711) • UjI 1-800-464-4000 (TTY 711) Chinese: R fOX NN 7 )�, X)� 24 T,HI, #19PAi V#J o 18"7�R-*1914t Q 4-ry". --.14V4 UNW% ' 'uPTmiA R A0 Z'LT7L AAW ]�Ji��'r�ZftMim W11sAfpi�%Zro i* T i �Af17�'J ��R � ' ',��, �R�5 H 1��7 p 7 24 �1�� C i 4 „%h) • Pff4 7n,: 1-800-757-7585 (TTY 711) `:LiA -qj 7 9 .3j'6tiL,:—LW 24 :Farsi �cLDcio)s a � j&U�j a��S j a o-%.�, 3�)` �j j 7 9 -gjA� L. 24 9-� jc y ,luLi,c�.ly,�La ySlyo ,� I, jS��vc1�`SroS (TTY 711) 1-855-839-7613 :Medi-Cal • (TTY 711) 1-800-464-4000 :AL- • Hindi: fir f�7* RTTcT 4i gm Trgzrffr, f�F i�F 24 Et, TFaT t �B7t f�F _j qM st.T f I 3TTLf S Tftf;� zRf #dT3it t f�4v, zrr fir fir* RTjTiT t Tfi z�r 3m-�ft aTmT # 3T dTz� chiciiA zt f Av, ;ff c STY zhT 3 Jzh7 Tw�r t 13Trq NuzrcT fiAT3cAchiuf t f� a# 3mttTq�T TrEFfttm- Ttf�4vTgt �r #dT3iI ;t � Z�r, f�7t24-dt, TirFt �T fiit�T ( 4 m-4 ftfzii�r T6-icf T-W z rt I • Medi-Cal: 1-855-839-7613 (TTY 711) • Wctt �"`: 1-800-464-4000 (TTY 711) Hmong: Muaj kev pab txhais lus pub dawb rau koj, 24 teev tuaj ib hnub twg, 7 hnub tuaj ib lim tiam twg. Koj thov tau cov kev pab txhais lus, muab cov ntaub ntawv txhais ua koj hom lus, los yog ua lwm hom. Koj kuj thov tau lwm yam kev pab thiab khoom siv hauv peb tej tsev hauj lwm. Hu rau peb Qhov Chaw Pab Cov Tswv Cuab 24 teev tuaj ib hnub twg, 7 hnub tuaj ib lim tiam twg (cov hnub caiv kaw). • Medi-Cal: 1-855-839-7613 (TTY 711) • Dua lwm cov: 1-800-464-4000 (TTY 711) Japanese: g F=l PF BAR AfA< 24HiralMPN7H ) o • Medi-Cal: 1-855-839-7613 (TTY 711) • -�:OTAO�) ANq-,Ac: 1-800-464-4000 (TTY 711) Khmer (Cambodian): �� w�5� �� 24 � �� 41 7C=t�ScE3[S�S�iJLfl`1 c=t cz � iUi��U LJ'�1i�S1S�wGlStli �Ui��U �'fl�1i �L51�2µb � c� r��i� sU�,l�cis �ws� �sc��s�� .ju anri �S''IItSSIfiutO-31inftiSU€bI J''ItOtll=l)UlcSUJ 24 VL3n''IF'lL-UJIt; 7 1IL i tlUUit1iC1i Ul (� CLISU�5��31i5��)`i • Medi-Cal: 1-855-839-7613 (TTY 711) • ttat�� s� s3€,t: 1-800-464-4000 (TTY 711) K{,�lorean: °� �y�1l�l 7L� �l ��1�11��l^/l�^Jlal�l}}� ��l�l�� T_��'�'1{ °1l o�l�� t l Ll . ' 1 tt L O 01 A] ~I Zi 1E L ' I t�9 L I 1 L /fit� 1- ��I d �� _�d l- T �� 7, � A1�i:l N-�71� 7171 z ° �o o}t °� �rl. �� } �} A] A I Z 4 FI Ol 7 - o}7 24 Al 7L�(oT) �1 }o}Al A] �� • Medi-Cal: 1-855-839-7613 (TTY 711) • 71 q E-L o-°T: 1-800-464-4000 (TTY 711) Laotian: ain�ua��cuieci�u��uc��i�2rnccriui�u, 24 a�Fu�c��u, 7 61)C'M- o. ui-uAgz°) .U-)Ok65n°)uqcct3w.)z.) IB can L—()cctscisuw.)z')2equi°)u In 2uquccuueuZ6 putnauaC)ecsa) cc;:)t c�ie�u�s��uu�n�u�e��nc��Zc% Ftntn� uc�cic�u�n�u��u�an 2Bowonc6.)ct iak6)0.)aU�oe)cuna, 24 gJ'Augc�6u, 7 6x)c�a-)Coo (iA)6u6n). • Medi-Cal: 1-855-839-7613 (TTY 711) • au9tn96)o: 1-800-464-4000 (TTY 711) Mien: Mbenc nzoih houh wangv-henh tengx nzie faan waac bun muangx meih maiv cingv, yietc hnoi mbenc maaih 24 norm ziangh hoc, yiete norm leiz baaix mbenc maaih 7 hnoi. Meih se haih tov heuc tengx faan benx meih nyei waac bun muangx, a'fai zoux benx nyungc horngh jaa-sic zoux benx meih nyei waac. Meih corc haih tov tengx nyungc horngh jaa-dorngx aengx caux jaa-sic nzie bun yiem njiec zorc goux baengc zingh gorn zangc. Beiv hnangv qiemx zuqc longc mienh nzie weih nor done waac lorx taux yie mbuo ziux goux baengc mienh nyei gorn zangc, yietc hnoi tengx duqv 24 norm ziangh hoc, yietc norm leiz baaix tengx duqv 7 hnoi (simv cuotv gingc nyei hnoi se guon oc). • Medi-Cal: 1-855-839-7613 (TTY 711) • Yietc zungv da'nyeic deix: 1-800-464-4000 (TTY 711) Navajo: Dii h6zh6 nizhoni bee hane' d66 jiik'ah j66ni doonilwo'. Ndik'e yadi naaltsoos bee haz'aanii bee hane' doo yadi nihookaa doo nadaahagii yadi nihookaa. Shi ei bee haidinii bibee' haz'aanii doo bee fah kodi bizikinii wo'da'gi dooly6. Ah6hee' bik'ehgo noh6lggn'igii, 24 t'aadawolii, 7 t'aadawohigo (t'aadoo t'aalwo'). • Medi-Cal: 1-855-839-7613 (TTY 711) • Yadilzingo bilk'ehgo bee: 1-800-464-4000 (TTY 711) Punjabi: t t f--I*BTUFT tt, t�5 tt 24 W�, UU:E�tt 7 ftli5, SAT 3cT-.:t FE�@14 8EI14 cal -3A A�ifto T FS�ft, TT 7i� 2S WIft 3FIT Ae f u T4a qd<5 FSift Eu5c t d3 7F-T}cal 3AA ATT Affr�T f�t A-7-fu,� ATL46* wt T FS ft El 3 7d 7risi }u l wrI - FS ft 7ITt)�f 7�T t TkFdd�d t fiE z5 t�24 4�, U3tt7frz5( T-,;=-Tftfe?5EfFE3f-eT9)qitail • Medi-Cal: 1-855-839-7613 (TTY 711) • ;�U 7iri�: 1-800-464-4000 (TTY 