Page numbers referenced within this brochure apply only to the printed brochure

Kaiser Permanente Washington Options Federal

www.kp.org/feds/wa-options
Member Services: 888-901-4636

2021



IMPORTANT:
  • Rates
  • Changes for 2021
  • Summary of Benefits
  • Accreditations
A Prepaid Comprehensive Medical Plan (Standard Option) with a Point of Service product, and a High Deductible Health Plan

This plan's health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it provides. See page (Applies to printed brochure only) for details. This plan is accredited. See page (Applies to printed brochure only)

Serving: All of Washington state, except San Juan County

Enrollment in this Plan is limited. You must live or work in our geographic service area to enroll. See page 15 for requirements.

 

Enrollment codes for this Plan:

L11 Standard Option – Self Only
L13 Standard Option – Self Plus One
L12 Standard Option – Self and Family

L14 High Deductible Health Plan (HDHP) – Self Only
L16 High Deductible Health Plan (HDHP) – Self Plus One
L15 High Deductible Health Plan (HDHP) – Self and Family

FEHB LogoOPM Logo
RI73-051








Important Notice

Important Notice from Kaiser Permanente Washington Options Federal About
Our Prescription Drug Coverage and Medicare

The Office of Personnel Management (OPM) has determined that the Kaiser Permanente Washington Options Federal prescription drug coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all Plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and your FEHB Plan will coordinate benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that is at least as good as Medicare's prescription drug coverage, your monthly Medicare Part D premium will go up at least 1% per month for every month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the next Annual Coordination Election Period (October 15 through December 7) to enroll in Medicare Part D.

Medicare’s Low Income Benefits

For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov, or call the SSA at 800-772-1213 (TTY 800-325-0778).

  • Visit www.medicare.gov for personalized help.
  • Call 800-MEDICARE (800-633-4227). (TTY: 877-486-2048).



Table of Contents

(Page numbers solely appear in the printed brochure)

Table of Content



Introduction

This brochure describes the benefits of Kaiser Permanente Washington Options Federal under Kaiser Foundation Health Plan of Washington Options, Inc. d/b/a "Kaiser Permanente Washington Options Federal" contract (CS 1767) with the United States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Member services may be reached at 888-901-4636 or through our website: www.kp.org/feds/wa-options. The address for Kaiser Permanente Washington Options Federal administrative offices is:

Administrative Office:
Kaiser Foundation Health Plan of Washington Options, Inc.
MSBD GNW-C1W-04
1300 SW 27th Street
Renton, Washington 98057-9813

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

Mailing Address:
Kaiser Permanente
P.O. Box 34803
Seattle, Washington 98124-1803


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

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self Plus One or Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were available before January 1, 2021, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2021, and changes are summarized on page (Applies to printed brochure only). Rates are shown at the end of this brochure.




Plain Language

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples, 

  • Except for necessary technical terms, we use common words. For instance, “you” means the enrollee and each covered family member, “we” means Kaiser Permanente Washington Options Federal, Options Federal or Kaiser Permanente. 
  • We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean.
  • Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.



Stop Health Care Fraud!

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

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

Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:

  • Do not give your plan identification (ID) number over the phone or to people you do not know, except to your health care providers, authorized health benefits plan, or OPM representative.
  • Let only the appropriate medical professionals review your medical record or recommend services.
  • Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
  • Carefully review explanations of benefits (EOBs) statements that you receive from us.
  • Periodically review your claims history for accuracy to ensure we have not been billed for services you did not receive.
  • Do not ask your doctor to make false entries on certificates, bills, or records in order to get us to pay for an item or service.
  • If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:
    • Call the provider and ask for an explanation. There may be an error.
    • If the provider does not resolve the matter, call us toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711 and explain the situation.
    • If we do not resolve the issue:
CALL - THE HEALTH CARE FRAUD HOTLINE
 
877-499-7295

OR go to www.opm.gov/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/

The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker response time.

You can also write to:

United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC 20415-1100
  • Do not maintain as a family member on your policy:
    • Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
    • Your child age 26 or over (unless he/she was disabled and incapable of self-support prior to age 26
    • We may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.
  • If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under Temporary Continuation of Coverage (TCC).
  • Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and your agency may take action against you. Examples of fraud include falsifying a claim to obtain FEHB benefits, trying to or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan when you are no longer eligible.
  • If your enrollment continues after you are no longer eligible for coverage (i.e., you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed by your provider for services received. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member is no longer eligible to use your health insurance coverage.



Discrimination is Against the Law

Kaiser Foundation Health Plan of Washington Options, Inc. complies with all applicable Federal civil rights laws, including Title VII of the Civil Rights Act of 1964.

You can also file a civil rights complaint with the Office of Personnel Management by mail at:

Office of Personnel Management
Healthcare and Insurance
Federal Employee Insurance Operations
Attention: Assistant Director, FEIO
1900 E Street NW, Suite 3400-S
Washington, D.C. 20415-3610




Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. While death is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer recoveries, and even additional treatments. Medical mistakes and their consequences also add significantly to the overall cost of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical mistakes by their accrediting bodies.  You can also improve the quality and safety of your own health care and that of your family members by learning more about and understanding your risks. Take these simple steps:

1. Ask questions if you have doubts or concerns.

  • Ask questions and make sure you understand the answers.
  • Choose a doctor with whom you feel comfortable talking.
  • Take a relative or friend with you to help you take notes, ask questions and understand answers.

2. Keep and bring a list of all the medications you take.

  • Bring the actual medication or give your doctor and pharmacist a list of all the medications and dosages that you take, including non-prescription (over-the-counter) medications and nutritional supplements.
  • Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as to latex.
  • Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your doctor or pharmacist says.
  • Make sure your medication is what the doctor ordered. Ask the pharmacist about your medication if it looks different than you expected.
  • Read the label and patient package insert when you get your medication, including all warnings and instructions.
  • Know how to use your medication. Especially note the times and conditions when your medication should and should not be taken.
  • Contact your doctor or pharmacist if you have any questions.
  • Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

  • Ask when and how you will get the results of tests or procedures. Will it be in person, by phone, mail, through the Plan or Provider's portal?
  • Don’t assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your results.
  • Ask what the results mean for your care.

4. Talk to your doctor about which hospital or clinic is best for your health needs.

  • Ask your doctor about which hospital or clinic has the best care and results for your condition if you have more than one hospital or clinic to choose from to get the health care you need.
  • Be sure you understand the instructions you get about follow-up care when you leave the hospital or clinic.

5. Make sure you understand what will happen if you need surgery.

  • Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
  • Ask your doctor, “Who will manage my care when I am in the hospital?”
  • Ask your surgeon:
    • "Exactly what will you be doing?"
    • "About how long will it take?" 
    • "What will happen after surgery?" 
    • "How can I expect to feel during recovery?"
  • Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications or nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

  • www.jointcommission.org/speakup.aspx. The Joint Commission's Speak Up™ patient safety program.
  • www.jointcommission.org/topics/patient_safety.aspx. The Joint Commission helps health care organizations to improve the quality and safety of the care they deliver. 
  • www.ahrq.gov/patients-consumers/. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality health care providers and improve the quality of care you receive.
  • www.bemedwise.org. The National Council on Patient Information and Education is dedicated to improving communication about the safe, appropriate use of medication.
  • www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.
  • www.ahqa.org. The American Health Quality Association represents organizations and health care professionals working to improve patient safety.  

Preventable Healthcare Acquired Conditions ("Never Events")

When you enter a Plan hospital for a covered service, you do not expect to leave with additional injuries, infections, or other serious conditions that occur during the course of your stay.  Although some of these complications may not be avoidable, patients do suffer from injuries or illnesses that could have been prevented if doctors or the hospital had taken proper precautions.  Errors in medical care that are clearly identifiable, preventable and serious in their consequences for patients, can indicate a significant problem in the safety and credibility of a health care facility. These conditions and errors are sometimes called "Never Events" or "Serious Reportable Events."(See Section 10. Definitions of terms we use in this brochure.)

We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as certain infections, severe bedsores, and fractures, and to reduce medical errors that should never happen.  When such an event occurs, neither you nor your FEHB plan will incur costs to correct the medical error. If you are charged a cost share for a never event that occurs while you are receiving an inpatient covered service, or for treatment to correct a never event that occurred at a Plan provider, please notify us.  




FEHB Facts

TermDefinition

Coverage Information

Coverage information below

No pre-existing condition limitation

We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

Minimum essential coverage (MEC)

Coverage under this plan qualifies as minimum essential coverage. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the individual requirement for MEC.

Minimum value standard

Our health coverage meets the minimum value standard of 60% established by the ACA. This means that we provide benefits to cover at least 60% of the total allowed costs of essential health benefits.  The 60% standard is an actuarial value, your specific out-of-pocket costs are determined as explained in this brochure.

Where you can get information about enrolling in the FEHB Program

See www.opm.gov/healthcare-insurance for enrollment information as well as:

  • Information on the FEHB Program and plans available to you
  • A health plan comparison tool
  • A list of agencies that participate in Employee Express
  • A link to Employee Express
  • Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give you brochures for other plans and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

  • When you may change your enrollment
  • How you can cover your family members
  • What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
  • What happens when your enrollment ends
  • When the next Open Season for enrollment begins

We don’t determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office. For information on your premium deductions, you must also contact your employing or retirement office.

Types of coverage available for you and your family

Self Only coverage is for you alone. Self Plus One coverage is for you and one eligible family member. Self and Family coverage is for you and one eligible family member, or your spouse, and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form. Benefits will not be available to your spouse until you are married. We may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.

If you or one of your family members is enrolled in one FEHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another FEHB plan.

If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the FEHB Program, change your enrollment, or cancel coverage.  For a complete list of QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events.  If you need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/payroll office, or retirement office.

Family member coverage

Family members covered under your Self and Family enrollment are your spouse (including a valid common law marriage) and children as described in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member as described in the chart below.

Natural children, adopted children, and stepchildren

Coverage: Natural, adopted children and stepchildren are covered until their 26th birthday.

Foster children

Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children Incapable of self-support 

Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children

Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday. 

Children with or eligible for employer-provided health insurance

Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthda

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

Children's Equity Act

OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

If this law applies to you, you must enroll in Self Plus One or Self and Family coverage in a health plan that provides full benefits in the area where your children live or provide documentation to your employing office that you have obtained other health benefits coverage for your children. If you do not do so, your employing office will enroll you involuntarily as follows:

  • If you have no FEHB coverage, your employing office will enroll you for Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.
  • If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same plan; or
  • If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

As long as the court/administrative order is in effect, and you have at least one child identified in the order who is still eligible under the FEHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue your FEHB coverage into retirement (if eligible) and cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your children live as long as the court/administrative order is in effect. Similarly, you cannot change to Self Plus One if the court/administrative order identifies more than one child. Contact your employing office for further information.

When benefits and premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or Plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2021 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2020 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service) and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not paid. You may be billed for services received directly from your provider. You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

When you retire

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).




TermDefinition

When you lose benefits

Information below

  • When FEHB coverage ends

You will receive an additional 31 days of coverage, for no additional premium, when:

  • Your enrollment ends, unless you cancel your enrollment; or
  • You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC).

  • Upon divorce

If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM's website at www.opm.gov/healthcare-insurance/healthcare/plan-information/. We may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

  • Temporary Continuation of Coverage (TCC)

If you leave Federal service, tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Patient Protection and Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, if you are a covered dependent child and you turn 26, etc.

You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance. It explains what you have to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of tax credit that lowers your monthly premiums.  Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan (such as your spouse's plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing FEHBP coverage.

  • Converting to individual coverage

You may convert to a non-FEHB individual policy if:

  • Your coverage under TCC or the spouse equity law ends (If you canceled your coverage or did not pay your premium, you cannot convert);
  • You decided not to receive coverage under TCC or the spouse equity law; or
  • You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal or Tribal service, your employing office will notify you of your right to convert.  You must contact us in writing within 31 days after you receive this notice. However, if you are a family member who is losing coverage, the employing or retirement office will not notify you. You must contact us in writing within 31 days after you are no longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state’s relay line by dialing either 800-833-6388 or 711 or visit our website at www.kp.org/feds/wa-options.

  • Health Insurance Marketplace

If you would like to purchase health insurance through the ACA's Health Insurance Marketplace, please visit www.Healthcare.gov.  This is a website provided by the U.S. Department of Health and Human Services that provides up-to-date information on the Marketplace.




Section 1. How This Plan Works

We are a Prepaid Comprehensive Medical Plan with a Point of Service product. OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Kaiser Foundation Health Plan Washington Options, Inc. holds the following accreditations: National Committee for Quality Assurance (NCQA), a private, non-profit organization dedicated to improving health care quality. To learn more about this plan's accreditation, please visit the following website: www.ncqa.org.  This means that we offer health services in whole or substantial part on a prepaid basis, with professional services provided by individual physicians who agree to accept the payments provided by the Plan and the members’ cost-sharing amounts as full payment for covered services. We give you a choice of enrollment in a Standard Option, or a High Deductible Health Plan (HDHP).

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

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

Questions regarding what protections apply may be directed to us toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711. You can also read additional information from the U.S. Department of Health and Human Services at www.healthcare.gov.

General features of our Standard Option

The Standard Option provides comprehensive medical, surgical and hospitalization benefits in addition to coverage for alternative care providers, preventive dental benefits, mental health care, and an open drug formulary prescription benefit.

We have Point of Service (POS) benefits

Our Plan offers POS benefits. This means you can receive covered services from a non-Plan provider. However,
out-of-network benefits may have higher out-of-pocket costs than our in network benefits. Please see Standard Option Section 5(i), page (Applies to printed brochure only), for POS benefit details.

How we pay providers

We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (deductible, copayments, coinsurance and non-covered services and supplies). We pay dental providers based on a scheduled allowance amount, and you will only be responsible for charges over and above the scheduled allowance amount.

We emphasize comprehensive medical and surgical care received from Plan providers. A Plan provider is any facility or licensed practitioner who contracts with the Plan, the First Choice Health Network (FCHN), or First Health Network. A Plan pharmacy is a pharmacy contracted with our pharmacy benefit management company and a Plan dentist is any licensed dentist within Washington state.

To receive the highest level of benefits, you must use Plan providers, pharmacies, and dentists.

When you reside outside the state of Washington under any of the following conditions, 1) part-time, 2) as a dependent child, or 3) on Temporary Duty Assignment, a Plan provider is a First Health Network provider; in Alaska, Idaho, Montana, and Oregon, a Plan provider is a First Choice Health Network provider; or in a different Kaiser Foundation Health Plan service area, a designated Kaiser Permanente provider. If you are in an area where Plan providers are difficult to access (e.g., 50 miles from home or work), please contact us to confirm that we will pay a non-Plan provider at the non-Plan provider rate based on the billed amount rather than our allowed amount, which will eliminate the non-Plan provider "balance billing" you. You can reach us toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711.

General features of our High Deductible Health Plan (HDHP)

HDHPs have higher annual deductibles and annual out-of-pocket maximum limits than other types of FEHB plans. FEHB Program HDHPs also offer health savings accounts or health reimbursement arrangements. Please see below for more information about these savings features.

Preventive care services: Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles or annual limits when received from a Plan provider. Preventive dental care is paid on a fee basis and may result in “balance billing” by your dentist.

Annual deductible: The annual deductible must be met before Plan benefits are applied, except for preventive medical care services, preventive dental care, and tobacco cessation treatment and medications when received through the Quit For Life® program.

Health Savings Account (HSA):
You are eligible for an HSA if you:

  • Are enrolled in an HDHP;
  • Are not covered by any other health plan that is not an HDHP (including a spouse’s health plan, excluding specific injury insurance and accident, disability, dental care, vision care, or long-term coverage);
  • Are not enrolled in Medicare;
  • Have not received VA (except for veterans with a service-related disability) or Indian Health Service (IHS) benefits within the last three months;
  • Are not covered by your own or your spouse’s flexible spending account (FSA); and
  • Are not claimed as a dependent on someone else’s tax return.

You may use the money in your HSA to pay all or a portion of the annual deductible, copayments, coinsurance, or other out-of-pocket costs that meet the IRS definition of a qualified medical expense.

Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even if they are not covered by an HDHP.

You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income tax and, if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.

For each month that you are enrolled in an HDHP and eligible for an HSA, the HDHP will pass through (contribute) a portion of the health Plan premium to your HSA. In addition, you (the account holder) may contribute your own money to your HSA up to an allowable amount determined by IRS rules. Your HSA dollars earn tax-free interest.

You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable – you may take the HSA with you if you leave the Federal government or switch to another plan.

Health Reimbursement Arrangement (HRA): If you are not eligible for an HSA, or become ineligible to continue an HSA, you are eligible for a Health Reimbursement Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.

  • An HRA does not earn interest.
  • An HRA is not portable if you leave the Federal government or switch to another plan.

Catastrophic protection: We protect you against catastrophic out-of-pocket expenses for covered services. The IRS limits annual out-of-pocket expenses for covered services, including deductibles and copayments, to no more than $7,000 for Self Only enrollment, or $14,000 for a Self Plus One or Self and Family enrollment. The out-of-pocket limit for this Plan may differ from the IRS limit, but cannot exceed that amount.

Health education resources and account management tools: Kaiser Permanente Washington Options Federal has chosen HealthEquity® to be our HSA and HRA administrator. As a Kaiser Permanente Washington Options Federal HDHP enrollee, you will have the following health education resources and account management tools provided or made available to you:

  • A HealthEquity® new enrollee welcome letter with your account information will be mailed to you shortly after enrolling.
  • Convenient access to funds is made available through a HealthEquity® Visa® account.
  • At the HealthEquity® website (www.healthequity.com) you can easily view account balances and information, change investment options, download forms and link to a list of covered expenses.
  • Through the HealthEquity® toll-free customer service line at 866-346-5800 you can access automated information, or speak with a helpful customer service representative.

Other important tools and information are available by visiting the Kaiser Permanente Washington Options Federal website at www.kp.org/feds/wa-options.

Your rights and responsibilities

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

  • We are a health care service contractor that has provided health care services to Washingtonians since 1946.
  • Kaiser Foundation Health Plan of Washington Options, Inc. is a for-profit organization.

You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan.  You can view the complete list of these rights and responsibilities by visiting our website, Kaiser Permanente Washington Options Federal at www.kp.org/feds/wa-options. You can also contact us to request that we mail a copy to you.

If you want more information about us, call toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711, or write to P.O. Box 34803, Seattle, Washington 98124-1803. You may also visit our website at www.kp.org/feds/wa-options.

By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website at www.kp.org/feds/wa-options to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.

Your medical and claims records are confidential

We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.

Service Area

To enroll in this Plan, you must live or work in our service area. This is where our providers practice. Our service area is all of Washington state except for San Juan County.

If you receive care from non-Plan providers in our service area, as described in "How we pay providers" on page (Applies to printed brochure only), we will pay benefits based on our contracted rates for Plan providers. You will be responsible for any copayments, coinsurance, deductible, and any additional balance billed by a non-Plan provider. For details regarding out-of-network services, please see Section 5(i), Point of Service (POS) benefits for Standard Option, page (Applies to printed brochure only), and page (Applies to printed brochure only) for the HDHP Out-of-network services.

If you or a covered family member move outside of our service area, you can enroll in another plan. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.




Section 2. Changes for 2021

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

Changes to Standard Option and HDHP

  • Preventive care. To align with preventive care guidelines, you pay $0 cost-sharing for: (1) screening for anxiety in adolescent and adult women; (2) aromatase inhibitors for women at increased risk for breast cancer and at low risk for adverse medication effects; and (3) preexposure prophylaxis (PrEP) to persons at risk of HIV acquisition. You pay nothing for adult retinopathy screening for the chronic condition of diabetes. We reduced the cost-sharing from 20% in-network lab cost-share to no charge for low-density lipoprotein (LDL) testing for the chronic condition of heart disease and International Normalized Ratio (INR) testing for the chronic condition of liver disease and/or bleeding disorders. See pages (Applies to printed brochure only), (Applies to printed brochure only), (Applies to printed brochure only), and (Applies to printed brochure only).
  • Diabetic Supplies:  We no longer apply the deductible to peak flow meter, glucometer, lancets, test strips and control solution. See pages (Applies to printed brochure only) and (Applies to printed brochure only).
  • Applied Behavior Analysis therapy. We have increased coverage to include treatment for developmental disabilities. See pages (Applies to printed brochure only) and (Applies to printed brochure only).
  • Substance User Disorder benefit. Inpatient stays for a period of no less than 2 days, or 3 days for withdrawal management, are not subject to prior authorization. See pages (Applies to printed brochure only) and (Applies to printed brochure only).
  • Balance billing. The State of Washington prohibits out-of-network providers from “surprise billing” - billing you the difference between the provider’s charge and our allowed amount when you get emergency services in the State of Washington and surrounding states, and for surgical and ancillary services performed at an in-network hospital or ambulatory surgical facility. See page (Applies to printed brochure only).
  • Pulmonary Rehabilitation. We have added pulmonary rehabilitation as part of the physical, occupational, speech therapy 60 combined visits limitation.  See page (Applies to printed brochure only) and (Applies to printed brochure only). 

Changes to Standard Option only

  • Premium. Your share of the non-Postal premium will increase for Self Only, Self Plus One and decrease for Self and Family. See page (Applies to printed brochure only).

Changes to HDHP only

  • Premium. Your share of the non-Postal premium will increase for Self Only, Self Plus One and Self and Family. See page (Applies to printed brochure only).




Section 3. How You Get Care

TermDefinition

Identification cards

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711, or write to us at P.O. Box 34803, Seattle, Washington 98124-1803. You also may request replacement cards through our website at www.kp.org/feds/wa-options and choosing Member Services.

Where you get covered care

In Washington state, you get care from "Plan providers" and "Plan facilities." You will only pay copayments, deductibles, and/or coinsurance, and you will not have to file claims. If you use our Point of Service program, you also can get care from non-Plan providers in Washington state, but it will cost you more.


You get dental care from any licensed dentist within Washington state.

Plan providers

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We contract with Washington Permanente Medical Group (Medical Group) to provide or arrange covered services for our members. Medical care is provided through physicians, nurse practitioners, physician assistants, and other skilled medical personnel. Specialists in most major specialties are available as part of the medical teams for consultation and treatment. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. Directories are available at the time of enrollment or upon request by calling our Member Service at 888-901-4636 (TTY: 711). The list is also on our website at www.kp.org/feds.

Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. Kaiser Permanente offers comprehensive health care at Plan facilities conveniently located throughout our service areas.

We list Plan facilities in the facility directory, with their locations and phone numbers. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling our Member Service Call Center at 800-464-4000 (TTY: 711). The list is also on our website at www.kp.org/feds.

You must receive your health services at Plan facilities, except if you have an emergency, authorized referral, or out-of-area urgent care. If you are visiting another Kaiser Permanente or allied plan service area, you may receive health care services at those Kaiser Permanente facilities. See Section 5(h), Special features, for more details.

What you must do to get covered care

It depends on the type of care you need. You can go to any provider you want but we must approve some care in advance.

Primary care

Primary care providers are family practitioners, general practitioners, pediatricians, obstetricians/gynecologists, naturopaths, physician assistants (under the supervision of a physician), or advanced registered nurse practitioners (ARNPs). If your primary care provider is no longer a Plan provider, the same time frames described on page (Applies to printed brochure only) under Specialty care will apply for you to transfer to a new primary care Plan provider.

Specialty care

Specialists are listed in our provider directory. No referral is required.

Here are some other things you should know about specialty care:

  • If you are seeing a specialist and your specialist leaves the Plan, you will be allowed 60 days from the date we notify you that the specialist has left the Plan to either
    (i) complete your course of treatment, or (ii) appropriately transfer your care to another Plan provider. If, after 60 days, you have not completed your course of treatment or transferred your care to another Plan provider, your benefits will be paid at the lower Point of Service (POS) rate described in Section 5(i), Point of Service (POS) benefits, page (Applies to printed brochure only), for Standard Option and page (Applies to printed brochure only) for HDHP Out-of-network services.
  • If you have a chronic and disabling condition and lose access to your specialist because we:
    • terminate our contract with your specialist for other than cause
    • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Program plan; or
    • reduce our service area and you enroll in another FEHB plan;

you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or, if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Complementary care

The term "complementary care" refers to services provided by the following licensed providers when those services are within the scope of their licenses:

  • East Asian Medicine Practitioner (Acupuncturist)
  • Chiropractor
  • Massage therapist

When receiving services from these providers, you are subject to the same benefit conditions and limitations that exist for other Plan providers. In addition, spinal and extremity manipulations, acupuncture needle treatments; except for the treatment of substance use disorder, and massage therapy are each limited to 20 treatments per calendar year.

The non-Plan provider reduction in benefits applies (see Standard Option Section 5(i), Point of Service benefits, page (Applies to printed brochure only), and HDHP Section 5, High Deductible Health Plan Benefits Overview, Out-of-network services, page (Applies to printed brochure only).

Hospital care

Your physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of facility.

If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Member Services department immediately toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

  • you are discharged, not merely moved to an alternative care center;
  • the day your benefits from your former plan run out; or
  • the 92nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family member's benefits under the new plan begin on the effective date of enrollment.

You need prior Plan approval for certain services

Since we do not have a primary care physician or a referral requirement, and we allow you to use non-Plan providers, you need to obtain our approval before you receive certain services. The pre-service claim approval processes for inpatient hospital admissions (called precertification) and for other services and equipment, are detailed in this section. A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care, services, or equipment. In other words, a pre-service claim for benefits (1) requires a precertification or prior approval and (2) will result in a denial or reduction of benefits if you do not obtain precertification or prior approval.

Inpatient hospital admission

Precertification is the process by which - prior to your inpatient hospital admission - we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. The authorization is valid for 30 days. Approval for each admission or re-admission is required. We will provide coverage only for the number of hospital days that are medically necessary and appropriate for your condition. If your hospital stay is extended due to complications, your provider must obtain benefit authorization for the extension.

After your doctor notifies you that hospitalization or skilled nursing care is necessary, ask your doctor to obtain precertification. Your doctor or care facility must request precertification before admission. This is a feature that allows you to know, prior to admission, which services are considered medically necessary and eligible for payment under this Plan.

We will send you written confirmation of the approved admission, once certification is obtained.

Other services

For certain services or equipment your physician must obtain prior approval from us. Before giving approval, we consider if the service or equipment is covered, medically necessary, and follows generally accepted medical practice. Your physician or medical equipment supplier must obtain prior approval for the services, treatments, or items listed below.

Note: The list is not all inclusive and is subject to change at any time.

  • Bariatric Surgery
  • Certain drugs as shown on the Preferred drug list, including chemotherapy and growth hormone therapy
  • Clinical trials
  • Cochlear implants
  • High end radiology services, such as CAT scan, MRI, PET and SPECT scans
  • Inpatient facility services, such as hospital, rehabilitation, skilled nursing, mental health and substance use disorder treatment facilities
  • Non-emergent air transportation
  • Organ transplants
  • Reconstructive breast surgery
  • Sex transformation for gender reassignment (transgender services)
  • Surgeries for sleep disorders
  • TMJ surgery

How to request precertification for an admission or get prior authorization for Other services

First, your physician, your hospital, you, or your representative, must call us toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711 before admission, services, or equipment requiring prior authorization are rendered.

Member Services will confirm that the service, treatment, or equipment requires preauthorization. If it does, your physician or care facility must submit a preauthorization request. All requests for prior authorization must include the following information:

  • enrollee's name and Plan identification number;
  • patient's name, birth date, identification number and phone number;
  • reason for hospitalization, proposed treatment, surgery, or equipment; and (if applicable)
  • name and phone number of admitting physician;
  • name of hospital or facility; and
  • number of days requested for hospital stay.

A staff nurse will review the request and send you and your provider notification in writing of the decision. The same process applies when the service or treatment is received from a non-Plan provider; or if an extension to the prior authorization is required.

Non-urgent care claims

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the
pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

Urgent care claims

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim. You will then have up to 48 hours to provide the required information. We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with written or electronic notification within three days of oral notification.

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us toll-free at 888-901-4636. You may also call OPM's FEHB 2 at (202) 606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us toll-free at 888-901-4636. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

Concurrent care claims

A concurrent care claim involves care provided over a period of time or over a number of treatments. We will treat any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments as an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

Emergency inpatient admission

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

Maternity care

Maternity care does not require preauthorization. 

If your treatment needs to be extended

If an extension of an ongoing course of treatment is requested at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 24 hours after we receive the claim.

What happens when you do not follow the precertification rules

If a service or treatment that requires precertification is performed either by a Plan provider/facility or a non-Plan provider/facility without obtaining the authorization, a retro-review may be done to determine if it is a covered benefit and if it was medically necessary. We will not pay for services or treatments that are not covered or that are not medically necessary.

If the hospitalization and treatment is not preauthorized, our allowance for the admitting physician's fees and benefits for the hospital stay will be reduced by 20%. The same reduction applies to inpatient mental health or substance use disorder treatment that is not preauthorized.

Circumstances beyond our control

Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In that case, we will make all reasonable efforts to provide you with the necessary care.

If you disagree with our pre-service claim decision

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.

If you have already received the service, equipment, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

To reconsider a non-urgent care claim

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to

  1. Precertify your hospital stay or, if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, supply, or equipment; or

  2. Ask you or your provider for more information.

    You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.

    If we do not receive the information within 60 days, we will decide within 30 days of.the date the information due. We will base our decision on the information we already have. We will write to you with our decision

  3. Write to you and maintain our denial.

To reconsider an urgent care claim

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

To file an appeal with OPM

After we reconsider your pre-service claim, if you do not agree with our decision, you may ask OPM to review it by following Step 3 of the disputed claims process detailed in Section 8 of this brochure.

Help us control costs

Outpatient Surgery: Hospitalization is no longer necessary for many surgical and diagnostic procedures. These procedures can be performed safely and less expensively on an outpatient basis without sacrificing quality of care.

The elective surgeries and diagnostic procedures listed below must be performed in a hospital outpatient unit, surgical center, or doctor's office. These facilities are more convenient than a hospital because surgery can be scheduled easily and quickly, and the patient can return home sooner. The cost of surgery is reduced because hospital room and board charges are eliminated.

If circumstances indicate that it is medically necessary to perform a procedure on an inpatient basis, full Plan benefits will be provided.

If a procedure is performed on an inpatient basis when hospitalization is not medically necessary, benefits for the surgical fee will be reduced by 20% and benefits for the hospital stay will be denied. No reduction in benefits will occur for emergency admissions.

The procedures listed below must be performed on an outpatient basis.

Note: The list is not all inclusive and is subject to change at any time.

To obtain information regarding procedures that must be performed on an outpatient basis, please contact Member Services toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711.

  • Biopsy procedures
  • Breast surgery (minor) (However, anyone who undergoes a mastectomy may, at their option, have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.)
  • Diagnostic examination with scopes
  • Dilation and curettage (D&C)
  • Ear surgery (minor)
  • Facial reconstruction surgery
  • Hemorrhoid surgery
  • Inguinal hernia surgery
  • Knee surgery
  • Nose surgery
  • Removal of bunions, nails, hammertoes, etc.
  • Removal of cataracts
  • Removal of cysts, ganglions, and lesions
  • Sterilization procedures
  • Tendon, bone, and joint surgery of the hand and foot
  • Tonsillectomy and adenoidectomy

The Federal Flexiable Spending Account Program- FSAFEDS

  • Health Care FSA (HCFSA)–Reimburses you for eligible out-of-pocket health care expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children(through the end of the calendar year in which they turn 26).
  • FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.



Section 4. Your Cost for Covered Services

This is what you will pay out-of-pocket for covered care:



TermDefinition

Cost-sharing

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, coinsurance, and copayments) for the covered care you receive.

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services.

Example:

Under Standard Option, you pay a copayment of $25 (no deductible) for primary care per office visit and $35 (no deductible) for specialty care per office visit. You pay a $20 copayment for Tier 1 drugs, a $40 copayment for Tier 2 drugs and a $60 copayment for Tier 3 drugs. (Coinsurance amounts apply to Tier 4 and 5 drugs).  

Under the High Deductible Health Plan (HDHP), once you have met the annual deductible, you pay a $20 copayment for Tier 1 drugs, a $40 copayment for Tier 2 drugs, and a $60 copayment for Tier 3 drugs. (Coinsurance amounts apply to Tier 4 and Tier 5 drugs.).

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Copayments do not count toward any deductible.

  • The Standard Option calendar year deductible is $350 per person.
  • Under Standard Option Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible reach $350.
  • Under Standard Option Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $700.
  • Under Standard Option Self and Family Enrollment, the deductible is considered satisfied for all family members when their combined covered expenses applied to the calendar year deductible for family members reach $700.
  • The Standard Option deductible is waived for preventive care.
  • The High Deductible Health Plan (HDHP) calendar year deductible is $1,500 for Self Only enrollment and $1,500 per person for Self Plus One or Self and Family enrollment not to exceed a total family deductible of $3,000 (each applies separately for services received from Plan providers and non-Plan providers).

Note: If you change plans during Open Season, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your prior option to the deductible of your new option.

Coinsurance

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance does not begin until you have met your calendar year deductible. You pay 20% coinsurance in-network or 40% out-of-network for most services, except for infertility services that have a 50% coinsurance.

See Your catastrophic protection out-of-pocket maximum page (Applies to printed brochure only); for more information regarding coinsurance.

Difference between our Plan allowance and the bill

Our “Plan allowance” is the amount we use to calculate our payment for covered services. As a general rule, you may receive care from any licensed or certified health care provider or hospital. We do not require a referral for specialty care. However, your choice of providers and hospitals affects the level of benefit coverage you receive, as well as your out-of-pocket costs.

When you choose a Plan provider, your out-of-pocket costs are the least. Plan providers agree to limit what they will bill you. Because of that, when you use a Plan provider, your share of covered charges consists only of your deductible (if applicable), coinsurance, or copayment. For non-emergency surgical or ancillary services performed at an in-Plan hospital or ambulatory surgical facility in Washington, under Washington law a non-Plan provider may not charge you more than our allowance.

If you choose a non-Plan provider, we pay 60% of our allowed amount for covered services. It is your responsibility to pay the difference between the amount billed by the non-Plan provider and the amount allowed by us. This is called “balance billing.” 

In certain instances, the care you receive from a non-Plan provider or facility is not subject to the reduction in the level of benefit coverage described above. Those instances are:

  • Medical Emergency. Emergency care is covered in full after you have met any applicable deductible, copayment, or coinsurance. If you are admitted to a non-Plan hospital as a result of your emergency, we reserve the right to arrange for your transportation to a Plan hospital (see Section 5(d), Emergency services/accidents, pages (Applies to printed brochure only) and (Applies to printed brochure only).
  • Services Not Available from Plan Providers/Facilities. We have the right to determine whether care and services are, or are not, available from a Plan provider or facility. If you believe the care or service you require is not available from a Plan provider or facility, please contact Member Services toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711 before obtaining the care or service and ask for a review to determine if it is appropriate for you to see a non-Plan provider. If we determine that the care or service you require can only be obtained from a non-Plan provider, your care will be covered in full (if it is a medically necessary/covered benefit) after you have met any applicable deductible, copayment, or coinsurance.

Your catastrophic protection out-of-pocket maximum

After your cost-sharing total is $5,000 per person up to $10,000 per family enrollment in any calendar year, you do not have to pay any more for certain covered services.  This includes any services required by group health plans to count toward the catastrophic protection out-of-pocket maximum by federal health care reform legislation (the Affordable Care Act and implementing regulations).

Example: Your plan has a $5,000 per person up to $10,000 per family maximum out-of-pocket limit. If you or one of your covered family members has out-of-pocket qualified medical expenses of $5,000 in a calendar year, any cost-sharing for qualified medical expenses for that individual will be covered fully by your health plan for the remainder of the calendar year. With a family enrollment, the out-of-pocket maximum will be satisfied once two or more family members have out-of-pocket qualified medical expenses of $10,000 in a calendar year, and any cost–sharing for qualified medical expenses for all enrolled family members will be covered fully by your health plan for the reminder of the calendar year.

For Standard Option: However, cost-sharing for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay cost-sharing for these services:

  • Services of non-Plan providers and facilities
  • Dental services
  • Expenses in excess of the Plan's allowable amount or benefit maximum
    (e.g., preventive dental care fee schedule amounts)

For HDHP Option:  However, cost-sharing for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay cost-sharing for these services:

  • Expenses in excess of the Plan’s allowable amount or benefit maximum
    (e.g., preventive dental care fee schedule amounts)

Carryover

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your prior option to the catastrophic protection limit of your new option.

When Government facilities bill usFacilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow. You may be responsible to pay for certain services and charges. Contact the government facility directly for more information.



Section 5. Standard Option Benefits (Standard Option)

See page (Applies to printed brochure only) for how our benefits changed this year and page (Applies to printed brochure only) for a benefits summary. Make sure that you review the benefits that are available under this option.




(Page numbers solely appear in the printed brochure)

Table of Content



Section 5. Standard Option Benefits Overview (Standard Option)

This Plan offers a Standard Option. The benefit package is described in Section 5. Make sure that you review the benefits that are available under the option in which you are enrolled.

The Standard Option Section 5 is divided into subsections. Please read Important things you should keep in mind at the beginning of the subsections. Also read the general exclusions in Section 6; they apply to the benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about Standard Option benefits, contact us toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711, or on our website at www.kp.org/feds/wa-options.

Unique features:

  • Preventive dental benefit
  • Alternative care provider coverage



Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals (Standard Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The calendar year deductible is: $350 per person ($700 per Self Plus One or Self and Family enrollment). The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how
    cost-sharing works. Also, read Section 9, Coordinating benefits with Medicare and other coverage.
  • For the non-Plan provider benefit see Section 5(i), Point of Service (POS) benefits, page (Applies to printed brochure only).



Benefit Description : Diagnostic and treatment servicesStandard Option (You pay After the calendar year deductible… )

Professional services of physicians and other health care professionals

  • In physician’s office
  • In an urgent care center
  • Office medical consultations
  • Second surgical opinion

Note: You pay a copayment for office visits billed with codes corresponding to these services.