711) Russian:A3biKOBaA TIOMoiAb AOCTyIIHa AJIA Bac 6ecrinaTHo KpyrrlocyToHHo, eWeAHeBHO. Bbi MO)KeTe 3aHpOCHTb yCJIyr 4 nepeBOq H3Ka HJIH MaTepHaTIbI,nepeseAexxble Ha BaHI A3bHC HJIH B anbTepxaTHBHble C opMaTbI. BbI TaIUKe MoweTe 3axa3aTb BcnoMoraTenbxble cpeACTBa H IIPHCH0006JieHHA.Aim iioa IeHI3A HOMOMH H03BOHHTe B Ham rjeHTp 06CJIy)MBaHM ygaCTHIHKOB eweAHeBHO,KpyrJIOCyTO'hIO(KpoMe Hpa3AHI3'IHbIX AHeil). • Medi-Cal: 1-855-839-7613 (JIHHHA TTY 711) • Bce OCTaJibHbie: 1-800-464-4000 (JIHHHA TTY 711) Spanish: Tenemos disponible asistencia en su idioma sin ningun costo para usted 24 horas al dia, 7 dias a la semana. Usted puede solicitar los servicios de un interprete, que los materiales se traduzcan a su idioma o formatos alternativos. Tambien puede solicitar recursos para discapacidades en nuestros centros de atenci6n. Llame a nuestra Central de Llamadas de Servicio a los Miembros para recibir ayuda 24 horas al dia, 7 dias a la semana(excepto los dias festivos). • Para todos los demas: 1-800-788-0616 (TTY 711) Tagalog: May magagamit na tulong sa wika nang wala kayong babayaran, 24 na oras sa isang araw, 7 araw sa isang linggo. Maaari kayong humiling ng mga serbisyo ng interpreter, o mga babasahin na isinalin sa inyong wika o sa mga alternatibong format. Maaari rin kayong humiling ng mga pantulong na gamit at device sa aming mga pasilidad. Tawagan ang aming Center sa Pakikipag-ugnayan ng Serbisyo sa Miyembro para sa tulong, 24 na oras sa isang araw, 7 araw sa isang linggo (sarado sa mga pista opisyal). • Medi-Cal: 1-855-839-7613 (TTY 711) • Lahat ng iba pa: 1-800-464-4000 (TTY 711) Thai: 24 q-vjuAAamaz)m 24 g3'-AmiAn�au (�1mvA-in-in -wau"Fjm) • Medi-Cal: 1-855-839-7613 (TTY 711) • W)ugiUiNP: 1-800-464-4000 (TTY 711) Ukrainian: 110CJIyrH nepeKJlagaga HagaIOTbcA 6e3KOIIiTOBHO, LjinoAo6OBO, 7 AHiB Ha TH)KAeHb. BH MO)KeTe 3po6HTH 3anHT Ha HOCJIYTH YCHOrO nepeimaAaga a6o oTpI3MaHHA MaTepiaiiiB y nepemaAi MOBOIO,AKOIO BOJIOAiCTe,iIH B anbTepxaTIIBHI3x()opMaTax. TaKOx(BI3 Mo)KeTe 3po6HTH 3aHHT Ha OTPHMaHHA AOHOMi)KHHX 3aco6iB i HPHCTpOIB y 3aKJIaAaX HamoY Mepe)Ki KOMnaHII3. TeJIe4)OHyf4Te B Ham KOHTaKTHHI3 ijeHTp AJIA o6CJIYTOBYBaHHA KJIICHTIB IjIJIOAo6OBO, 7 AHiB Ha TH)KAeHb(KpIM CBATKOBHX AHiB). • Medi-Cal: 1-855-839-7613 (TTY 711) • YCi iHIHi: 1-800-464-4000 (TTY 711) Vietnamese: Dich vu ho trg ng6n nix dugc cung cap mien phi cho quy vi 24 gia moi ngay, 7 ngay trong tuan. Quy vi co the yeu cau dich vu thong dich,hoar tai lieu dugc dich ra ngon ngir cua quy vi hoac nhieu hinh th*c khac. Quy vi tong co the yeu cau cac phuong tien trg gifip va thiet bi bo trg tai cac co so cfia chung t6i. Goi cho Trung Tam Lien Lac ban Dich Vu 1-16i Vien cua thong toi de dugc trg giup, 24 gi&moi ngay, 7 ngay trong tuan(trix cac ngay le). • Medi-Cal: 1-855-839-7613 (TTY 711) • Moi chuong trinh khac: 1-800-464-4000 (TTY 711) Nondiscrimination Notice Discrimination is against the law. Kaiser PermanenteI follows State and Federal civil rights laws. Kaiser Permanente does not unlawfully discriminate, exclude people, or treat them differently because of age, race, ethnic group identification, color, national origin, cultural background, ancestry, religion, sex, gender, gender identity, gender expression, sexual orientation, marital status, physical or mental disability, medical condition, source of payment, genetic information, citizenship, primary language, or immigration status. Kaiser Permanente provides the following services: • No-cost aids and services to people with disabilities to help them communicate better with us, such as: ♦ Qualified sign language interpreters ♦ Written information in other formats (braille, large print, audio, accessible electronic formats, and other formats) • No-cost language services to people whose primary language is not English, such as: ♦ Qualified interpreters ♦ Information written in other languages If you need these services, call our Member Service Contact Center, 24 hours a day, 7 days a week (closed holidays). The call is free: • Medi-Cal: 1-855-839-7613 (TTY 711) • All others: 1-800-464-4000 (TTY 711) Upon request, this document can be made available to you in braille, large print, audiocassette, or electronic