In-network: $25 per primary care office visit or $35 per specialty care office visit (no deductible)

Out-of-network:  $25 per primary care office visit or $35 per specialty care office visit, then 40% of the Plan allowance and any difference between our allowance and the billed amount (no deductible)

Procedures received during an office visit

Note: Procedures include lab, X-ray, other diagnostic procedures and surgical services. For more information, see Sections 5(a), Lab, X-ray and other diagnostic tests, and 5(b), Surgical and anesthesia services provided by physicians and other health care professionals.

In-network: 20% of Plan allowance   

Out-of-network: 40% of the Plan allowance and any difference between our allowance and the billed amount

Professional services of physicians and other health care professionals

  • At a hospital - inpatient and outpatient visits
  • In a skilled nursing facility
  • At home

In-network: 20% of Plan allowance

Out-of-Network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Telehealth ServicesStandard Option (You pay After the calendar year deductible… )

Professional services of physicians and other health care professionals delivered through telehealth, such as:

  • Interactive video
  • Phone visits
  • Email

Note: Visits may be limited by provider type, location and benefit specific limitations, such as visit limits.

In-network: Nothing (no deductible)

Out-of-network:  $25 per primary care office visit or $35 per specialty care office visit, then 40% of the Plan allowance and any difference between our allowance and the billed amount (no deductible)

Benefit Description : Lab, X-ray and other diagnostic testsStandard Option (You pay After the calendar year deductible… )

Tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine Pap tests
  • Pathology
  • X-rays
  • Non-routine mammograms
  • CAT Scans/MRI
  • Ultrasound
  • Electrocardiogram and EEG

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Preventive care, adultStandard Option (You pay After the calendar year deductible… )
  • One annual routine physical 
  • One annual routine eye exam

In-network: Nothing

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

(No deductible)

We cover preventive services required by federal health care reform legislation (the Affordable Care Act and implementing regulations) and additional services that we include in our preventive services benefit.


Including:

  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations visit the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules
  • Screenings such as for breast cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. For a complete list of A and B recommended screenings visit the U.S. Preventive Services Task Force (USPSTF) website at www.uspreventiveservicestaskforce.org
  • Individual counseling on prevention and reducing health risks
  • Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at www.healthcare.gov/preventive-care-women
  • Services such as routine prostate specific antigen (PSA) test and retinal photography screening. For a complete list of Kaiser Permanente preventive services visit our website at https://wa.kaiserpermanente.org/healthandwellness



In-network: Nothing

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

(No deductible)

Routine mammogram - covered for women.

In-network: Nothing

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

(No deductible)

Notes:

  • You may pay cost-sharing for any procedure, injection, diagnostic service, laboratory or X-ray service that is provided in conjunction with a routine physical exam and is not included in the recommended list of preventive services.
  • You should consult with your physician to determine what is appropriate for you.

Refer to Notes

Not covered:

  • Physical exams and immunizations required for obtaining or continuing employment or insurance, attending camp, athletic exams or travel.
All Charges
Benefit Description : Preventive care, childrenStandard Option (You pay After the calendar year deductible… )

We cover preventive services required by federal health care reform legislation (the Affordable Care Act and implementing regulations) and additional services that we include in our preventive services benefit. I

Including:

  • Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines visit www.brightfutures.aap.org
  • Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations visit the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules/index.html
  • You can also find a complete list of A and B recommended preventive care services under the U.S. Preventive Services Task Force (USPSTF) online at www.uspreventiveservicestaskforce.org
  • For a complete list of Kaiser Permanente preventive services visit our website at https://wa.kaiserpermanente.org/healthandwellness

In-network: Nothing

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

(No deductible)

Notes:

• You may pay cost-sharing for any procedure, injection, diagnostic service, laboratory or X-ray service that is provided in conjunction with a routine physical exam and is not included in the recommended list of preventive services.

Refer to Notes

Not covered:

  • Physical exams and immunizations required for obtaining or continuing employment or insurance, attending camp, athletic exams or travel.
All Charges
Benefit Description : Maternity careStandard Option (You pay After the calendar year deductible… )

Complete maternity (obstetrical) care by a physician, certified nurse midwife, or licensed midwife for:

  • Prenatal care (see Preventive care, adult)
  • Screening for gestational diabetes for pregnant women
  • Delivery (including home births)
  • Postnatal care

Breastfeeding support, supplies and counseling for each birth.

Notes: Here are some things to keep in mind:

  • When seen in an emergency room for any reason, the Emergency services/accidents benefit cost-share will apply.
  • You do not need to preauthorize your vaginal delivery; see Section 3 for other information.
  • You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a Cesarean delivery. We will extend your inpatient stay if medically necessary.
  • We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to medically necessary circumcision. See Section 5(b), for circumcision benefits. We cover routine circumcision under Preventive care, children 
  • When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in his or her own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.
  • Dependent child – pregnancy, delivery, and care of newborn during mother's hospital stay is covered.
  • We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
  • Hospital/birthing center costs, see Section 5(c) and Surgical benefits Section 5(b).

In-network: Nothing

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

(No deductible)

Not covered:

  • Care of a dependent child’s newborn once the mother is discharged from the hospital unless the newborn is determined to be your dependent by your personnel office.
All Charges
Benefit Description : Family planning Standard Option (You pay After the calendar year deductible… )

A range of voluntary family planning services, limited to:

  • Voluntary male sterilization (vasectomy)

In-network: Nothing 

(No deductible)

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

  • Voluntary female sterilization (tubal ligation)
  • Contraceptive methods and counseling
    • Surgically implanted contraceptives 
    • Injectable contraceptive drugs (such as Depo Provera)  
    • Intrauterine devices (IUDs) 
    • Diaphragms

Note: See also Preventive care, adult for female sterilization and contraceptives.

In-network: Nothing

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

(No deductible)

Not covered:

  • Reversal of voluntary surgical sterilization
All Charges
Benefit Description : Infertility servicesStandard Option (You pay After the calendar year deductible… )

Diagnosis & treatment of infertility such as:

  • Artificial insemination (AI):
    • Intravaginal insemination (IVI)
    • Intracervical insemination (ICI)
    • Intrauterine insemination (IUI)

In-network: 50% of Plan allowance

Out-of-network: 50% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Assisted reproductive technology (ART) procedures, such as:
    • In vitro fertilization (IVF)
    • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
    • Zygote transfer
  • Services and supplies related to excluded ART procedures
  • Cost of donor sperm
  • Cost of donor egg
  • Fertility drugs 
 
All Charges
Benefit Description : Allergy careStandard Option (You pay After the calendar year deductible… )
  • Testing and treatment
  • Allergy injections

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Allergy serum

In-network: Nothing

Out-of-network: 40% of Plan allowance and any difference between the Plan's allowed amount and the billed charges

(No deductible)

Not covered:

  • Provocative food testing and sublingual allergy desensitization.
All Charges
Benefit Description : Treatment therapiesStandard Option (You pay After the calendar year deductible… )
  • Chemotherapy and radiation therapy – some types of chemotherapy require preauthorization. Your physician should call Member Services toll-free at 888-901-4636 prior to you receiving therapy.

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Section 5(b), Organ/tissue transplants.

  • Respiratory and inhalation therapy
  • Dialysis – hemodialysis and peritoneal dialysis
  • Cardiac rehabilitation following a qualifying event/condition 
  • Intravenous (IV)/Infusion Therapy in a medical office or outpatient hospital facility
  • Growth hormone therapy (GHT)
  • Ultraviolet light treatments

Notes:

  • Growth hormone is covered under the prescription drug benefit and requires preauthorization.
  • We only cover GHT when we preauthorize the treatment. Your physician must obtain preauthorization before you begin treatment.  See Other services under You need prior Plan approval for certain services.
  • See Section 5(e), Professional services, for coverage of Applied Behavior Analysis (ABA).

In-network: $25 per primary care office visit or $35 per specialty care office visit (no deductible)

Out-of-network:  $25 per primary care office visit or $35 per specialty care office visit, then 40% of the Plan allowance and any difference between our allowance and the billed amount (no deductible)

  • Intravenous (IV)/infusion therapy - Associated infused medications

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Intravenous (IV)/Infusion Therapy at home

Nothing (No deductible)

  • Enteral nutritional therapy when necessary due to malabsorption and an eosinophilic gastrointestinal disorder, including equipment and supplies
  • Total parenteral nutritional therapy and supplies necessary for its administration

Note: See Section 5(a), Durable medical equipment (DME) for coverage of equipment and supplies.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Neurodevelopmental therapiesStandard Option (You pay After the calendar year deductible… )

Coverage for the restoration and improvement of function in a neurodevelopmentally disabled individual includes:

  • Inpatient and outpatient physical, speech and occupational therapy; and
  • Ongoing maintenance care in cases where significant deterioration of the child’s condition would occur without the care

All therapy treatments must be performed by a physician, registered physical therapist (PT), ASHA-certified speech therapist or an occupational therapist certified by the American Occupational Therapy Association.

Coverage does not duplicate coverage for therapy services provided under any other benefit of this Plan.

In-network: $25 per primary care office visit or $35 per specialty care office visit (no deductible)

Out-of-network: $25 per primary care office visit or $35 per specialty care office visit, then 40% of the Plan allowance and any difference between our allowance and the billed amount (no deductible)

Benefit Description : Physical and occupational therapiesStandard Option (You pay After the calendar year deductible… )

Up to 60 combined visits for rehabilitative or habilitative care per condition per calendar year for physical, occupational, and speech therapy and pulmonary rehabilitation. This limit does not apply to rehabilitative or habilitative care for the treatment of mental health conditions. Services must be provided by qualified physical, occupational, respiratory, speech therapists or other provider.

Notes:

  • Outpatient therapies that are provided in a rehabilitation unit that is part of an acute-care hospital, a stand-alone rehabilitation hospital, or an extended care/skilled nursing facility apply toward the maximum 60 combined visits per condition. See Speech therapy, and Home health services.
  • For inpatient therapy benefit, see Section 5(c).

In-network: $25 per primary care visit or $35 per specialty care individual office visit (no deductible)

Out-of-network: $25 per primary care office visit or $35 per specialty care individual office visit, then 40% of the Plan allowance and any difference between our allowance and the billed amount (no deductible)

Note: You pay one-half of the individual office visit copayment for group office visits, rounded down to the nearest dollar 

Not covered:

  • Long-term rehabilitative therapy
  • Exercise programs
  • Reflexology
  • Rolfing
All Charges
Benefit Description : Pulmonary rehabilitationStandard Option (You pay After the calendar year deductible… )

Up to 60 combined visits for rehabilitative or habilitative care per condition per calendar year for physical, occupational, and speech therapy and pulmonary rehabilitation. This limit does not apply to rehabilitative or habilitative care for the treatment of mental health conditions. Services must be provided by qualified respiratory therapists.

Notes:

• Outpatient therapy services that are provided in a rehabilitation unit that is part of an acute-care hospital, a stand-alone rehabilitation hospital, or an extended care/skilled nursing facility apply toward the maximum 60 combined visits per condition.

• For inpatient therapy benefit, see Section 5(c).

In-network: $25 per primary care visit or $35 per specialty care individual office visit (no deductible)

Out-of-network: $25 per primary care office visit or $35 per specialty care individual office visit, then 40% of the Plan allowance and any difference between our allowance and the billed amount (no deductible)

Note: You pay one-half of the individual office visit copayment for group office visits, rounded down to the nearest dollar

Benefit Description : Speech therapy Standard Option (You pay After the calendar year deductible… )

Up to 60 combined visits for rehabilitative or habilitative care per condition per calendar year for physical, occupational, and speech therapy and pulmonary rehabilitation. This limit does not apply to rehabilitative or habilitative care for the treatment of mental health conditions. Services must be provided by qualified speech therapists.

Notes:

  • For inpatient therapy benefit, see Section 5(c).
  • Outpatient therapy services that are provided in a rehabilitation unit that is part of an acute-care hospital, a stand-alone rehabilitation hospital, or an extended care/skilled nursing facility apply toward the maximum 60 combined visits per condition.

In-network: $25 per primary care visit or $35 per specialty care individual office visit (no deductible)

Out-of-network:  $25 per primary care office visit or $35 per specialty care individual office visit, then 40% of the Plan allowance and any difference between our allowance and the billed amount (no deductible)

Note: You pay one-half of the individual office visit copayment for group office visits, rounded down to the nearest dollar 

Benefit Description : Hearing services (testing, treatment, and supplies)Standard Option (You pay After the calendar year deductible… )
  • For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist 

Note: For routine hearing screening performed during a child's preventive care visit, see Preventive care, children.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

  • External hearing aids and testing to fit them when prescribed by a qualified provider

Note: For benefits for implanted hearing-related devices (BAHA), see Orthopedic and prosthetic devices.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

(Hearing aids are limited to $1,000 for one hearing aid per ear every year for children through age 17 and every 2 years for adults)

Not covered:

  • Hearing services that are not shown as covered
  • Replacement parts and batteries, repair of hearing aids, and replacement of lost or broken hearing aids
All Charges
Benefit Description : Vision services (testing, treatment, and supplies)Standard Option (You pay After the calendar year deductible… )
  • One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

  • Diagnostic eye exams provided by an optometrist or ophthalmologist to determine the need for vision correction. For routine screening eye exam benefit see Preventive care, adult and Preventive care, children.

In-network: $25 per primary care office visit or $35 per specialty care  office visit (no deductible)

Out-of-network:  $25 per primary care office visit or $35 per specialty care office visit, then 40% of the Plan allowance and any difference between our allowance and the billed amount (no deductible)

Annual routine eye exam for adults.

In-network: Nothing

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

(No deductible)

Not covered:

  • Eyeglasses or contact lenses, except as related to accidental ocular injury or intraocular surgery
  • Eye exercises and orthoptics
  • Radial keratotomy and other refractive surgery
All Charges
Benefit Description : Foot careStandard Option (You pay After the calendar year deductible… )
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

Note: See Orthopedic and prosthetic devices, for information on podiatric shoe inserts.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
  • Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or
    subluxation of the foot (unless the treatment is by open cutting surgery)
All Charges
Benefit Description : Diabetic education, equipment and suppliesStandard Option (You pay After the calendar year deductible… )
  • Health Education and training
    • Nutritional guidance

In-network: $25 per primary care office visit or $35 per specialty care office visit (no deductible)

Out-of-network:  $25 per primary care office visit or $35 per specialty care office visit, then 40% of the Plan allowance and any difference between our allowance and the billed amount (no deductible)

  • Medical Equipment
    • Dialysis equipment
    • Insulin pumps
    • Insulin infusion devices
    • Medically necessary orthopedic shoes and inserts
  • Supplies other than those covered under Prescription drug benefits such as:
    • Orthopedic and corrective shoes
    • Arch supports
    • Foot orthotics
    • Heel pads and heel cups
    • Elastic stockings, support hose
    • Prosthetic replacements

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

  • Glucometers

In-network: 20% of Plan allowance (no deductible)

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Orthopedic and prosthetic devices Standard Option (You pay After the calendar year deductible… )
  • Artificial limbs and eyes
  • Prosthetic sleeve or sock
  • Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
  • Osseointegrated implants/bone anchored hearing aids (BAHA); preauthorization is required. Please refer to the preauthorization information provided in Section 3.
  • Cochlear implants - requires preauthorization
  • Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Notes:

  • For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical and anesthesia services. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.
  • For information on external hearing aids, see Section 5(a) Hearing services.
  • Orthopedic and prosthetic devices must be obtained from a Medicare certified provider. Purchases made through the Internet generally do not meet this requirement and are not covered under this Plan. If you have questions about a provider you are considering, please contact us before obtaining the device(s).

Refer to Notes

Not covered:

  • Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
  • Lumbosacral supports
  • Corsets, trusses, elastic stockings, support hose, and other supportive devices
  • Prosthetic replacements provided less than 3 years after the last one we covered  (except for externally worn breast prostheses and surgical bras)
  • Devices and supplies purchased through the Internet
  • Replacement of devices, equipment and supplies due to loss, theft, breakage or damage
All Charges
Benefit Description : Durable medical equipment (DME)Standard Option (You pay After the calendar year deductible… )

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Listed below are some of the items that are covered. The list is not all inclusive. For more details please contact Member Services toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711.

  • Oxygen
  • Hospital beds
  • Wheelchairs
  • Crutches
  • Walkers
  • Motorized wheelchairs
  • Audible prescription reading device
  • Speech generating device

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

  • Peak flow meters

In-network: 20% of Plan allowance (no deductible)

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Note: DME must be obtained from a Medicare certified provider. Purchases made through the Internet generally do not meet this requirement and are not covered under this Plan. If you have questions about a provider you are considering, please contact us before obtaining the equipment.

Refer to Notes

Not covered:

  • Exercise equipment such as Nordic Track and/or exercise bicycles
  • Equipment which is primarily used for
    non-medical purposes such as hot tubs and massage pillows
  • Convenience items
  • DME purchased through the Internet
  • Wigs and hair prostheses
  • Replacement of devices, equipment and supplies due to loss, theft, breakage or damage
All Charges
Benefit Description : Home health servicesStandard Option (You pay After the calendar year deductible… )
  • Home health care ordered by a physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), master of social work (M.S.W.), or home health aide. Up to two hours per visit.
  • Services include oxygen therapy, intravenous therapy and assistance with medications. IV therapy supplies and medications are covered separately under the Treatment therapies benefit. Oxygen is covered separately under the Durable medical equipment (DME) benefit.

Note: These services require preauthorization. Please refer to the preauthorization information shown in Section 3.

Note: Therapy (physical, occupational, speech) received in your home is paid under the Physical and occupational therapies benefit and applies towards your therapy maximum of 60 visits per condition. See Physical and occupational therapies.

In-network: 20% of Plan allowance per visit

Out-of-network: 40% of Plan allowance per visit and any difference between our allowance and the billed amount

Not covered:

  • Nursing care requested by, or for the convenience of, the patient or the patient’s family.
  • Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.
All Charges
Benefit Description : Chiropractic Standard Option (You pay After the calendar year deductible… )
  • Up to 20 treatments per calendar year for manipulation of the spine and extremities

In-network: $25 per primary care treatment (no deductible)

Out-of-network: $25 per primary care treatment, then 40% of the Plan allowance and any difference between our allowance and the billed amount (no deductible)

Not covered:

  • Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy,
    and cold pack application
All Charges
Benefit Description : Alternative treatmentsStandard Option (You pay After the calendar year deductible… )
  • Massage therapy - up to 20 treatments per calendar year when treatment prescribed by a qualified provider and received from a licensed massage therapist
  • Acupuncture – up to 20 treatments per calendar year when treatment is received from a licensed provider for:
    • anesthesia
    • pain relief
    • substance use disorder - unlimited 
  • Naturopathic services

In-network: $25 per primary care office visit or $35 per specialty care office visit (no deductible)

Out-of-network:  $25 per primary care office visit or $35 per specialty care office visit, then 40% of the Plan allowance and any difference between our Plan allowance and the billed amount (no deductible)

Not covered:

  • Herbs prescribed by an East Asian Medicine Practitioner (acupuncturist) or naturopath
  • Hypnotherapy
  • Biofeedback
  • Reflexology
  • Rolfing
All Charges
Benefit Description : Educational classes and programsStandard Option (You pay After the calendar year deductible… )

Coverage is provided for:

  • Tobacco Cessation when participating in the Quit For Life® program. You will receive up to two (2) quit attempts per year and a minimum of four (4) counseling sessions that include individual, group, and phone counseling, along with physician prescribed over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence.