form. To obtain a copy in one of these alternative formats, or another format, call our Member Service Contact Center and ask for the format you need. How to file a grievance with Kaiser Permanente You can file a discrimination grievance with Kaiser Permanente if you believe we have failed to provide these services or unlawfully discriminated in another way. You can file a grievance by phone, by mail, in person, or online. Please refer to your Evidence of Coverage or Certificate of Insurance for details. You can call Member Services for more information on the options that apply to you, or for help filing a grievance. You may file a discrimination grievance in the following ways: • By phone: Medi-Cal members may call 1-855-839-7613 (TTY 711). All other members may call 1-800-464-4000 (TTY 711). Help is available 24 hours a day, 7 days a week (closed holidays) • By mail: Download a form at kp.org or call Member Services and ask them to send you a form that you can send back. Kaiser Pennanente is inclusive of Kaiser Foundation Health Plan,Inc,Kaiser Foundation Hospitals,The Pennanente Medical Group,and the Southern California Medical Group • In person: Fill out a Complaint or Benefit Claim/Request form at a member services office located at a Plan Facility (go to your provider directory at kp.org/facilities for addresses) • Online: Use the online form on our website at kp.org You may also contact the Kaiser Permanente Civil Rights Coordinator directly at the addresses below: Attn: Kaiser Permanente Civil Rights Coordinator Member Relations Grievance Operations P.O. Box 939001 San Diego CA 92193 How to file a grievance with the California Department of Health Care Services Office of Civil Rights (For Medi-Cal Beneficiaries Only) You can also file a civil rights complaint with the California Department of Health Care Services Office of Civil Rights in writing, by phone or by email: • By phone: Call DHCS Office of Civil Rights at 916-440-7370 (TTY 711) • By mail: Fill out a complaint form or send a letter to: Deputy Director, Office of Civil Rights Department of Health Care Services Office of Civil Rights P.O. Box 997413, MS 0009 Sacramento, CA 95899-7413 Complaint forms are available at: http://www.dhcs.ca.gov[Pages/Language_Access.aspx • Online: Send an email to CivilRights@dhcs.ca.gov How to file a grievance with the U.S. Department of Health and Human Services Office of Civil Rights You can file a discrimination complaint with the U.S. Department of Health and Human Services Office for Civil Rights. You can file your complaint in writing, by phone, or online: • By phone: Call 1-800-368-1019 (TTY 711 or 1-800-537-7697) • By mail: Fill out a complaint form or send a letter to: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 Complaint forms are available at: https://www.hhs.gov/ocr/complaints/index.html • Online: Visit the Office of Civil Rights Complaint Portal at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsL KAISER PERMANEWE® Kaiser Foundation Health Plan, Inc. Northern California Region EOC #9 - Chiropractic Services Amendment of the Kaiser Foundation Health Plan, Inc. Evidence of Coverage for COUNTY OF FRESNO, RETIREE Group ID: 604334 Contract: 1 Version: 36 EOC Number: 9 Issue Date: October 30, 2024 January 1,2025,through December 31, 2025 ASH Plans Customer Service Department Monday through Friday, 5 a.m. to 6 p.m. 1-800-678-9133 (TTY users call 711)toll free ashlink.com/ash/kp TABLE OF CONTENTS FOR EOC #9 BenefitHighlights..................................................................................................................................................................I Introduction............................................................................................................................................................................2 Definitions..............................................................................................................................................................................2 ASHParticipating Providers..................................................................................................................................................3 