    Call 866-784-8454 toll-free or visit the Quit For Life® website at www.quitnow.net for information on how to enroll. 

Nothing for two quit attempts per calendar year through the Quit For Life® program.

Nothing for physician prescribed over-the-counter and prescription drugs authorized by the Quit For Life® program and approved by the FDA to treat tobacco dependence.

(No deductible)

  • Outpatient nutritional guidance counseling services by a certified dietitian or certified nutritionist for conditions such as:
    • Cancer
    • Endocrine conditions
    • Swallowing conditions after stroke
    • Hyperlipidemia
    • Colitis
    • Coronary artery disease
    • Dysphagia
    • Gastritis
    • Inactive colon
    • Anorexia
    • Bulimia
    • Short bowel syndrome (post surgery)
    • Food allergies or intolerances
    • Obesity 

In-network: $25 per primary care office visit or $35 per specialty care office visit (no deductible)

Out-of-network:  $25 per primary care office visit or $35 per specialty care office visit, then 40% of the Plan allowance and any difference between our Plan allowance and the billed amount (no deductible)

Not covered: 

  • Over-the-counter drugs, except for physician prescribed tobacco cessation medications received through the  Quit For Life® program and approved by the FDA for treatment of tobacco dependence
  • Weight loss medications
All Charges
Benefit Description : Sleep disordersStandard Option (You pay After the calendar year deductible… )

Coverage under this benefit is limited to sleep studies, including provider services, appropriate durable medical equipment, and surgical treatments. No other benefits for the purposes of studying, monitoring and/or treating sleep disorders, other than as described below, is provided.

 Sleep studies – Coverage for sleep studies includes:

  • Polysomnographs
  • Multiple sleep latency tests
  • Continuous positive airway pressure (CPAP) studies
  • Related durable medical equipment and supplies, including CPAP machines
  • The condition giving rise to the sleep disorder (such as narcolepsy or sleep apnea) must be diagnosed by your provider. Preauthorization of sleep studies is not required; however, you must be referred to the sleep studies program by your provider.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Any service not listed above for the purpose of studying, monitoring and/or treating sleep disorders.
All Charges
Benefit Description : Temporomandibular joint (TMJ) disordersStandard Option (You pay After the calendar year deductible… )

Treatment of TMJ, includes surgical and non-surgical intervention, corrective orthopedic appliances and physical therapy.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Services primarily for cosmetic purposes
  • Related dental work
All Charges
Benefit Description : Phenylketonuria (PKU) formulasStandard Option (You pay After the calendar year deductible… )
Special dietary formulas designed for use by those diagnosed with phenylketonuria.

In-network: Nothing

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

(No deductible)




Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals (Standard Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary. 
  • The calendar year deductible is $350 per person ($700 per Self Plus One or Self and Family enrollment). The calendar year deductible applies to all benefits in this Section.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing Also, read Section 9, Coordinating benefits with Medicare and other coverage.
  • The services listed below are for the charges billed by a physician or other health care professional for your surgical care. See Section 5(c) for charges associated with the facility (i.e., hospital, surgical center, ).
  • YOUR PHYSICIAN MUST GET PREAUTHORIZATION FOR SOME SURGICAL PROCEDURES. Please refer to the preauthorization information shown in Section 3 and contact Member Services toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state’s relay line by dialing either 800-833-6388 or 711 to be sure which services require preauthorization and identify which surgeries require preauthorization.

For non-Plan provider benefit see Section 5(i), Point of Service (POS) benefits, page (Applies to printed brochure only).




Benefit Description : Surgical proceduresStandard Option (You pay After the calendar year deductible… )

A comprehensive range of services, such as:

  • Operative procedures
  • Treatment of fractures, including casting
  • Normal pre- and post-operative care by thesurgeon
  • Correction of amblyopia and strabismus
  • Endoscopy procedures
  • Biopsy procedures
  • Removal of tumors and cysts
  • Correction of congenital anomalies (see Reconstructive surgery)
  • Insertion of internal prosthetic devices. See Section 5(a), Orthopedic and prosthetic devices, for device coverage information.

    Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done.  For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.
  • Circumcision as medically necessary
  • Transgender reassignment surgery
    • For female to male surgery: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, and placement of testicular and erectile prosthesis
    • For male to female surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, labiaplasty
  • Treatment of burns
  • Surgical treatment (bariatric surgery) and all services associated with the surgical treatment of morbid obesity.

    Note: The surgical candidate must be at least 18 years or older, have no other health conditions with a Body Mass Index (BMI) of 40 or greater, or have at least one complicating medical condition with a BMI of 35 or greater. All inpatient and outpatient surgical treatment for morbid obesity must be preauthorized and performed through a bariatric surgery Center of Excellence. See Other services under You need prior Plan approval for certain services.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

  • Voluntary male sterilization (vasectomy)

In-network: Nothing 

(No Deductible)

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

  • Voluntary female sterilization (tubal ligation)

In-network: Nothing

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

(No Deductible)

Not covered:

  • Reversal of voluntary sterilization
  • Routine treatment of conditions of the foot (see Foot care)
  • Weight loss medications
  • Services for the promotion, prevention, or other treatment of hair loss or hair grow
  • Cosmetic surgery, any surgery procedure (or any portion of the procedure) performed primarily to improve physical appearance through change in bodily form
  • Facial feminization and breast augmentation for the treatment of gender dysphoria 
  • Services not listed above as covered
All Charges
Benefit Description : Reconstructive surgery Standard Option (You pay After the calendar year deductible… )
  • Surgery to correct a functional defect
  • Surgery to correct a condition caused by injury or illness if:
    • the condition produced a major effect on the member’s appearance and
    • the condition can reasonably be expected to be corrected by such surgery
  • Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers; and webbed toes.
  • All stages of breast reconstruction surgery following a mastectomy, such as:
    • Surgery to produce a symmetrical appearance of breasts
    • Treatment of any physical complications, such as lymphedema
    • Breast prostheses and surgical bras and replacements (see Section 5(a), Orthopedic and prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

All Charges
Benefit Description : Oral and maxillofacial surgery Standard Option (You pay After the calendar year deductible… )

Oral surgical procedures, limited to:

  • Reduction of fractures of the jaws or facial bones;
  • Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
  • Removal of stones from salivary ducts;
  • Excision of leukoplakia or malignancies;
  • Excision of cysts and incision of abscesses when done as independent procedures; and
  • Other surgical procedures that do not involve the teeth or their supporting structures.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Oral implants and transplants
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
All Charges
Benefit Description : Organ/tissue transplantsStandard Option (You pay After the calendar year deductible… )

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services

  • Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
  • Cornea
  • Heart
  • Heart/lung
  • Intestinal transplants
    • Isolated small intestine
    • Small intestine with the liver
    • Small intestine with multiple organs such as the liver, stomach, and pancreas
  • Kidney
  • Kidney/pancreas 
  • Liver
  • Lung: single/bilateral/lobar 
  • Pancreas

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

  • Autologous tandem transplants for
    • AL Amyloidosis
    • Multiple myeloma (de novo and treated)
    • Recurrent germ cell tumors (including testicular cancer)

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Blood or marrow stem cell transplants The Plan extends coverage for the diagnoses as indicated below.

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant.

  • Allogeneic transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Acute myeloid leukemia
    • Advanced Hodgkin's lymphoma with recurrence (relapsed)
    • Advanced Myeloproliferative Disorders (MPDs)
    • Advanced neuroblastoma
    • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • Infantile malignant osteopetrosis
    • Kostmann’s syndrome
    • Leukocyte adhesion deficiencies
    • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
    • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
    • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
    • Sickle cell anemia
    • X-linked lymphoproliferative syndrome
  • Autologous transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Breast cancer
    • Ependymoblastoma
    • Epithelial ovarian cancer
    • Ewing’s sarcoma
    • Medulloblastoma
    • Multiple myeloma
    • Pineoblastoma
    • Neuroblastoma
    • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Mini-transplants performed in a clinical setting (non-myeloblative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other services in Section 3 for prior authorization procedures.

  • Allogeneic transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Acute myeloid leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced Myeloproliferative Disorders (MPDs)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
  • Autologous transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Neuroblastoma

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Health approved clinic trial or a Plan-designated center of excellence and if approved by the Plan’s medical director in accordance with the Plan’s protocols.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

  • Allogeneic transplants for
    • Advanced Hodgkin's lymphoma
    • Advanced non-Hodgkin's lymphoma
    • Beta Thalassemia Major
    • Chronic inflammatory demyelination polyneuropathy (CIDP)
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Multiple myeloma
    • Multiple sclerosis
    • Sickle cell anemia
  • Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin's lymphoma
    • Advanced non-Hodgkin's lymphoma
    • Breast cancer 
    • Chronic lymphocytic leukemia
    • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
    • Chronic myelogenous leukemia
    • Colon cancer 
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Multiple myeloma
    • Multiple sclerosis 
    • Myelodysplasia/Myelodysplastic Syndromes
    • Myeloproliferative disorders (MPDs)
    • Non-small cell lung cancer
    • Ovarian cancer
    • Prostate cancer
    • Renal cell carcinoma
    • Sarcomas 
    • Sickle cell anemia
  • Autologous transplants for
    • Advanced childhood kidney cancers
    • Advanced Ewing sarcoma
    • Advanced Hodgkin's lymphoma
    • Advanced non-Hodgkin's lymphoma
    • Aggressive non-Hodgkin's lymphomas (Mantel Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms)
    • Breast cancer
    • Childhood rhabdomyosarcoma
    • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
    • Chronic myelogenous leukemia
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Epithelial Ovarian Cancer
    • Mantle Cell (non-Hodgkin lymphoma)
    • Multiple sclerosis
    • Small cell lung cancer
    • Systemic lupus erythematosus
    • Systemic sclerosis

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

National Transplant Program (NTP)

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Notes:

  • We cover related medical and hospital expenses of the donor when we cover the recipient.
  • We cover donor screening tests and donor search expenses for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

Refer to Notes

Not covered:

  • Donor screening tests and donor search expenses, except as shown above
  • Implants of artificial organs
  • Any transplant not specifically listed as a covered benefit
All Charges
Benefit Description : Sleep DisordersStandard Option (You pay After the calendar year deductible… )

Surgical treatment – Coverage for the medically necessary surgical treatment of diagnosed sleep disorders is covered under this benefit.

Preauthorization of surgical procedures for the treatment of sleep disorders is required. See Other services under You need prior Plan approval for certain services. Surgical treatment includes all professional and facility fees related to the surgical treatment including pre- and post-operative care and complications.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : AnesthesiaStandard Option (You pay After the calendar year deductible… )

Professional services provided in –

  • Hospital (inpatient)
  • Hospital outpatient department
  • Skilled nursing facility
  • Ambulatory surgical center
  • Office

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount




Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services (Standard Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The calendar year deductible is $350 per person ($700 per Self Plus One or Self and Family enrollment). The calendar year deductible applies to almost all benefits in this Section. We added "(No deductible)" to show when the calendar year deductible does not apply.
  • Be sure to read Section 4, Your costs for covered services for valuable information about how cost-sharing works. Also, read Section 9, Coordinating benefits with Medicare and other coverage.
  • The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge (i.e., physicians, etc.) are in Sections 5(a) and (b).
  • YOUR PHYSICIAN MUST GET PREAUTHORIZATION FOR HOSPITAL Please refer to Section 3 and contact Member Services toll-free at 888-901-4636; for the deaf and hearing- impaired use Washington state's relay line by dialing either 800-833-6388 or 711 to be sure which services require preauthorization.

For non-Plan provider benefit see Section 5(i), Point of Service (POS) benefits, page (Applies to printed brochure only).




Benefit Description : Inpatient hospitalStandard Option (You pay After the calendar year deductible...)

Room and board, such as:

  • Ward, semiprivate, or intensive care accommodations
  • General nursing care
  • Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Note: Included under this benefit are admissions for inpatient physical, occupational, and speech therapies and pulmonary rehabilitation provided in a rehabilitation unit that is part of an acute-care hospital or standalone rehabilitation hospital.

Other hospital services and supplies, such as:

  • Operating, recovery, and other treatment rooms
  • Prescribed drugs and medications 
  • Diagnostic laboratory tests and X-rays
  • Administration of blood and blood products
  • Blood or blood products, if not donated or replaced
  • Dressings, splints, casts, and sterile tray services
  • Medical supplies and equipment, including oxygen
  • Anesthetics, including nurse anesthetist services
  • Take-home items (except medications)
  • Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home
  • Private nursing care

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference our allowance and the billed amount

Maternity delivery charges in a hospital or birthing center.

In-network: Nothing

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

(No deductible)

Not covered:

  • Custodial care
  • Non-covered facilities, such as nursing homes, schools
  • Personal comfort items, such as phone, television, barber services, guest meals and beds
  • Take home medications
All Charges
Benefit Description : Outpatient hospital or ambulatory surgical centerStandard Option (You pay After the calendar year deductible...)
  • Operating, recovery, and other treatment rooms
  • Prescribed drugs and medications
  • Diagnostic laboratory tests, X-rays, and pathology services
  • Administration of blood, blood products, and other biologicals
  • Blood and blood plasma, if not donated or replaced
  • Pre-surgical testing
  • Dressings, casts, and sterile tray services
  • Medical supplies, including oxygen
  • Anesthetics and anesthesia service

Note:

  • We cover hospital services and supplies related to dental procedures when necessitated by a
    non-dental, physical impairment. We do not cover the dental procedures listed under Section 5(g), Dental benefits.
  • See Section 5(a), for Telehealth Services.  

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:  

  • Take home medications
  • Audio-only, phone, fax and e-mail communications
All Charges
Benefit Description : Extended care benefits/Skilled nursing care facility benefitsStandard Option (You pay After the calendar year deductible...)

When appropriate, as determined by a doctor and approved by us, we cover full-time skilled nursing care with no dollar or day limit.  Intensive physical and occupational therapies in a skilled nursing facility apply toward the maximum 60 combined visits per condition. Extended care benefits require preauthorization by our medical director.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

   Not covered: 

  • Custodial care
All Charges
Benefit Description : Hospice careStandard Option (You pay After the calendar year deductible...)

Supportive and palliative care for a terminally ill member is covered when services are provided under the direction of a doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately 6 months or less.

Services include:

  • Medical care
  • Family counseling
  • Inpatient hospice benefits are available only when services are preauthorized and determined necessary to:
    • Control pain and manage the patient’s symptoms; or
    • Provide an interval of relief (respite) to the family not to exceed seven (7) consecutive days; each respite care admission must be preauthorized and separated by at least 21 days.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Independent nursing, homemaker services
All Charges
Benefit Description : AmbulanceStandard Option (You pay After the calendar year deductible...)

Coverage for ambulance services includes:

  • Ground transportation
  • Air transportation

Air ambulance transportation is subject to review and approval by us. In cases where the patient’s condition does not warrant air transportation, coverage will be based on the benefit for ground transportation.

Note: If you are hospitalized in a non-Plan facility and Plan doctors believe care can be provided in a Plan hospital, you may ask to be transferred to a Plan provider when medically feasible with any ambulance charges covered in full.

20% of Plan allowance

Not covered: 

  • The use of any type of ambulance transportation for personal convenience.
All Charges



Section 5(d). Emergency Services/Accidents (Standard Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The calendar year deductible is $350 per person ($700 per Self Plus One or Self and Family enrollment). The calendar year deductible applies to almost all benefits in this Section. We added "(No deductible)" to show when the calendar year deductible does not apply.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how
    cost-sharing works. Also, read Section 9, Coordinating benefits with Medicare and other coverage.



What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.





What to do in case of emergency:

Emergencies within our service area: If you are in an emergency situation, please call your doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 phone system) or go to the nearest hospital emergency room.

If you need to be hospitalized, you or a family member must notify us unless it is not reasonably possible to do so. If you are hospitalized in a non-Plan facility, we will work with your doctor to determine when and if it is medically feasible to transfer you to a Plan hospital. You will be transferred when medically feasible with any ambulance charges covered in full.

Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, you or a family member must notify us unless it is not reasonably possible to do so. If you are hospitalized in a non-Plan facility, we will work with your doctor to determine when and if it is medically feasible to transfer you to a Plan hospital. You will be transferred when medically feasible with any ambulance charges covered in full.

Follow-up care received from non-Plan providers and/or at a non-Plan facility when the care could be received from a Plan provider and/or at a Plan facility, will be covered at the Point of Service (POS) benefit level. See Section 5(i), Point of Service (POS) benefits, page (Applies to printed brochure only).




Benefit Description : Emergency within our service areaStandard Option (You pay After the calendar year deductible… )
  • Emergency care at a doctor’s office
  • Emergency care at an urgent care center

$25 per primary care visit or $35 per specialty care visit (no deductible)

  • Emergency care as an outpatient or inpatient at a hospital, including doctor’s services

Note: If you receive emergency care and then are transferred to observation care, you pay the emergency services cost-sharing. If you are admitted as an inpatient, we will waive your emergency room copayment and you will pay your cost-sharing related to your inpatient hospital stay.

$150 copayment

Not covered:

  • Elective care or non-emergency care
All Charges
Benefit Description : Emergency outside our service areaStandard Option (You pay After the calendar year deductible… )
  • Emergency care at a doctor’s office
  • Emergency care at an urgent care center

$25 copayment per primary care visit or $35 copayment per specialty care visit (no deductible)

  • Emergency care as an outpatient or inpatient at a hospital, including doctor’s services

Note: If you receive emergency care and then are transferred to observation care, you pay the emergency services cost-sharing. If you are admitted as an inpatient, we will waive your emergency room copayment and you will pay your cost-sharing related to your inpatient hospital stay.

$150 copayment

Not covered:

  • Elective care or non-emergency care
  • Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
All Charges
Benefit Description : AmbulanceStandard Option (You pay After the calendar year deductible… )

Professional ambulance service when medically appropriate.

  • Ground transportation
  • Air transportation

In cases where the patient’s condition does not warrant air transportation, coverage will be based on the benefit for ground transportation.

Note: If you are hospitalized in a non-Plan facility and Plan doctors believe care can be provided in a Plan hospital, you may ask to transferred to a Plan provider when medically feasible with any ambulance charges covered in full.

See Section 5(c), for non-emergency service.