Howto Obtain Services......................................................................................................................................................3 CoveredServices....................................................................................................................................................................3 OfficeVisits.......................................................................................................................................................................4 LaboratoryTests and X-rays..............................................................................................................................................4 ChiropracticSupports and Appliances...............................................................................................................................4 SecondOpinions.................................................................................................................................................................4 Emergency and Urgent Services Covered Under this Amendment...................................................................................5 Exclusions..............................................................................................................................................................................5 CustomerService...................................................................................................................................................................5 Grievances..............................................................................................................................................................................6 Benefit Highlights 0 - We cover the Services described below,subject to exclusions described in the"Exclusions"section,only if all of the following conditions are satisfied: • You are a Member on the date that you receive the Services • ASH Plans has determined that the Services are Medically Necessary,except as described in this Amendment • You receive the Services from ASH Participating Providers or other licensed providers that ASH contracts to provide covered care,except as described in this Amendment Professional Services(ASH Participating Provider office visits) You Pay Chiropractic office visits(up to a total of 30 visits per 12-month period).. $10 per visit Other You Pay X-rays and laboratory tests that are covered Chiropractic Services............ No charge Chiropractic supports and appliances.......................................................... Amounts in excess of the$50 Allowance This is a summary of the most frequently asked-about benefits. This chart does not explain benefits,Cost Share,out-of- pocket maximums,exclusions,or limitations,nor does it list all benefits and Cost Share amounts.For a complete explanation,refer to the"Covered Services"and"Exclusions"sections. Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:36 EOC#9 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 1 Introduction ASH Plans:American Specialty Health Plans of California,Inc.,a California corporation. This document amends your Kaiser Foundation Health Plan,Inc.(Health Plan)EOC to add coverage Chiropractic Services:Chiropractic services include for Chiropractic Services as described in this spinal and extremity manipulation and adjunctive Chiropractic Services Amendment("Amendment"). therapies such as ultrasound,therapeutic exercise,or All provisions of the EOC apply to coverage described in electrical muscle stimulation,when provided during the this document except for the following sections: same course of treatment and in conjunction with chiropractic manipulative services,and other services • "How to Obtain Services"(except that the provided or prescribed by a chiropractor(including "Completion of Services from Non—Plan Providers" laboratory tests,X-rays,and chiropractic supports and section,or for Kaiser Permanente Senior Advantage appliances)for the treatment of your Musculoskeletal Members,the"Termination of a Plan Provider's and Related Disorder. contract and completion of Services"section,does apply to coverage described in this document) Emergency Chiropractic Services: Covered • "Plan Facilities" Chiropractic Services provided for the treatment of a • "Emergency Services and Urgent Care" Musculoskeletal and Related Disorder which manifests itself by acute symptoms of sufficient severity(including • "Benefits" severe pain)such that you could expect the absence of immediate Chiropractic Services to result in serious Kaiser Foundation Health Plan,Inc. contracts with jeopardy to your health or body functions or organs. American Specialty Health Plans of California,Inc. ("ASH Plans")to make the network of ASH Musculoskeletal and Related Disorders: Conditions Participating Providers available to you. with signs and symptoms related to the nervous, muscular,and/or skeletal systems.Musculoskeletal and When you need chiropractic care,you have direct access Related Disorders are conditions typically categorized as to more than 3,400 licensed chiropractors in California. structural,degenerative,or inflammatory disorders;or You can obtain covered Services from any ASH biomechanical dysfunction of the joints of the body Participating Provider without a referral from a Plan and/or related components of the muscle or skeletal Physician.Your Cost Share is due when you receive systems(muscles,tendons,fascia,nerves, covered Services. ligaments/capsules,discs and synovial structures)and related manifestations or conditions. Definitions Non—Participating Provider: A provider other than an ASH Participating Provider. In addition to the terms defined in the"Definitions" Treatment Plan: The course of treatment for your section of your Health Plan EOC,the following terms, Musculoskeletal and Related Disorder,which may when capitalized and used in any part of this include laboratory tests,X-rays,chiropractic supports Amendment,have the following meanings: and appliances,and a specific number of visits for chiropractic manipulations(adjustments)and adjunctive ASH Participating Provider:A chiropractor who is therapies that are Medically Necessary Chiropractic licensed to provide chiropractic services in California Services for you. and who has a contract with ASH Plans to provide Medically Necessary Chiropractic Services to you.A list of ASH Participating Providers is available on the ASH Urgent Chiropractic Services: Chiropractic Services Plans website at ashlink.com/ash/kaisercamedicare for that meet all of the following requirements: Kaiser Permanente Senior Advantage Members,or • They are necessary to prevent serious deterioration of ashlink.com/ash/ky for all other Members,or from the your health resulting from an unforeseen illness, ASH Plans Customer Service Department toll free at injury,or complication of an existing condition, 1-800-678-9133(TTY users call 711).The list of ASH including pregnancy Participating Providers is subject to change at any time, • They cannot be delayed until you return to the Service without notice.If you have questions,please call the Area ASH Plans Customer Service Department. Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:36 EOC#9 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 2 ASH Participating Providers -M will be informed of the scope of the authorized Services. If ASH Plans does not authorize all of the Services,ASH PLEASE READ THE FOLLOWING Plans will send you a written decision and explanation, INFORMATION SO YOU WILL KNOW FROM including the rationale for the decision and the criteria WHOM OR WHAT GROUP OF PROVIDERS used to make the decision,within two business days after HEALTH CARE MAY BE OBTAINED. the decision is made.The letter will also include information about your appeal rights,which are described in the"Coverage Decisions,Appeals,and ASH Plans contracts with ASH Participating Providers Complaints"section of your Health Plan EOC for Kaiser and other licensed providers to provide the Services permanente Senior Advantage Members,and"Dispute covered under this Amendment(including laboratory Resolution"section of your Health Plan EOC for all tests,X-rays,and chiropractic supports and appliances). other Members.Any written criteria that ASH Plans uses