20% of Plan allowance

Not covered:

  • The use of any type of ambulance transportation for personal convenience.
All Charges



Section 5(e). Mental Health and Substance Use Disorder Benefits (Standard Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The calendar year deductible is $350 per person ($700 per Self Plus One or Self and Family enrollment). The calendar year deductible applies to almost all benefits in this Section. We added "(No deductible)" to show when the calendar year deductible does not apply.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also, read Section 9, Coordinating benefits with Medicare and other coverage.
  • YOU MUST GET PREAUTHORIZATION FOR INPATIENT SERVICES.  Benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part of a treatment plan that we approve.  The treatment plan may include services, drugs, and supplies described elsewhere in this brochure. To be eligible to receive full benefits, you must follow the preauthorization process and get Plan approval of your treatment plan:
  • All inpatient stays must be preauthorized by the Plan. You or your mental health or substance use disorder treatment provider must obtain preauthorization by calling 800-223-6114 before services are provided except as required by state law. If preauthorization is not obtained, a retro-review may be done to determine if the services are covered and if they were medically necessary. Services that are not preauthorized will be reduced by 20%. Please see Section 3, “What happens when you don’t follow the precertification rules.”

We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.

Note: Preauthorization is not required for treatment rendered by a state hospital when the member has been involuntarily committed.

  • OPM will base its review of disputes about treatment plans on the treatment plan’s clinical appropriateness. 
  • OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.
  • For non-Plan provider benefit see Section 5(i), Point of Service (POS) benefits, page (Applies to printed brochure only)



Benefit Description : Professional servicesStandard Option (You pay After the calendar year deductible… )

We cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:

  • Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
  • Crisis intervention and stabilization for acute episodes
  • Medication evaluation and management  (pharmacotherapy)
  • Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
  • Treatment and counseling (including individual or group therapy visits)
  • Diagnosis and treatment of alcoholism and drug use disorder, including detoxification, treatment and counseling
  • Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
  • Electroconvulsive therapy
  • Applied Behavioral Analysis (ABA) therapy - for the treatment of autism spectrum disorder or a developmental disability

In-network: $25 per individual visit (no deductible)

Nothing for group therapy (No deductible)

Out-of-network: $25 per individual visit, then 40% of the Plan allowance and any difference between our allowance and the billed amount (no deductible)  

Nothing for group therapy (No deductible)

Benefit Description : DiagnosticsStandard Option (You pay After the calendar year deductible… )
  • Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
  • Inpatient diagnostic tests provided and billed by a hospital or other covered facility

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Inpatient hospital or other covered facilityStandard Option (You pay After the calendar year deductible… )

Inpatient services provided and billed by a hospital or other covered facility.

  • Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
  • Professional services of physicians

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Outpatient hospital or other covered facilityStandard Option (You pay After the calendar year deductible… )

Outpatient services provided and billed by a hospital or other covered facility.

  • Services in approved treatment programs, such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, or facility-based intensive outpatient treatment

In-Network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Physical, Occupational and Speech TherapiesStandard Option (You pay After the calendar year deductible… )

Services must be provided by qualified physical, occupational, or speech therapists.

In-network: $25 per primary care visit or $35 per specialty care office visit (no deductible)

Out-of-network: $25 primary care visit or $35 per specialty care office visit, then 40% of the Plan allowance and any difference between our allowance and the billed amount (no deductible)

Benefit Description : Not CoveredStandard Option (You pay After the calendar year deductible… )
  • Services that, upon review, are determined to be inappropriate to treat your condition or are Plan exclusions.
  • Long-term rehabilitative therapy
  • Exercise programs
All Charges



Section 5(f). Prescription Drug Benefits (Standard Option)

Important things you should keep in mind about these benefits:

  • We cover prescribed drugs and medications, as described in the chart on page (Applies to printed brochure only).
  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Members must make sure their prescribers obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies. Prior approval/authorizations must be renewed periodically.
  • Federal law prevents the pharmacy from accepting unused medications.
  • There is no calendar year deductible for this benefit.
  •  Be sure to read Section 4, Your costs for covered services, for valuable information about how
    cost-sharing works. Also, read Section 9, Coordinating benefits with Medicare and other coverage.



There are important features you should be aware of. These include:

  • Who can write your prescription. A licensed physician, dentist, and in states allowing it, licensed/certified providers with prescriptive authority within their scope of practice. 

Note: Some drugs require prior authorization and may be limited to a specific quantity or day supply (see Section 3, Other services, regarding prior approval).

  • Where you can obtain them. You must fill the prescription at a Plan retail pharmacy or through a Plan mail order program, except for emergencies. If you have any questions regarding your pharmacy benefit, please call Member Services toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711.
  • Mail Order Program. Covered prescription drugs are available through the mail order program. Prescriptions ordered through this program are subject to the same copayments, guidelines, and limitations set forth above. Mail order issues up to a 90-day supply per fill.  To begin using mail order, or to transfer an existing prescription from a retail pharmacy, ask your prescriber to send the prescription directly to the mail order pharmacy:

Kaiser Permanente  
Mail Order Pharmacy
P.O. Box 34383
Seattle, WA 98124-1383

Phone: 800-245-7979
Fax: 206-901-4443

  • These are the dispensing limitations. Prescription drugs will be dispensed for up to a 30-day supply per fill, except for certain drugs, which may be dispensed on a 90-day supply basis with two (2) copayments. For prescribed hormonal contraceptives, you may obtain up to a 12-month supply at a Plan pharmacy or through our mail-delivery program.If a drug is a Tier 4 or 5 drug, you will pay the applicable coinsurance. Refills for any prescription drug cannot be obtained until at least 75% of the drug has been used. Drugs designated as specialty may be covered for up to a 30-day supply per fill. If you have a new prescription for a chronic condition, you may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized).  Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Most drugs can be mailed from our mail order pharmacy. Some drugs (for example, drugs that are extremely high cost, require special handling, have standard packaging or requested to be mailed outside of the state of Washington) may not be eligible for mailing and/or a mail order discount. The pharmacy may reduce the day supply dispensed to a 30-day supply in any 30-day period if the pharmacy determines that the item is 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).
  • A generic equivalent will be dispensed if it is available. If your physician believes that a name brand product is medically necessary, or if there is no generic equivalent available, your physician may prescribe a name brand drug.  If you elect to purchase a name brand instead of the generic equivalent you are responsible for paying the difference in cost in addition to the prescription drug cost share.

Plan members called to active military duty (or members in a time of national emergency) who need to obtain prescribed medications should call Member Services toll-free at 888-901-4636.

We have an open Drug Formulary. Drug Formulary (approved drug list) is defined as a list of preferred pharmaceutical products the Pharmacy & Therapeutic Committee (made up of pharmacists and physicians) have developed to assure that you receive quality prescription drugs at a reasonable price. This means we classify MOST drugs into one of five “tier” categories:

      • Tier 1 generally includes generic drugs, but may include some brand formulary or preferred brands. Usually represents the lowest copays.
      • Tier 2 generally includes brand formulary and preferred brand drugs, but may include some generics and brands not included in Tier 1. Usually represents brand or middle-range copays.
      • Tier 3 may include all other covered drugs not on tiers 1 and 2 (i.e., non-formulary or non-preferred).
      • Tier 4 includes preferred specialty drugs.
      • Tier 5 includes non-preferred specialty drugs.

Because of their lower cost to you, we recommend that you ask your provider to prescribe preferred drugs as the first choice of therapy. To order a Drug Formulary, call us toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711. You may also access the Drug Formulary on our website at www.kp.org/feds/wa-options.

Preferred drugs are branded, single source or multi-source agents, or generic drugs that are determined to be preferred by us.

Non-preferred drugs are branded, single source or multi-source agents, or generic drugs that are determined to be
non-preferred by us.

Note: The Drug Formulary is continually reviewed and revised. We reserve the right to update this list at any time. For the most up-to-date information about our Drug Formulary, visit our website at www.kp.org/feds/wa-options.

  • Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the name brand is the name under which the manufacturer advertises and sells a drug.  Generic drugs must contain the same active ingredient and must be equivalent in strength and dosage to the original name brand product.  Under Federal law, generic and name brand drugs must meet the same standards for safety, purity, strength, and effectiveness. A generic drug costs you – and us – less than a name brand drug.
  • When you do have to file a claim. When you use a Plan pharmacy, you will not be responsible for submitting a claim form to the Plan. In the event of an accidental injury or medical emergency, you may utilize the services of a non-Plan pharmacy. For reimbursement of pharmacy claims, please submit an itemized claim form with the following information:
    • Member’s name and ID#
    • Drug name, quantity, prescription number
    • Cost of drug and amount you paid
    • NDC number
    • Drug strength
    • Pharmacy name
    • Pharmacy address
    • Pharmacy NABP number

Submit your request for reimbursement to:
                           Member Claims
                           P.O. Box 30766
                           Salt Lake City, UT 84130-0766

  • For additional information on your pharmacy benefits, call Member Services toll-free at 888-901-4636.
  • Specialty medications. Certain medications must be ordered only through our specialty drug pharmacy program. Your physician must obtain preauthorization for these medications. For a list of specialty drugs, please go to Drug Lists on our website at www.kp.org/feds/wa-options or call Member Services toll-free at 888-901-4636 prior to receiving services.




Benefit Description : Covered medications and suppliesStandard Option (You pay )

We cover the following medications and supplies prescribed by a physician and obtained from a Plan retail pharmacy or through the mail order program:

  • Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered
  • Insulin
  • Diabetic supplies limited to:
    • Disposable needles and syringes for the administration of covered medications
    • Lancets, test strips and control solution
  • Drugs for sexual dysfunction limited to eight (8) pills per prescription per month
  • Preauthorized compounded drugs
  • Hormone therapy

Tier 1
$20 per prescription/refill
$40 per 90-day supply

Tier 2 – Preferred
$40 per prescription/refill
$80 per 90-day supply

Tier 3 – Non-Preferred
$60 per prescription/refill
$120 per 90-day supply

Tier 4 – Preferred Specialty
25% up to a maximum out of pocket of $200 per 30-day supply

Tier 5 – Non-Preferred Specialty
35% up to a maximum out of pocket of $300 per 30-day supply

  • Male and female contraceptive drugs and devices 

Note: Over-the-counter contraceptive drugs and devices, including emergency contraceptives, approved by the FDA require a written prescription by an approved provider. Contraceptive drugs purchased at a non-Plan pharmacy are not covered, except emergencies.

Nothing    

(No deductible)

Mail Order Drug Program

  • Prescription medications mailed to your home by the Kaiser Permanente mail order pharmacy (mail order issues up to a 90-day supply per fill)

Tier 1
$20 per prescription/refill
$40 per 90-day supply

Tier 2 – Preferred
$40 per prescription/refill
$80 per 90-day supply

Tier 3 – Non-Preferred
$60 per prescription/refill
$120 per 90-day supply

Mail order not available for specialty drugs

Limited Benefits

  • Drugs to aid in tobacco cessation when prescribed and dispensed as part of the Plan's tobacco cessation program
  • Over-the-counter tobacco cessation drugs when obtained through the Kaiser Permanente mail order pharmacy and plan retail pharmacy
Nothing

Not covered:

  • Drugs and supplies for cosmetic purposes
  • Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them, except treatment of phenylketonuria (PKU) as described elsewhere in this brochure
  • Non-prescription medications, except certain
    over-the-counter substances approved by the Plan
  • Medical supplies such as dressings and antiseptics
  • Fertility drugs
  • Drugs to enhance athletic performance
  • Drugs prescribed to treat any non-covered service
  • Drugs obtained at a non-Plan pharmacy, except
    for emergencies
  • Compounded drugs for hormone replacement therapy
  • Drugs that are not medically necessary according to accepted medical, dental, or psychiatric practice as determined by the Plan
  • Lost or stolen medications
  • Non-self administered medications
    (e.g., intramuscular, intravenous, intrathecal)
  • Weight loss medications 

All charges

Note: Over-the-counter and prescription drugs authorized by the Quit For Life® program and approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefit (see Educational classes and programs).

Refer to Notes

Benefit Description : Preventive Care MedicationsStandard Option (You pay )

The following are covered:

  • Aspirin to reduce the risk of heart attack
  • Oral fluoride for children to reduce the risk of tooth decay
  • Folic acid for women to reduce the risk of birth defects
  • Liquid iron supplements for children age 0-1 year
  • Medications to reduce the risk of breast cancer
  • Statins for adults at risk of cardiovascular disease

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a health care professional and filled by a network pharmacy. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Nothing

Not covered:

  • Prescriptions filled at a non-Plan pharmacy except for emergencies as described in Section 5(d), Emergency services/accidents 
  • Vitamins, nutritional, herbal supplements that can be purchased without a prescriptions, unless they are included in our drug formulary or listed as covered above 
  • Nonprescription drugs, unless they are included in our drug formulary or listed as covered above
  • Prescription drugs not on our drug formulary, unless approved through an exception process 
  • Any requested packaging of drugs other than the dispensing pharmacy's standard packaging 
  • Replacement of lost, stolen, damaged prescription, drugs, and accessories
  • Drugs related to non-covered services 

All charges




Section 5(g). Dental Benefits (Standard Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) dental plan, your FEHB Plan will be first/primary payor of any benefit payments and your FEDVIP plan is secondary to your FEHB Plan. See Section 9, Coordinating benefits with Medicare and other coverage.
  • Only those procedures that are part of a routine/preventive dental exam are covered.
  • We cover hospitalization for dental procedures only when a non-dental, physical impairment exists, which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c),
    for inpatient hospital benefits.
  • The dental procedures listed below are not all-inclusive and are subject to change. Please call us toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711 for additions/changes to the list of covered American Dental Association (ADA) codes.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how
    cost-sharing works. Also, read Section 9, Coordinating benefits with Medicare and other coverage.



Benefit Description : Accidental injury benefitStandard Option (You Pay After the calendar year deductible . . . )

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. Sound natural teeth are those that do not have any restoration. (See Section 10, Definitions of terms we use in this brochure.)  The need for these services must result from an accidental injury (not biting or chewing). All services must be performed and completed within 12 months of the date of injury.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount




Dental benefits : Dental ServicesCodes (We pay scheduled allowance (you pay all excess charges) )Standard Option (We pay scheduled allowance (you pay all excess charges) )

PREVENTIVE DENTAL CARE
(no deductible) 

  • Diagnostic
  • X-rays
  • Intraoral - periapical first film

D0220

$20.00

PREVENTIVE DENTAL CARE
(no deductible) 

  • Diagnostic
  • X-rays
  • Intraoral – periapical each additional film

D0230

$19.00

PREVENTIVE DENTAL CARE
(no deductible) 

  • Diagnostic
  • X-rays
  • Intraoral – occlusal film

D0240

$41.00

Bitewing X-rays – twice per calendar year

Bitewing – single film

D0270

$20.00

Bitewing X-rays – twice per calendar year

Bitewing – two films

D0272

$31.00

Bitewing X-rays – twice per calendar year

Bitewing – four films

D0274

$45.00

Full mouth or panorex X-rays - once every 3 calendar years

Panoramic film

D0330

$77.00

Full mouth or panorex X-rays - once every 3 calendar years        

Intraoral - complete series (including bitewings)

D0210

$95.00

Oral Exam

Periodic oral exam – twice per calendar year

D0120

$41.00

Oral Exam

Limited oral evaluation – problem focused

D0140

$58.00

Oral Exam     

Comprehensive oral evaluation

D0150

$57.00

 Oral Exam

 Pulp vitality tests

D0460

$38.00

Prophylaxis (cleaning) – twice per calendar year

Prophylaxis – through age 13

D1120

$51.00

Prophylaxis (cleaning) – twice per calendar year

Prophylaxis – after age 13

D1110

$88.00

Fluoride – twice per calendar year through age 17

Topical application of fluoride (prophylaxis not included) 

D1208

$32.00

Other Preventive Services

Application of sealants for permanent molars and bicuspids only (with a 3 year limitation per surface) through age 13; sealant per tooth

D1351

$28.00

Space Maintenance (Passive Appliances)    

Space maintainer – fixed – unilateral

D1510

No benefit




Section 5(h). Wellness and Other Special Features (Standard Option)

TermDefinition

Flexible benefits option

In certain cases, Kaiser Permanente Washington Options Federal, at its sole discretion, may choose to authorize coverage for benefits or services that are not otherwise included as covered under this Plan. Such authorization is done on a case-by-case basis if a particular benefit or service is judged to be medically necessary, beneficial, and cost effective. However, our decision to authorize services in one instance does not commit us to cover the same or similar services for you in other instances or to cover the same or similar services in any other instance for any other enrollee. Our decision to authorize services does not constitute a waiver of our right to enforce the provisions, limitations, and exclusions of this Plan.

Under the flexible benefits option, we determine the most effective way to provide services. 

  • We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
  • Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
  • By approving an alternative benefit, we do not guarantee you will get it in the future.
  • The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
  • If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
  • Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

Services for deaf, hard of hearing, or speech impaired

We provide a TTY/text number at: 711. Sign language services are also available.

Travel benefit/services overseas

If you are on Temporary Duty Assignment or reside temporarily outside of Washington state you are covered for all of the benefits described in this brochure.  You pay the applicable cost-share per visit for services. For non-urgent and non-emergent services you should receive care from a Plan provider; in Idaho, Oregon, Montana and Alaska, a Plan provider is a First Choice Health Network provider; in all other states, a Plan provider is a First Health Network provider; or in a different Kaiser Foundation Health Plan service area, a designated Kaiser Permanente provider or facility. Designated Kaiser Permanente providers are members of a Permanente Medical Group or are employed at Kaiser Permanente medical facilities. If a Kaiser Permanente provider refers you to a provider who is not affiliated with the Permanente Medical Group, you may pay out-of-network cost-sharing.

Medications obtained at a participating pharmacy in connection with non-urgent, non-emergent services will also be covered. See also Section 1. How we pay providers.

If you need assistance while anywhere in the world, call Member Services toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state’s relay line by dialing either 800-833-6388 or 711.

Filing Overseas Claims for Urgent or Emergent Care
Most overseas providers are under no obligation to file claims on behalf of our members. You may need to pay for the services at the time you receive them and then submit a claim to us for reimbursement. To file a claim for covered urgent or emergent care received outside the United States, send a completed Overseas Claim Form and itemized bills to:

Member Claims
P.O. Box 30766
Salt Lake City, UT 84130-0766

We will do the translation and currency conversion for you. You may obtain the Overseas Claim Form by calling Member Services toll-free at 888-901-4636 or from our website at www.kp.org/feds/wa-options, Members/Forms and Information.




Section 5(i). Point of Service (POS) Benefits (Standard Option)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The calendar year deductible is $350 per person ($700 per family).
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how
    cost-sharing works. Also, read Section 9, Coordinating benefits with Medicare and other coverage.



Facts about this Plan's POS option
You may choose to obtain benefits covered by this Plan from non-Plan doctors and hospitals whenever you need care. All copayments, coinsurance, and deductibles apply.

What is covered
All services/treatments listed in this brochure as covered.

What is not covered
All services/treatments listed in this brochure as not covered, including the following:

  • Orthopedic and prosthetic devices/supplies and durable medical equipment (DME) purchased through the Internet.
  • Expenses in excess of the Plan's allowable amount or benefit maximum (e.g., dental fee schedule amounts).
  • The difference between the billed amount and the amount allowed by Kaiser Permanente Washington Options Federal.

Emergency benefits
Emergency care is always payable at the Plan provider level of benefit. Please see Section 5(d), Emergency
services/accidents, page (Applies to printed brochure only), for benefit details.

What you pay
When you choose to obtain services from a non-Plan provider or hospital:

  • We will determine what our allowable amount would have been for a Plan provider*.
  • We will apply your appropriate cost-sharing (i.e., deductible and/or copayment) to the allowed amount.
  • You pay the non-Plan provider 40% of the allowed amount balance after you have paid your appropriate cost-sharing.
  • The non-Plan provider may balance bill you for the difference between what we pay and the original charges.

*Note: If our allowed amount is more than what the non-Plan provider or hospital bills, we will base our payment on their billed amount.




Section 5. High Deductible Health Plan Benefits (HDHP)

See page (Applies to printed brochure only) for how our benefits changed this year and page (Applies to printed brochure only) for a benefits summary.




(Page numbers solely appear in the printed brochure)

Table of Content



Section 5. High Deductible Health Plan Benefits Overview (HDHP)

This Plan offers a High Deductible Health Plan (HDHP). The HDHP benefit package is described in this section. Make sure that you review the benefits that are available under the benefit product in which you are enrolled.

HDHP Section 5, which describes the HDHP benefits, is divided into subsections. Please read Important things you should keep in mind at the beginning of each subsection. Also read the general exclusions in Section 6; they apply to benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about HDHP benefits, contact us toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711; or visit our website at www.kp.org/feds/wa-options.

Our HDHP option provides comprehensive coverage for high-cost medical events and a tax-advantaged way to help you build savings for future medical expenses. The Plan gives you greater control over how you use your health care benefits.

Based on your eligibility, when you enroll in this HDHP, you can have either a Health Savings Account (HSA) or a Health Reimbursement Arrangement (HRA) account. We automatically pass through a portion of your total health Plan premium to your HSA each month or credit an equal amount to your HRA.  

The first year you enroll in this HDHP, funds will be prorated based on your enrollment effective date. If your enrollment is effective other than the first day of a month, your HSA funds (or HRA credit) will be prorated based on the first of the following month. Before funding for either an HSA or HRA can occur, we must receive an HSA Eligibility Worksheet from you (the worksheet is sent to you with your new member materials or is available on our website at 
www.kp.org/feds/wa-options). If you are eligible for an HSA, in addition to the worksheet, you must complete the HSA enrollment process with HealthEquity®.

With this Plan, preventive care is covered in full. As you receive other non-preventive medical care, you must meet the Plan’s deductible before we pay benefits according to the benefits described on pages (Applies to printed brochure only) - (Applies to printed brochure only). You can choose to use funds available in your HSA to make payments toward the deductible or you can pay toward your deductible entirely out-of-pocket, allowing your savings to continue to grow.

This HDHP includes five key components: preventive care; traditional medical coverage health care that is subject to the deductible; savings; catastrophic protection for out-of-pocket expenses; and health education resources and account management tools.




TermDefinition

Preventive care

The Plan covers preventive care services, such as periodic health evaluations (e.g., annual physicals), screening services (e.g., mammograms), well-child care, child and adult immunizations, tobacco cessation programs and preventive dental care. These services, except for preventive dental, are covered at 100% if you use a network provider and the services are described in Section 5, page (Applies to printed brochure only), Preventive care. You do not have to meet the deductible before using these services.

The Plan covers the Quit For Life® tobacco cessation program, obesity weight loss programs, and nutritional guidance under Educational classes and programs. Please see Section 5(a), page (Applies to printed brochure only) for benefit details.

Traditional medical coverage

After you have paid the Plan’s deductible, we pay benefits under traditional medical coverage described in Section 5, Traditional medical coverage subject to the deductible. The Plan typically pays 80% for in-network and 60% for out-of-network care.

Covered services include:

  • Medical services and supplies provided by physicians and other health care professionals
  • Surgical and anesthesia services provided by physicians and other health care professionals
  • Hospital and other facility services
  • Ambulance services
  • Emergency services/accidents
  • Mental health and substance use disorder benefits
  • Prescription drug benefits
  • Accidental dental injury benefits

Out-of-network services

You may choose to obtain benefits covered by this Plan either in-network from Plan providers or out-of-network from non-Plan providers whenever you need care.

When you use non-Plan providers, your benefits are significantly less than if you use Plan providers. Kaiser Permanente Washington Options Federal will pay 60% of our allowed amount or the non-Plan provider's billed amount, whichever is less. In addition, it is your responsibility to pay the difference between any amounts billed by the non-Plan provider and the amount allowed by Kaiser Permanente Washington Options Federal. This is called "balance billing."

What is covered
All services/treatments listed in this brochure as covered under the HDHP, except preventive care, including preventive dental care.

What is not covered
All services/treatments listed in this brochure as not covered including the following:

  • Expenses in excess of the Plan’s allowable amount or benefit maximum
    (e.g., preventive dental care fee schedule amounts).
  • The difference between the billed amount and the amount allowed by Kaiser Permanente Washington Options Federal.

Emergency benefits
Emergency care is always payable at the in-network benefit level. Please see Section 5(d), Emergency services/accidents, page (Applies to printed brochure only), for benefit details.

Savings

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see page (Applies to printed brochure only) for more details).

Health Savings Accounts (HSAs)

By law, HSAs are available to members who:

  • Are not enrolled in Medicare;
  • Cannot be claimed as a dependent on someone else’s tax return;
  • Have not received VA (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits within the last three months; or
  • Do not have other health insurance coverage other than another High Deductible Health Plan.

In 2021, for each month you are eligible for an HSA premium pass through, we will contribute to your HSA $62.50 per month for a Self Only enrollment or $125 per month for a Self Plus One or Self and Family enrollment. In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $3,600 for an individual and $7,200 for a family. See maximum contribution information on page (Applies to printed brochure only). You can use funds in your HSA to help pay your health Plan deductible. You own your HSA, so the funds can go with you if you change plans or employment.

NOTE: When you enroll in this HDHP, we will send you an HSA Eligibility Worksheet and instructions on how to enroll in an HSA with HealthEquity®. The worksheet is sent to you with your new member materials or is available on our website at www.kp.org/feds/wa-options. The first year you enroll in this HDHP, funds will be prorated based on your enrollment effective date. If your enrollment is effective other than the first day of a month, your HSA funds will be prorated based on the first of the following month. Before funding for an HSA can occur, we must receive the HSA Eligibility Worksheet. In addition to the worksheet, you must complete the HSA enrollment process with HealthEquity®.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as possible. Your HSA contribution payments are fully deductible on your Federal tax return. By fully funding your HSA early in the year, you have the flexibility of paying medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you don’t deplete your HSA and you allow the contributions and the tax-free interest to accumulate, your HSA grows more quickly for future expenses.

HSA features include:

  • Your HSA is administered by HealthEquity®.
  • Your contributions to the HSA are tax deductible.
  • You may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions
    (i.e., Employee Express, MyPay, etc.). 
  • Your HSA earns tax-free interest.
  • You can make tax-free withdrawals for qualified medical expenses for you, your spouse and dependents (see IRS publication 502 for a complete list of eligible expenses).
  • Your unused HSA funds and interest accumulate from year to year.
  • It’s portable - the HSA is owned by you and is yours to keep, even when you leave Federal employment or retire.
  • When you need them, your funds are available up to the actual HSA balance.

Important consideration if you want to participate in a Health Care Flexible Spending Account (HCFSA): If you are enrolled in this HDHP with a Health Savings Account (HSA), and start or become covered by a HCFSA (such as FSAFEDS offers – see Section 11, Other Federal Programs), this HDHP cannot continue to contribute to your HSA. Similarly, you cannot contribute to an HSA if your spouse enrolls in an HCFSA. Instead, when you inform us of your coverage in an HCFSA, we will establish a Health Reimbursement Arrangement (HRA) account for you.

Health Reimbursement Arrangements (HRA)

If you are not eligible for an HSA, for example you are enrolled in Medicare or are covered on another health plan, we will establish an HRA for you instead. You must notify us that you are ineligible for an HSA by returning the HSA Eligibility Worksheet from your new member materials; the worksheet also is available on our website at
www.kp.org/feds/wa-options.

In 2021, we will give you an HRA credit of $750 per year for a Self Only enrollment and $1,500 per year for a Self Plus One or Self and Family enrollment (these amounts may be prorated the first year you are enrolled in this HDHP). You can use funds in your HRA to help pay your Plan deductible and/or for certain expenses that do not count toward the deductible. 

HRA features include:

  • Your HRA is administered by HealthEquity®.
  • When you need them, your funds are available up to the actual HRA balance.

    NOTE: If your enrollment in this HDHP becomes effective other than the first day of a month, your HRA credit will be available to you the first of the following month.
  • The tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP.
  • Unused credit carries over from year to year.
  • The HRA credit does not earn interest.
  • The HRA credit is forfeited if you leave Federal employment or switch health insurance plans.
  • An HRA does not affect your ability to participate in an FSAFEDS Health Care Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility requirement

Catastrophic protection
for out-of-pocket expenses

Your annual maximum for out-of-pocket expenses (deductibles, coinsurance, and copayments) for covered services is limited to $5,000 for Self Only enrollment or $5,000 per person for Self Plus One or Self and Family enrollment not to exceed a total out-of-pocket maximum of $10,000 (each applies separately for services received from Plan providers and non-Plan providers). However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan’s allowable amount or benefit maximum). Refer to Section 4, Your catastrophic protection out-of-pocket maximum, for more details.

Health education resources and account management tools

HDHP Section 5(i), describes the health education resources and account management tools available to you to help you manage your health care and your health care dollars.




Section 5. Savings – HSAs and HRAs (HDHP)

TermDefinition 1Definition 2
Feature Comparison

Health Savings Account (HSA)

Health Reimbursement Arrangement (HRA)
Provided when you are ineligible
for an HSA

AdministratorThe Plan will establish an HSA with HealthEquity®, this HDHP’s fiduciary (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS.)The Plan will establish an HRA with HealthEquity®, this HDHP's fiduciary (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS.).
FeesMonthly administration fee charged by the fiduciary is paid by the Plan.Monthly administration fee charged by the fiduciary is paid by the Plan.

Eligibility

You must:

  • Enroll in this HDHP
  • Have no other health insurance coverage (does not apply to specific injury, accident, disability, dental, vision, or long-term care coverage)
  • Not be enrolled in Medicare 
  • Not be claimed as a dependent on someone else’s tax return
  • Not have received VA (except for veterans with a service-connected disability) and/or Indian Health Service (IHS) benefits in the last three months
  • Complete and return the HSA Eligibility Worksheet to the Plan  

You must:

  • Enroll in this HDHP
  • Complete and return the HSA Eligibility Worksheet to the Plan

 

Funding

If you are eligible for HSA contributions, a portion of your monthly health Plan premium is deposited to your HSA each month. Premium pass through contributions are based on the effective date of your enrollment in the HDHP.

In addition, you may establish pre-tax HSA deductions from your paycheck to fund your HSA up to IRS limits using the same method that you use to establish other deductions (i.e., Employee Express, MyPay, etc.).

NOTE: If your enrollment effective date in this HDHP is other than the first day of a month, you will be eligible to receive the premium pass through contribution beginning the first of the following month.

HRA contributions are a portion of your monthly health plan premium which is credited to your HRA each month. Premium pass through contributions are based on the effective date of your enrollment in the HDHP.

NOTE: If your enrollment effective date in this HDHP is other than the first day of a month, funding for your HRA will be prorated based on the first of the following month.

  • Self Only enrollment

For 2021, a monthly premium pass through of $62.50 will be made by the HDHP directly into your HSA each month.

For 2021, a monthly premium pass through of $62.50 will be made by the HDHP directly into your HRA each month.

  • Self Plus One enrollment

For 2021, a monthly premium pass through of $125 will be made by the HDHP directly into your HSA each month.

For 2021, a monthly premium pass through of $125 will be made by the HDHP directly into your HRA each month.

  • Self and Family
    enrollment

For 2021, a monthly premium pass through of $125 will be made by the HDHP directly into your HSA each month.

For 2021, a monthly premium pass through of $125 will be made by the HDHP directly into your HRA each month.

Contributions/credits

The maximum that can be contributed to your HSA is an annual combination of the HDHP premium pass through and enrollee contribution funds, which when combined, do not exceed the maximum contribution amount set by the IRS of $3,600 for an individual and $7,200 for a family.

If you enroll during Open Season, you are eligible to fund your account up to the maximum contribution limit set by the IRS. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum allowable contribution.

You are eligible to contribute up to the IRS limit for partial year coverage as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility. To determine the amount you may contribute, take the IRS limit and subtract the amount the Plan will contribute to your account for the year.

If you do not meet the 12 month requirement, the maximum contribution amount is reduced by 1/12 for any month you were ineligible to contribute to an HSA.

If you exceed the maximum contribution amount, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability. 

You may rollover funds you have in other HSAs to this HDHP HSA (rollover funds do not affect your annual maximum contribution under this HDHP.

HSAs earn tax-free interest (interest does not affect your annual maximum contribution).

Catch-up contributions are discussed on page (Applies to printed brochure only).

Your monthly premium pass through will be credited to your HRA each month. The HRA does not earn interest.

NOTE: If your enrollment effective date in this HDHP is other than the first day of a month, funding for your HRA will be prorated based on the first of the following month.

  • Self Only enrollment

You may make an annual maximum contribution of $2,850 if your enrollment effective date is January 1.

 

 

You cannot contribute to the HRA.

  • Self Plus One enrollment

You may make an annual maximum contribution of $5,700 if your enrollment effective date is January 1.

You cannot contribute to the HRA.

  • Self and Family enrollment

You may make an annual maximum contribution of $5,700 if your enrollment effective date is January 1.

You cannot contribute to the HRA.

Access funds

You can access your HSA by the following methods:

  • HealthEquity® Visa® account
  • Online portal
  • Withdrawal form

You can access your HRA by the following methods:

  • HealthEquity® Visa® Card
  • Online portal
  • Withdrawal form

Distributions/withdrawals

  • Medical

You can pay the out-of-pocket expenses for yourself, your spouse, or your dependents (even if they are not covered by the HDHP) from the funds available in your HSA.

See IRS Publication 502 for a list of eligible medical expenses.

You can pay the out-of-pocket expenses for qualified medical expenses for individuals covered under the HDHP.

Non-reimbursed qualified medical expenses are allowable if they occur after the effective date of your enrollment in this Plan.

See Availability of funds, page (Applies to printed brochure only) for information on when funds are available in the HRA.

See IRS Publication 502 for a list of eligible medical expenses. Physician prescribed over-the-counter drugs and Medicare premiums are also reimbursable. Most other types of medical insurance premiums are not reimbursable. 

  • Non-medical

If you are under age 65, withdrawal of funds for non-medical expenses will create a 20% income tax penalty in addition to any other income taxes you may owe on the withdrawn funds.

When you turn age 65, distributions can be used for any reason without being subject to the 20% penalty; however, they will be subject to ordinary income tax.

Not applicable – distributions will not be made for anything other than non-reimbursed qualified medical expenses.

Availability of funds

Funds are not available for withdrawal until all the following steps are completed:

  • Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change).
  • The Plan receives record of your enrollment. 
  • The Plan sends you an HSA Eligibility Worksheet and instructions on how to enroll in an HSA with HealthEquity®.
  • You return the HSA Eligibility Worksheet to the Plan, confirming you meet the HSA eligibility requirements.
  • You enroll in an HSA with HealthEquity®.

Funds are not available for withdrawal until all the following steps are completed:

  • Your enrollment in this HDHP is effective (effective date is determined by your agency in accord with the event permitting the enrollment change).
  • The Plan receives record of your enrollment.
  • The Plan sends you an HSA Eligibility Worksheet for you to complete.
  • You return the completed worksheet to the Plan, showing you are not eligible for an HSA.
  • The Plan forwards your enrollment information to HealthEquity® and establishes your HRA

Availability of funds (cont.)

  • The Plan confirms your HSA enrollment with HealthEquity®
  • The Plan initiates premium pass through contributions to your HSA.

NOTE: If your enrollment effective date in this HDHP is other than the first day of a month, you will be eligible to receive funding for your HSA the first of the following month.

Your monthly premium pass through will be credited to your HRA each month, beginning the first of the month following the Plan’s receipt of the HSA Eligibility Worksheet. Accumulated funds will be made available to you to pay for qualified medical expenses and Medicare Part B premium.

NOTE: If your enrollment effective date in this HDHP is other than the first day of a month, funding for your HRA will be prorated based on the first of the following month.

Account owner FEHB enrolleeHDHP

Portable

You can take this account with you when you change plans, separate, or retire.

If you do not enroll in another HDHP, you can no longer contribute to your HSA. See page (Applies to printed brochure only) for HSA eligibility.

If you retire and remain in this HDHP, you may continue to use and accumulate credits in your HRA.

If you terminate employment or change health plans, only eligible expenses incurred while covered under the HDHP will be eligible for reimbursement, subject to timely filing requirements. Unused funds are forfeited.

Annual rollover Yes, accumulates without a maximum cap.Yes, accumulates without a maximum cap.



If You Have an HSA (HDHP)

If you have an HSA




TermDefinition
  • Contributions

All contributions are aggregated and cannot exceed the maximum contribution amount set by the IRS. You may contribute your own money to your account through payroll deductions, or you may make lump sum contributions at any time, in any amount not to exceed an annual maximum limit. If you contribute, you can claim the total amount you contributed for the year as a tax deduction when you file your income taxes. Your own HSA contributions are tax deductible. To determine the amount you may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum contribution amount set by the IRS. You have until April 15 of the following year to make HSA contributions for the current year.

If you newly enroll in an HDHP during Open Season and your effective date is after January 1st, or you otherwise have partial year coverage, you are eligible to fund your account up to the maximum contribution limit set by the IRS as long as you maintain your HDHP enrollment for 12 months following the last month of the year of your first year of eligibility. If you do not meet this requirement, a portion of your tax reduction is lost and a 10% penalty is imposed. There is an exception for death or disability.

Contact HealthEquity® toll-free at 866-346-5800 for more details.

  • Catch-up contributions

If you are age 55 or older, the IRS permits you to make additional “catch-up” contributions to your HSA. The allowable catch-up contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the U.S. Department of Treasury website at www.treasury.gov/resource-center/faqs/Taxes/Pages/Health-Savings-Accounts.aspx.

  • If you die
If you have not named beneficiary and you are married, your HSA becomes your spouse’s; otherwise, your HSA becomes part of your taxable estate.
  • Qualified expenses

You can pay for “qualified medical expenses,” as defined by IRS Code 213(d). These expenses include, but are not limited to, medical plan deductibles, diagnostic services covered by your plan, long-term care premiums, health insurance premiums if you are receiving Federal unemployment compensation, physician prescribed over-the-counter drugs, LASIK surgery, and some nursing services.

When you enroll in Medicare, you can use the account to pay Medicare premiums or to purchase health insurance other than a Medigap policy. You may not, however, continue to make contributions to your HSA once you are enrolled in Medicare.