You must receive Services covered under this to make the decision to authorize,modify,delay,or deny Amendment from an ASH Participating Provider or the request for authorization will be made available to another licensed provider with which ASH contracts to you upon request.If you have questions or concerns, provide covered care,except for Services covered under please contact ASH Plans or Kaiser Permanente as "Emergency and Urgent Services Covered Under this described under"Customer Service"in this Amendment. Amendment"in the"Covered Services"section and Services that are not available from contracted providers and that are authorized in advance by ASH Plans. Covered Services How to Obtain Services We cover the Services listed in this"Covered Services" To obtain Services covered under this Amendment call section,subject to exclusions described in the an ASH Participating Provider to schedule an initial "Exclusions"section,only if all of the following examination.If additional Services are required after the conditions are satisfied: initial examination,verification that the Services are • You are a Member on the date that you receive the Medically Necessary may be required,as described Services under"Decision time frames"below.Your ASH • ASH Plans has determined that the Services are Participating Provider will request any required medical Medically Necessary,except for: necessity determinations.An ASH Plans clinician in the same or similar specialty as the provider of Services ♦ the initial examination described under"Office under review will determine whether the Services are or Visits"in this"Covered Services"section were Medically Necessary Services. ♦ Services covered under"Emergency and Urgent Services Covered Under this Amendment"in this Decision time frames "Covered Services"section The ASH Plans' clinician will make the authorization • You receive the Services from ASH Participating decision within the time frame appropriate for your Providers or other licensed providers with which condition,but no later than five business days after ASH contracts to provide covered care,except for: receiving all of the information(including additional ♦ Services covered under"Emergency and Urgent examination and test results)reasonably necessary to Services Covered Under this Amendment"in this make the decision,except that decisions about urgent "Covered Services"section Services will be made no later than 72 hours after receipt of the information reasonably necessary to make the ♦ Services that are not available from ASH decision.If ASH Plans needs more time to make the Participating Providers or other licensed providers decision because it doesn't have information reasonably with which ASH contracts to provide covered care necessary to make the decision,or because it has and that are authorized in advance by ASH Plans requested consultation by a particular specialist,you and your ASH Participating Provider will be informed in When you receive covered Services,you must pay the writing about the additional information,testing,or Cost Share listed in this"Covered Services"section.If specialist that is needed,and the date that ASH Plans you receive Services that are not covered under this expects to make a decision. Amendment,you may be liable for the full price of those Services. Your ASH Participating Provider will be informed of the decision within 24 hours after the decision is made.If the Services are authorized,your ASH Participating Provider Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:36 EOC#9 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 3 Note:If Charges for Services are less than the Laboratory Tests and X-rays Copayment described in this"Covered Services"section, you will pay the lesser amount. We cover Medically Necessary laboratory tests and X- rays when prescribed as part of covered chiropractic care The Cost Share you pay for Services covered under this described under"Office Visits"in this"Covered Amendment does not apply toward any Plan Deductible Services"section at no charge when an ASH or Plan Out-of-Pocket Maximum described in your Participating Provider provides the Services or refers