For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by calling 800-829-3676, or visit the IRS website at www.irs.gov and click on “Forms and Publications.” Note: Although physician prescribed over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA. Also, insurance premiums are reimbursable under limited circumstances.
  • Non-qualified expenses
You may withdraw money from your HSA for items other than qualified health expenses, but it will be subject to income tax and if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.
  • Tracking your HSA balance
You will receive a periodic statement that shows the "premium pass through," withdrawals, and interest earned on your account. In addition, you will receive an Explanation of Payment statement when you withdraw money from your HSA.
  • Minimum reimbursements from your HSA
You can request reimbursement in any amount.



If You Have an HRA (HDHP)

TermDefinition

If you have an HRA

See information below

  • Why an HRA is established
If you don’t qualify for an HSA when you enroll in this HDHP, or later become ineligible for an HSA, we will establish an HRA for you. If you are enrolled in Medicare, you are ineligible for an HSA and we will establish an HRA for you. You must tell us if you become ineligible to contribute to an HSA.
  • How an HRA differs

Please review the chart on page (Applies to printed brochure only), which details the differences between an HRA and an HSA. The major differences are:

  • you cannot make contributions to an HRA,
  • funds are forfeited if you leave the HDHP,
  • an HRA does not earn interest,
  • HRAs can only pay for qualified medical expenses, such as deductibles, copayments, and coinsurance expenses for individuals covered by the HDHP. FEHB law does not permit qualified medical expenses to include services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.

Contact HealthEquity® toll-free at 866-346-5800 for more details.




Section 5. Preventive Care (HDHP)

Important things you should keep in mind about these benefits:

  • Preventive care services listed in this Section are not subject to the deductible.
  • You must use Plan providers. 
  • For all other covered expenses, please see Section 5 – Traditional medical coverage subject to the deductible, page (Applies to printed brochure only).



Benefit Description : Preventive care, adultHDHP (You pay)
  • One annual routine physical 
  • One annual routine eye exam

Nothing

We cover preventive services required by federal health care reform legislation (the Affordable Care Act and implementing regulations) and additional services that we include in our preventive services benefit.

Including:

  • Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations visit the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules
  • Screenings such as for breast cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. For a complete list of A and B recommended screenings visit the U.S. Preventive Services Task Force (USPSTF) website at www.uspreventiveservicestaskforce.org
  • Individual counseling on prevention and reducing health risks
  • Well woman care such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of Well Women preventive care services please visit the Health and Human Services (HHS) website at www.healthcare.gov/preventive-care-women

  • Services such as routine prostate specific antigen (PSA) test and retinal photography screening. For a complete list of Kaiser Permanente preventive services visit our website at https://wa.kaiserpermanente.org/healthandwellness

Nothing

Routine mammogram - covered for women.

Nothing

Notes:

  • You may pay cost-sharing for any procedure, injection, diagnostic service, laboratory or X-ray service that is provided in conjunction with a routine physical exam and is not included in the recommended list of preventive services.
  • You should consult with your physician to determine what is appropriate for you

Refer to Notes

Not covered:

  • Physical exams and immunizations required for obtaining or continuing employment or insurance, attending camp, athletic exams or travel.
  • Preventive services received from a non-Plan provider
All Charges
Benefit Description : Preventive care, childrenHDHP (You pay)

Well-child visits, examinations, and immunizations

Nothing

We cover preventive services required by federal health care reform legislation (the Affordable Care Act and implementing regulations) and additional services that we include in our preventive services benefit. Including:

  • Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines visit www.brightfutures.aap.org
  • Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations visit the Centers for Disease Control (CDC) website at www.cdc.gov/ vaccines/schedules/index.html
  • You can also find a complete list of A and B recommended preventive care services under the U.S. Preventive Services Task Force (USPSTF) online at www. uspreventiveservicestaskforce.org
  • For a complete list of Kaiser Permanente preventive services visit our website at https://wa.kaiserpermanente.org/ healthandwellness

Nothing

Notes:

• You may pay cost-sharing for any procedure, injection, diagnostic service, laboratory or X-ray service that is provided in conjunction with a routine physical exam and is not included in the recommended list of preventive services.

Refer to Notes

Not covered:

  • Physical exams and immunizations required for obtaining or continuing employment or insurance, attending camp, athletic exams or travel.
  • Preventive services received from a non-Plan provider
All Charges



Dental preventive care : Dental ServicesCodes (HDHP)We Pay Scheduled Allowance (you pay all excess charges) (HDHP)

Diagnostic

X-rays

Intraoral - periapical first film

D0220

$20.00

Diagnostic

X-rays

Intraoral - periapical each additional film

D0230

$19.00

Diagnostic

X-rays

Intraoral - occlusal film

D0240

$41.00

Bitewing X-rays - twice per calendar year

Bitewing - single film

D0270

$20.00

Bitewing X-rays - twice per calendar year  

Bitewing - two films

D0272

$31.00

Bitewing X-rays - twice per calendar year

Bitewing - four films

D0274

$45.00

Full mouth or panorex X-rays - once every 3 calendar years

Panoramic film

D0330

$77.00

Full mouth or panorex X-rays - once every 3 calendar years

Intraoral - complete series (including bitewings)

D0210

$95.00

Oral exam        

Periodic oral exam - twice per calendar year

D0120

$41.00

Oral exam

Limited oral evaluation - problem focused

D0140

$58.00

Oral exam        

Comprehensive oral evaluation

D0150

$57.00

Oral exam        

Pulp vitality tests

D0460

$38.00

Prophylaxis (cleaning) - twice per calendar year        

Prophylaxis - through age 13

D1120

$51.00

Prophylaxis (cleaning) - twice per calendar year        

Prophylaxis - after age 13

D1110

$88.00

Fluoride - twice per calendar year through age 17        

Topical application of fluoride (prophylaxis not included)

D1208

$32.00

Application of sealants for permanent molars and bicuspids only (with a 3 year limitation per surface) through age 13; sealant per tooth

D1351

$28.00

Not covered:

  • Dental services not on our schedule allowance list

See benefit description

No benefit




NOTE:  The procedures and scheduled allowances listed in this brochure are intended as a summary of the most common procedures, not an exhaustive list.  For questions regarding other specific procedures and scheduled allowances that fall under any of the preventive dental care procedures listed above, please call our Member Services department toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711.




Section 5. Traditional Medical Coverage Subject to the Deductible (HDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • In-network preventive care is covered at 100% (see page (Applies to printed brochure only)) and is not subject to the calendar year deductible. 
  • The deductible is $1,500 per person for Self Only enrollment or $1,500 per person for Self Plus One or Self and Family enrollment not to exceed a total family deductible of $3,000 (each applies separately for services received from Plan providers and non-Plan providers). The deductible applies to all benefits under Traditional medical coverage. You must pay your deductible before your Traditional medical coverage may begin.
  • Under Traditional medical coverage, you are responsible for your coinsurance and copayments for covered expenses.
  • You are protected by an annual catastrophic maximum on out-of-pocket expenses for covered services. After your coinsurance, copayments, and deductibles total $5,000 per person up to $10,000 per family enrollment (each applies separately for services received from Plan providers and non-Plan providers) in any calendar year, you do not have to pay any more for covered services. However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan’s benefit maximum or amounts in excess of the Plan allowance).
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how 
    cost-sharing works. Also, read Section 9, Coordinating benefits with Medicare and other coverage.



Benefit Description : Deductible before Traditional medical coverage beginsHDHP (You pay After the calendar year deductible… )
The deductible applies to almost all benefits in this Section. In the You pay column, we say “No deductible” when it does not apply. When you receive covered services from network providers, you are responsible for paying the allowable charges until you meet the deductible.

100% of allowable charges until you meet the deductible of $1,500 per person for Self Only enrollment or $1,500 per person for Self Plus One or Self and Family enrollment, not to exceed a total family deductible of $3,000 (each applies separately for services received from Plan providers and non-Plan providers).

After you meet the deductible, we pay the allowable charge (less your coinsurance or copayment) until you meet the annual catastrophic out-of-pocket maximum.

In-network: After you meet the deductible, you pay the indicated coinsurance or copayments for covered services. You may choose to pay the coinsurance and copayments from your HSA or HRA, or you can pay for them out-of-pocket.

Out-of-network: After you meet the deductible, you pay the indicated coinsurance based on our Plan allowance and any difference between our allowance and the billed amount.




Section 5(a). Medical Services and Supplies Provided by Physicians and Other Health Care Professionals (HDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The deductible is $1,500 for Self Only enrollment or $1,500 per person for Self Plus One or Self and Family enrollment not to exceed a total family deductible of $3,000 (each applies separately for services received from Plan providers and non-Plan providers) each calendar year. The deductible applies to most benefits in this Section, unless we indicate differently.
  • After you have satisfied your deductible, coverage begins for traditional medical services.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how
    cost-sharing works. Also, read Section 9, Coordinating benefits with Medicare and other coverage.



Benefit Description : Diagnostic and treatment servicesHDHP (You pay After the calendar year deductible… )

Professional services of physicians and other health care professionals

  • In physician’s office
  • In an urgent care center
  • Office medical consultations
  • Second surgical opinion
  • At a hospital - inpatient & outpatient visits
  • In a skilled nursing facility
  • At home

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Telehealth ServicesHDHP (You pay After the calendar year deductible… )

Professional services of physicians and other health care professionals delivered through telehealth, such as:

  • Interactive video
  • Phone visits
  • Email

Note: Visits may be limited by provider type, location and benefit specific limitations, such as visit limits.

In-network: Nothing 

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Lab, X-ray and other diagnostic testsHDHP (You pay After the calendar year deductible… )

Tests, such as:

  • Blood tests
  • Urinalysis
  • Non-routine Pap tests
  • Pathology
  • X-rays
  • Non-routine mammograms
  • CAT Scans/MRI
  • Ultrasound
  • Electrocardiogram and EEG

In-network: 20% of Plan allowance                   

Out-of-network: Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Maternity careHDHP (You pay After the calendar year deductible… )

Complete maternity (obstetrical) care by a physician, certified nurse midwife, or licensed midwife for:

  • Prenatal care (see Preventive care, adult)
  • Delivery (including home births)
  • Postnatal care

Notes: Here are some things to keep in mind:

  • When seen in an emergency room for any reason, the Emergency services/accidents benefit cost-share will apply.
  • You do not need to preauthorize your vaginal delivery; see Section 3 for other information.
  • You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a Cesarean delivery. We will extend your inpatient stay if medically necessary.
  • We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or a Self and Family enrollment. Surgical benefits, not maternity benefits, apply to medically necessary circumcision. See Section 5(b), for circumcision benefits. We cover routine circumcision under Preventive care, children.
  • When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in his or her own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.
  • We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury. 
  • Dependent child – pregnancy, delivery, and care of newborn during mother's hospital stay is covered.
  • Hospital services are covered under Section 5(c) and Surgical benefit under Section 5(b)

In-network: 20% of Plan allowance                   

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

  • Breastfeeding support, supplies and counseling for each birth
  • Screening for gestational diabetes for pregnant women after 24 weeks

In-network: Nothing

(No deductible)

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Care of a dependent child’s newborn once the mother is discharged from the hospital, unless the newborn is determined to be your dependent by your personnel office
All Charges
Benefit Description : Family planning HDHP (You pay After the calendar year deductible… )

A range of voluntary family planning services, limited to:

  • Voluntary male sterilization (vasectomy)

In-network: Nothing          

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

  • Voluntary female sterilization (tubal ligation)
  • Contraceptive methods and counseling 
    • Surgically implanted contraceptives
    • Injectable contraceptive drugs (such as Depo Provera)
    • Intrauterine devices (IUDs)
    • Diaphragms

Note: See also Section 5. Preventive Care for female sterilization and contraceptives.

In-network: Nothing                   

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

(No deductible) 

Not covered:

  • Reversal of voluntary surgical sterilization
All Charges
Benefit Description : Infertility servicesHDHP (You pay After the calendar year deductible… )

Diagnosis and treatment of infertility such as:

  • Artificial insemination (AI):
    • Intravaginal insemination (IVI)
    • Intracervical insemination (ICI)
    • Intrauterine insemination (IUI) 

In-network: 50% of Plan allowance

Out-of-network: 50% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Assisted reproductive technology (ART) procedures, such as:
    • In vitro fertilization (IVF)
    • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
    • Zygote transfer
  • Services and supplies related to excluded ART procedures
  • Cost of donor sperm
  • Cost of donor egg
  • Fertility drugs
All Charges
Benefit Description : Allergy careHDHP (You pay After the calendar year deductible… )
  • Testing and treatment
  • Allergy injections

In-network: 20% of Plan allowance                   

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Allergy serum

In-network: Nothing

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered: 

  • Provocative food testing and sublingual allergy desensitization
All Charges
Benefit Description : Treatment therapiesHDHP (You pay After the calendar year deductible… )
  • Chemotherapy and radiation therapy – some types of chemotherapy require preauthorization. Your physician should call Member Services toll-free at 888-901-4636 prior to you receiving therapy.

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Section 5(b), Organ/tissue transplants.

  • Respiratory and inhalation therapy
  • Dialysis – hemodialysis and peritoneal dialysis
  • Cardiac rehabilitation following a qualifying event/condition 
  • Intravenous (IV)/Infusion Therapy – Home IV  supplies and medications that are self-administered, antibiotic therapy, hydration, pain management and associated infused medications. 
  • Growth hormone therapy (GHT)
  • Ultraviolet light treatments

Notes:

  • Growth hormone is covered under the prescription drug benefit and requires preauthorization.
  • We only cover GHT when we preauthorize the treatment. Your physician must obtain preauthorization before you begin treatment. See Other services under You need prior Plan approval for certain services.
  • See Section 5(e), Professional services, for coverage of Applied Behavior Analysis (ABA).

In-network: 20% of Plan allowance                    

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

  • Enteral nutritional therapy when necessary due to malabsorption and an eosinophilic gastrointestinal disorder, including equipment and supplies

  • Total parenteral nutritional therapy and supplies necessary for its administration

Note: See Section 5(a), Durable medical equipment (DME) for coverage of equipment and supplies.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Neurodevelopmental therapiesHDHP (You pay After the calendar year deductible… )

Coverage under this benefit for the restoration and improvement of function in a neurodevelopmentally disabled individual includes:

  • inpatient and outpatient physical, speech and occupational therapy; and
  • ongoing maintenance care in cases where significant deterioration of the child’s condition would occur without the care.

All therapy treatments must be performed by a physician, registered physical therapist (PT), ASHA-certified speech therapist or an occupational therapist certified by the American Occupational Therapy Association.

Coverage under this benefit does not duplicate coverage for therapy services provided under any other benefit of this Plan.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Physical and occupational therapies HDHP (You pay After the calendar year deductible… )

Up to 60 combined visits for rehabilitative or habilitative care per condition per calendar year for physical, occupational and speech therapy and pulmonary rehabilitation. This limit does not apply to rehabilitative or habilitative care for the treatment of mental health conditions. Services must be provided by qualified physical, occupational, respiratory, speech therapists or other provider.

Notes:

  • Outpatient therapies that are provided in a rehabilitation unit that is part of an acute-care hospital, a stand-alone rehabilitation hospital, or an extended care/skilled nursing facility apply toward the maximum 60 combined visits per condition. See Speech therapy and Home health services.
  • For inpatient therapy benefit, see Section 5(c).

In-network: 20% of Plan allowance                    

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

 

Not covered:

  • Long-term rehabilitative therapy
  • Exercise programs
  • Reflexology
  • Rolfing 
All Charges
Benefit Description : Pulmonary rehabilitationHDHP (You pay After the calendar year deductible… )

Up to 60 combined visits for rehabilitative or habilitative care per condition per calendar year for physical, occupational, and speech therapy and pulmonary rehabilitation. This limit does not apply to rehabilitative or habilitative care for the treatment of mental health conditions. Services must be provided by qualified physical, occupational, respiratory, speech therapists or other provider.

Notes:
• Outpatient therapy services that are provided in a rehabilitation unit that is part of an acute-care hospital, a stand-alone rehabilitation hospital, or an extended care/skilled nursing facility apply toward the maximum 60 combined visits per condition.
• For inpatient therapy benefit, see Section 5(c)

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Speech therapy HDHP (You pay After the calendar year deductible… )

Up to 60 combined visits for rehabilitative or habilitative care per condition per calendar year for physical, occupational and speech therapy and pulmonary rehabilitation, except we cover rehabilitative or habilitative therapy with no limits for the treatment of mental health conditions. Services must be provided by qualified physical, occupational, respiratory, speech therapists or other providers.

Notes:

  • Outpatient therapy services that are provided in a rehabilitation unit that is part of an acute-care hospital, a stand-alone rehabilitation hospital, or an extended care/skilled nursing facility apply toward the maximum 60 combined visits per condition.
  • For inpatient therapy benefit, see Section 5(c)

In-network: 20% of Plan allowance                    

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Hearing services (testing, treatment, and supplies)HDHP (You pay After the calendar year deductible… )
  • For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., or audiologist 

Note: For routine hearing screening performed during a child's preventive care visit, see Preventive care, children.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

  • External hearing aids and testing to fit them when prescribed by a qualified provider

Note: For benefits for implanted hearing-related devices (BAHA), see Orthopedic and prosthetic devices.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

(Hearing aids are limited to $1,000 for one hearing aid per ear every year for children through age 17 and every 2 years for adults)

Not covered:

  • Hearing services that are not shown as covered
  • Replacement parts and batteries, repair of hearing aids, and replacement of lost or broken hearing aids
All Charges
Benefit Description : Vision services (testing, treatment, and supplies)HDHP (You pay After the calendar year deductible… )
  • One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)
  • Diagnostic eye exams provided by an optometrist or ophthalmologist to determine the need for vision correction.

For routine screening eye exam benefits see Preventive care, adult, and Preventive care, children.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Eyeglasses or contact lenses, except as related to accidental ocular injury or intraocular surgery
  • Eye exercises and orthoptics
  • Radial keratotomy and other refractive surgery 
All Charges
Benefit Description : Foot care HDHP (You pay After the calendar year deductible… )
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

 

Not covered:

  • Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
  • Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)
All Charges
Benefit Description : Diabetic education, equipment and suppliesHDHP (You pay After the calendar year deductible… )
  • Health Education and Training
    • Nutritional guidance
  • Medical Equipment
    • Dialysis equipment
    • Insulin pumps 
    • Insulin infusion devices
    • Medically necessary orthopedic shoes and inserts
  • Supplies other than those covered under Prescription drug benefits such as:
    • Orthopedic and corrective shoes
    • Arch supports
    • Foot orthotics
    • Heel pads and heel cups
    • Elastic stockings, support hose
    • Prosthetic replacements

In-network: 20% of Plan allowance                    

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

  • Glucometers

In-network: 20% of Plan allowance (no deductible)             

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Orthopedic and prosthetic devices HDHP (You pay After the calendar year deductible… )
  • Artificial limbs and eyes
  • Prosthetic sleeve or sock
  • Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
  • Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
  • Osseointegrated implants/bone anchored hearing aids (BAHA); preauthorization is required. Please refer to the preauthorization information provided in Section 3.
  • Cochlear implants - requires preauthorization
  • Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy

Notes:

  • For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical and anesthesia services. For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services provided by a hospital or other facility, and ambulance services.
  • For information on external hearing aids, see Section 5(a) Hearing services.
  • Orthopedic and prosthetic devices must be obtained from a Medicare certified provider. Purchases made through the Internet generally do not meet this requirement and are not covered under this Plan. If you have questions about a provider you are considering, please contact us before obtaining the devices.