you Health Plan EOC. to another licensed provider with which ASH contracts to provide covered Services. If you have questions about your Cost Share for specific Services that you are scheduled to receive or that your provider orders during a visit or procedure,please call Chiropractic Supports and Appliances the ASH Plans Customer Service Department toll free at We provide a$50 Allowance per 12-month period 1-800-678-9133(TTY users call 711)weekdays from 5 toward the ASH Plans fee schedule price for chiropractic a.m.to 6 p.m. appliances listed in this paragraph when the item is prescribed and provided to you by an ASH Participating If you are a Kaiser Permanente Senior Advantage Provider as part of covered chiropractic care described Member,refer to your Health Plan EOC for information under"Office Visits"in this"Covered Services"section. about the chiropractic Services that we cover in accord If the price of the items in the ASH Plans fee schedule with Medicare guidelines,which are separate from the exceeds$50(the Allowance),you will pay the amount in Services covered under this Amendment. excess of$50(and that payment does not apply toward the Plan Out-of-Pocket Maximum described in your Office Visits Health Plan EOC).Covered chiropractic appliances are limited to: elbow supports,back supports(thoracic), We cover the following: cervical collars,cervical pillows,heel lifts,hot or cold packs,lumbar braces and supports,lumbar cushions, • Initial chiropractic examination:An examination orthotics,wrist supports,rib belts,home traction units performed by an ASH Participating Provider to (cervical or lumbar),ankle braces,knee braces,rib determine the nature of your problem(and,if supports,and wrist braces. appropriate,to prepare a Treatment Plan),and to provide Medically Necessary Chiropractic Services, which may include an adjustment and adjunctive Second Opinions therapy.We cover an initial examination only if you have not already received covered Chiropractic You may request a second opinion in regard to covered Services from an ASH Participating Provider in the Services by contacting another ASH Participating same 12-month period for your Musculoskeletal and Provider.Your visit to another ASH Participating Related Disorder Provider for a second opinion generally will count • Subsequent chiropractic office visits: Subsequent toward any visit limit,if applicable.An ASH ASH Participating Provider office visits for Participating Provider may also request a second opinion Chiropractic Services that are determined to be in regard to covered Services by referring you to another Medically Necessary by an ASH Plans clinician. ASH Participating Provider in the same or similar These subsequent office visits may include an specialty.When you are referred by an ASH adjustment adjunctive therapy, Participating Provider to another ASH Participating and a re-examination to assess the need to continue,extend,or change a Provider for a second opinion,your visit to the other Treatment Plan ASH Participating Provider will not count toward any visit limit,if applicable.An authorization or denial of Each office visit counts toward any visit limit,if your request for a second opinion will be provided in an applicable. expeditious manner,as appropriate for your condition.If your request for a second opinion is denied,you will be notified in writing of the reasons for the denial,and of You pay the following for these covered Services(up to your right to file a grievance as described under 30 visits per 12 month period): a$10 Copayment per "Grievances"in this Amendment. visit Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:36 EOC#9 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 4 Emergency and Urgent Services • Thermography Covered Under this Amendment • Experimental or investigational Services.If coverage for a Service is denied because it is experimental or We cover Emergency Chiropractic Services and Urgent investigational and you want to appeal the denial, Chiropractic Services provided by an ASH Participating refer to your Health Plan EOC for information about Provider or a Non—Participating Provider at a the appeal process $10 Copayment per visit.We do not cover follow-up or continuing care from a Non-Participating Provider unless • CT scans,MRIs,PET scans,bone scans,nuclear ASH Plans has authorized the Services in advance.Also, medicine,and any other type of diagnostic imaging or we do not cover Services from a Non-Participating radiology other than X-rays covered under the Provider that ASH Plans determines are not Emergency "Covered Services"section of this Amendment Chiropractic Services or Urgent Chiropractic Services. . Ambulance and other transportation • Education programs,non-medical self-care or self- How to file a claim help,any self-help physical exercise training,and any As soon as possible after receiving Emergency related diagnostic testing Chiropractic Services or Urgent Chiropractic Services, you must file an ASH Plans claim form.To request a • Services for pre-employment physicals or vocational claim form or for more information,please call ASH rehabilitation Plans toll free at 1-800-678-9133(TTY users call 711)or • Drugs and medicines,including non-legend or visit the ASH Plans website at ashlink.com.You must proprietary drugs and medicines send the completed claim form to: o Services you receive outside the state of California, ASH Plans except for Services covered under"Emergency and P.O.Box 509002 Urgent Services Covered Under this Amendment"in San Diego,CA 92150-9002 the"Covered Services"section • Hospital services,anesthesia,manipulation under anesthesia,and related services Exclusions • Dietary and nutritional supplements,such as vitamins, minerals,herbs,herbal products,injectable The items and services listed in this"Exclusions"section supplements,and similar products are excluded from coverage under this Amendment. • Massage therapy (Note: Some items and services listed in this "Exclusions"section may be covered Services under • Maintenance care(services provided to Members your Health Plan EOC.Please refer to your Health Plan whose treatment records indicate that they have EOC for details.)These exclusions apply to all Services reached maximum therapeutic benefit) that would otherwise be covered under this Amendment regardless of whether the services are within the scope of a provider's license or certificate: Customer Service ■ • Services provided by a chiropractor that are not within the scope of licensure for a chiropractor If you have a question or concern regarding the Services licensed in California you received from an ASH Participating Provider or any • Adjunctive therapy not associated with spinal, other licensed provider with which ASH contracts to muscle,or joint manipulations provide covered Services,you may call the ASH Plans Customer Service Department toll free at 1-800-678- • Air conditioners,air purifiers,therapeutic mattresses, 9133(TTY users call 711)weekdays from 5 a.m.to 6 chiropractic appliances,durable medical equipment, p.m.,or write ASH Plans at: supplies,devices,appliances,and any other item except those listed as covered under"Chiropractic ASH Plans Supports and Appliances"in the"Covered Services" Customer Service Department section of this Amendment P.O.Box 509002 • Services for asthma or addiction,such as nicotine San Diego,CA 92150-9002 addiction • Hypnotherapy,behavior training,sleep therapy,and weight programs Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:36 EOC#9 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 5 Grievances You can file a grievance with Kaiser Permanente regarding any issue.Your grievance must explain your issue,such as the reasons why you believe a decision was in error or why you are dissatisfied about Services you received.If you are a Kaiser Permanente Senior Advantage Member,you may submit your grievance orally or in writing to Kaiser Permanente as described in the"Coverage Decisions,Appeals,and Complaints" section of your Health Plan EOC. Otherwise,you may submit your grievance orally or in writing to Kaiser Permanente as described in the"Dispute Resolution" section of your Health Plan EOC. Group ID:604334 American Specialty Health Plans Chiropractic Plan Contract: 1 Version:36 EOC#9 Effective: 1/l/25-12/31/25 Issue Date:October 30,2024 Page 6