 

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
  • Lumbosacral supports
  • Corsets, trusses, elastic stockings, support hose, and other supportive devices
  • Prosthetic replacements provided less than 3 years after the last one we covered (except for externally worn breast prostheses and surgical bras)
  • Devices and supplies purchased through the Internet
  • Replacement of devices, equipment and supplies due to loss, theft, breakage or damage
All Charges
Benefit Description : Durable medical equipment (DME)HDHP (You pay After the calendar year deductible… )

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Listed below are some of the items that are covered. The list is not all inclusive.  For more details please contact Member Services toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711.

  • Oxygen
  • Hospital beds
  • Wheelchairs
  • Crutches
  • Walkers
  • Motorized wheelchairs
  • Audible prescription reading device
  • Speech generating device 

Note: DME must be obtained from a Medicare certified provider. Purchases made through the Internet generally do not meet this requirement and are not covered under this Plan. If you have questions about a provider you are considering, please contact us before obtaining the equipment.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

  • Peak flow meters

In-network: 20% of Plan allowance (no deductible)

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Exercise equipment such as Nordic Track and/or exercise bicycles
  • Equipment which is primarily used for non-medical purposes such as hot tubs and massage pillows
  • Convenience items
  • DME purchased through the Internet
  • Wigs and hair prostheses
  • Replacement of devices, equipment and supplies due to loss, theft, breakage or damage
All Charges
Benefit Description : Home health servicesHDHP (You pay After the calendar year deductible… )
  • Home health care ordered by a physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), master of social work
    (M.S.W.), or home health aide. Up to two hours per visit.
  • Services include oxygen therapy and assistance with medications. IV therapy is covered separately under the Treatment therapies benefit. Oxygen is covered separately under the Durable medical equipment (DME) benefit.

Note: These services require preauthorization. Please refer to the preauthorization information shown in Section 3.

Note: Therapy (physical, occupational, speech) received in your home is paid under the Physical and occupational therapies benefit and applies towards your therapy maximum of 60 visits per condition. See Physical and occupational therapies.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Nursing care requested by, or for the convenience of, the patient or the patient’s family
  • Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.
All Charges
Benefit Description : Chiropractic HDHP (You pay After the calendar year deductible… )
  • Up to 20 treatments per calendar year for manipulations of the spine and extremities

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered: 

  • Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application
All Charges
Benefit Description : Alternative treatmentsHDHP (You pay After the calendar year deductible… )
  • Massage therapy - up to 20 treatments per calendar year when treatment prescribed by a qualified provider and received from a licensed massage therapist
  • Acupuncture – up to 20 treatments per calendar year when treatment is received from a licensed provider for:
    • anesthesia
    • pain relief 
    • substance use disorder - unlimited
  • Naturopathic services

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Herbs prescribed by an East Asian Medicine Practitioner (acupuncturist) or naturopath
  • Hypnotherapy
  • Biofeedback
  • Reflexology
  • Rolfing

All Charges

Benefit Description : Educational classes and programsHDHP (You pay After the calendar year deductible… )

Coverage is provided for:

  • Tobacco Cessation when participating in the Quit For Life® program. You will receive up to two (2) quit attempts per year and a minimum of four (4) counseling sessions that include individual, group, and phone counseling, along with physician prescribed over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence.

    Call 866-784-8454 toll-free or visit the Quit For Life® website at www.quitnow.net for information on how to enroll. 

Nothing for two quit attempts per year through the Quit For Life® program.

Nothing for physician prescribed over-the-counter and prescription drugs authorized by the Quit For Life® program and approved by the FDA to treat tobacco dependence.

(No deductible)

  • Outpatient nutritional guidance counseling services by a certified dietitian or certified nutritionist for conditions such as:
    • Cancer
    • Endocrine conditions
    • Swallowing conditions after stroke
    • Hyperlipidemia
    • Colitis
    • Coronary artery disease
    • Dysphagia
    • Gastritis
    • Inactive colon
    • Anorexia
    • Bulimia
    • Short bowel syndrome (post surgery)
    • Food allergies or intolerances
    • Obesity

In-network: Nothing

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not Covered:

  • Over-the-counter drugs, except for physician prescribed tobacco cessation medications received through the Quit For Life® program and approved by the FDA for treatment of tobacco dependence
  • Weight-loss medications
All Charges
Benefit Description : Sleep disordersHDHP (You pay After the calendar year deductible… )

Coverage under this benefit is limited to sleep studies, including provider services, appropriate durable medical equipment, and surgical treatments. No other benefits for the purposes of studying, monitoring and/or treating sleep disorders, other than as described below, is provided.

Sleep studies - Coverage for sleep studies includes:

  • Polysomnographs
  • Multiple sleep latency tests
  • Continuous positive airway pressure (CPAP) studies
  • Related durable medical equipment and supplies, including CPAP machines

The condition giving rise to the sleep disorder (such as narcolepsy or sleep apnea) must be diagnosed by your provider. Preauthorization of sleep studies is not required; however, you must be referred to the sleep studies program by your provider.

In-network:  20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Any service not listed above for the purpose of studying, monitoring and/or treating sleep disorders.
All Charges
Benefit Description : Temporomandibular joint (TMJ) disordersHDHP (You pay After the calendar year deductible… )
Treatment of TMJ, includes surgical and non-surgical intervention, corrective orthopedic appliances and physical therapy.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Services primarily for cosmetic purposes
  • Related dental work
All Charges
Benefit Description : Phenylketonuria (PKU) formulasHDHP (You pay After the calendar year deductible… )
Special dietary formulas designed for use by those diagnosed with phenylketonuria.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount




Section 5(b). Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals (HDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The deductible is $1,500 for Self Only enrollment, $1,500 per person for Self Plus One or Self and Family enrollment not to exceed a total family deductible of $3,000 (each applies separately for services received from Plan providers and non-Plan providers) each calendar year. The deductible applies to all benefits in this Section.
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • The services listed below are for the charges billed by a physician or other health care professional for your surgical care. See Section 5(c) for charges associated with the facility (i.e., hospital, surgical center, etc.).
  • YOUR PHYSICIAN MUST GET PREAUTHORIZATION FOR SOME SURGICAL PROCEDURES. Please refer to the preauthorization information shown in Section 3 and contact Member Services toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711 to be sure which services and surgeries require preauthorization.



Benefit Description : Surgical proceduresHDHP (You pay After the calendar year deductible… )

A comprehensive range of services, such as:

  • Operative procedures
  • Treatment of fractures, including casting
  • Normal pre- and post-operative care by the surgeon
  • Correction of amblyopia and strabismus
  • Endoscopy procedures
  • Biopsy procedures
  • Removal of tumors and cysts
  • Correction of congenital anomalies (see Reconstructive surgery)
  • Insertion of internal prosthetic devices (See Section 5(a), Orthopedic and prosthetic devices, for device coverage information.)

    Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.
  • Circumcision as medically necessary
  • Transgender reassignment surgery
    • For female to male surgery: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy, metoidioplasty, phalloplasty, urethroplasty, scrotoplasty, and placement of testicular and erectile prosthesis
    • For male to female surgery: penectomy, orchiectomy, vaginoplasty, clitoroplasty, labiaplasty
  • Treatment of burns
  • Surgical treatment (bariatric surgery) and all services associated with the surgical treatment of morbid obesity.

    Note: The surgical candidate must be at least 18 years or older, have no other health conditions with a Body Mass Index (BMI) of 40 or greater, or have at least one complicating medical condition with a BMI of 35 or greater. All inpatient and outpatient surgical treatment for morbid obesity must be preauthorized and performed through a bariatric surgery Center of Excellence. See Other services under You need prior Plan approval for certain services.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Voluntary male sterilization (vasectomy)

In-network: Nothing 

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Voluntary female sterilization (tubal ligation)

In-network: Nothing 

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

(No deductible)

Not covered:

  • Reversal of voluntary sterilization
  • Routine treatment of conditions of the foot; (see Foot care)
  • Weight loss medications
  • Services for the promotion, prevention, or other treatment of hair loss or hair grow
  • Cosmetic surgery, any surgery procedure (or any portion of the procedure) performed primarily to improve physical appearance through change in bodily form
  • Facial feminization and breast augmentation for the treatment of gender dysphoria
  • Services not listed above as covered
All Charges
Benefit Description : Reconstructive surgery HDHP (You pay After the calendar year deductible… )
  • Surgery to correct a functional defect
  • Surgery to correct a condition caused by injury or illness if:
    • the condition produced a major effect on the member’s appearance and
    • the condition can reasonably be expected to be corrected by such surgery
  • Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.
  • All stages of breast reconstruction surgery following a mastectomy, such as:
    • surgery to produce a symmetrical appearance of breasts
    • treatment of any physical complications, such as lymphedema
    • breast prostheses and surgical bras and replacements (see Section 5(a), Orthopedic and prosthetic devices)
Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

In-network: 20% of Plan allowance                    

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

All Charges
Benefit Description : Oral and maxillofacial surgery HDHP (You pay After the calendar year deductible… )

Oral surgical procedures, limited to:

  • Reduction of fractures of the jaws or facial bones;
  • Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
  • Removal of stones from salivary ducts;
  • Excision of leukoplakia or malignancies;
  • Excision of cysts and incision of abscesses when done as independent procedures; and
  • Other surgical procedures that do not involve the teeth or their supporting structures.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Oral implants and transplants
  • Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
All Charges
Benefit Description : Organ/tissue transplantsHDHP (You pay After the calendar year deductible… )

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services

  • Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis
  • Cornea
  • Heart
  • Heart/lung
  • Intestinal transplants
    • Isolated Small intestine
    • Small intestine with the liver
    • Small intestine with multiple organs such as the liver, stomach, and pancreas
  • Kidney
  • Kidney/Pancreas 
  • Liver
  • Lung: single/bilateral/lobar 
  • Pancreas

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

These tandem blood or marrow stem cell transplants for covered transplants are subject to medical necessity review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

  • Autologous tandem transplants for
    • AL Amyloidosis
    • Multiple myeloma (de novo and treated)
    • Recurrent germ cell tumors (including testicular cancer)

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Blood or marrow stem cell transplants The Plan extends coverage for the diagnoses below.

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases may respond to treatment without transplant and which diseases may respond to transplant.

  • Allogeneic transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Acute myeloid leukemia
    • Advanced Hodgkin's lymphoma with recurrence (relapsed)
    • Advanced Myeloproliferative Disorders (MPDs)
    • Advanced neuroblastoma
    • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • Infantile malignant osteopetrosis
    • Kostmann’s syndrome
    • Leukocyte adhesion deficiencies
    • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
    • Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)
    • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
    • Sickle cell anemia
    • X-linked lymphoproliferative syndrome
  • Autologous transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Breast cancer
    • Ependymoblastoma
    • Epithelial ovarian cancer
    • Ewing’s sarcoma
    • Medulloblastoma
    • Multiple myeloma
    • Pineoblastoma 
    • Neuroblastoma
    • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Mini-transplants performed in a clinical setting
(non-myeloblative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other services in Section 3 for prior authorization procedures.

  • Allogeneic transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Acute myeloid leukemia
    • Advanced Myeloproliferative Disorders (MPDs)
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
    • Hemoglobinopathy
    • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
    • Myelodysplasia/Myelodysplastic syndromes
    • Paroxysmal Nocturnal Hemoglobinuria
    • Severe combined immunodeficiency
    • Severe or very severe aplastic anemia
  • Autologous transplants for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
    • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
    • Amyloidosis
    • Neuroblastoma

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of Health approved clinic trial or a Plan-designated center of excellence and if approved by the Plan’s medical director in accordance with the Plan’s protocols.

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient’s condition) if it is not provided by the clinical trial. Section 9 has additional information on costs related to clinical trials. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

  • Allogeneic transplants for
    • Advanced Hodgkin's lymphoma
    • Advanced non-Hodgkin's lymphoma
    • Beta Thalassemia Major
    • Chronic inflammatory demyelination polyneuropathy (CIDP)
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Multiple myeloma
    • Multiple sclerosis 
    • Sickle cell anemia
  • Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
    • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
    • Advanced Hodgkin's lymphoma
    • Advanced non-Hodgkin's lymphoma
    • Breast cancer
    • Chronic lymphocytic leukemia
    • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
    • Chronic myelogenous leukemia
    • Colon cancer
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Multiple myeloma
    • Multiple sclerosis
    • Myelodysplasia/Myelodysplastic Syndromes
    • Myeloproliferative disorders (MPDs)
    • Non-small cell lung cancer
    • Ovarian cancer
    • Prostate cancer
    • Renal cell carcinoma
    • Sarcomas
    • Sickle cell anemia
  • Autologous transplants for
    • Advanced childhood kidney cancers
    • Advanced Ewing sarcoma
    • Advanced Hodgkin's lymphoma
    • Advanced non-Hodgkin's lymphoma
    • Aggressive non-Hodgkin's lymphomas (Mantel Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms)
    • Breast cancer
    • Childhood rhabdomyosarcoma
    • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
    • Chronic myelogenous leukemia
    • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
    • Epithelial Ovarian Cancer 
    • Mantle Cell (Non-Hodgkin lymphoma)
    • Multiple sclerosis
    • Small cell lung cancer
    • Systemic lupus erythematosus
    • Systemic sclerosis

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

National Transplant Program (NTP)

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Notes:

  • We cover related medical and hospital expenses of the donor when we cover the recipient.
  • We cover donor screening tests and donor search expenses for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

Refer to Notes

Not covered:

  • Donor screening tests and donor search expenses, except as shown above
  • Implants of artificial organs 
  • Any transplant not specifically listed as a covered benefit
All Charges
Benefit Description : Sleep disordersHDHP (You pay After the calendar year deductible… )

Surgical treatment – Coverage for the medically necessary surgical treatment of diagnosed sleep disorders is covered under this benefit.

Preauthorization of surgical procedures for the treatment of sleep disorders is required. See Other services under You need prior Plan approval for certain services. Surgical treatment includes all professional and facility fees related to the surgical treatment including pre- and post-operative care and complications.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Anesthesia HDHP (You pay After the calendar year deductible… )

Professional services provided in –

  • Hospital (inpatient)
  • Hospital outpatient department
  • Skilled nursing facility
  • Ambulatory surgical center
  • Office

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount




Section 5(c). Services Provided by a Hospital or Other Facility, and Ambulance Services (HDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The deductible is $1,500 for Self Only enrollment, $1,500 per person for Self Plus One or Self and Family enrollment not to exceed a total family deductible of $3,000 (each applies separately for services received from Plan providers and non-Plan providers) each calendar year. The Self Plus One and Self and Family deductible can be satisfied by one or more family members. The deductible applies to all benefits in this Section.
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or copayments for eligible medical expenses and prescriptions.
  • Be sure to read Section 4, Your costs for covered services for valuable information about how
    cost-sharing works. Also, read Section 9, Coordinating benefits with Medicare and other coverage.
  • The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center) or ambulance service for your surgery or care. Any costs associated with the professional charge
    (i.e., physicians, etc.) are in Sections 5(a) and (b).
  • YOUR PHYSICIAN MUST GET PREAUTHORIZATION FOR HOSPITAL STAYS. Please refer to Section 3 and contact Member Services toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711 to be sure which services require preauthorization.



Benefit Description : Inpatient hospitalHDHP (You Pay After the calendar year deductible...)

Room and board, such as

  • Ward, semiprivate, or intensive care accommodations
  • General nursing care
  • Meals and special diets

Notes:

  • If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.
  • Included under this benefit are admissions for inpatient physical, occupational, and speech therapies and pulmonary rehabilitation provided in a rehabilitation unit that is part of an acute-care hospital or
    stand-alone rehabilitation hospital.

Other hospital services and supplies, such as:

  • Operating, recovery, maternity, birthing centers and other treatment rooms
  • Prescribed drugs and medications
  • Diagnostic laboratory tests and X-rays
  • Administration of blood and blood products
  • Blood or blood products, if not donated or replaced
  • Dressings, splints, casts, and sterile tray services
  • Medical supplies and equipment, including oxygen
  • Anesthetics, including nurse anesthetist services
  • Take-home items (except medications)
  • Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home 
  • Private nursing care

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Custodial care
  • Non-covered facilities, such as nursing homes, schools
  • Personal comfort items, such as phone, television, barber services, guest meals and beds
  • Take home medications
All Charges
Benefit Description : Outpatient hospital or ambulatory surgical centerHDHP (You Pay After the calendar year deductible...)
  • Operating, recovery, and other treatment rooms
  • Prescribed drugs and medications
  • Diagnostic laboratory tests, X-rays , and pathology services
  • Administration of blood, blood products, and other biologicals
  • Blood and blood products, if not donated or replaced
  • Pre-surgical testing
  • Dressings, casts, and sterile tray services
  • Medical supplies, including oxygen
  • Anesthetics and anesthesia service

Note:

  • We cover hospital services and supplies related to dental procedures when necessitated by a non-dental, physical impairment. We do not cover the dental procedures.
  • See Section 5(a), for Telehealth Services.  

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Take home medications
  • Audio-only, phone, fax and e-mail communications
All Charges
Benefit Description : Extended care benefits/Skilled nursing care facility benefitsHDHP (You Pay After the calendar year deductible...)

When appropriate, as determined by a doctor and approved by us, we cover full-time skilled nursing care with no dollar or day limit. Intensive physical and occupational therapies in a skilled nursing facility apply toward the maximum 60 combined visits per condition. Extended care benefits require preauthorization by our medical director.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Custodial care
All Charges
Benefit Description : Hospice careHDHP (You Pay After the calendar year deductible...)

Supportive and palliative care for a terminally ill member is covered when services are provided under the direction of a doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately 6 months or less.

Services include:

  • Medical care
  • Family counseling

Inpatient hospice benefits are available only when services are preauthorized and determined necessary to:

  • Control pain and manage the patient’s symptoms; or
  • Provide an interval of relief (respite) to the family not to exceed seven (7) consecutive days; each respite care admission must be preauthorized and separated by at least 21 days.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Not covered:

  • Independent nursing, homemaker services
All Charges
Benefit Description : AmbulanceHDHP (You Pay After the calendar year deductible...)

Coverage for ambulance services includes:

  • Ground transportation
  • Air transportation

Air ambulance transportation is subject to review and approval by us. In cases where the patient’s condition does not warrant air transportation, coverage will be based on the benefit for ground transportation.

20% of Plan allowance

Note: If you are hospitalized in a non-Plan facility and Plan doctors believe care can be provided in a Plan hospital, you may ask to be transferred to a Plan provider when medically feasible with any ambulance charges covered in full.

Refer to Note

Not covered:

  • The use of any type of ambulance transportation for personal convenience.
All Charges



Section 5(d). Emergency Services/Accidents (HDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The deductible is $1,500 for Self Only enrollment, $1,500 per person for Self Plus One or Self and Family enrollment not to exceed a total family deductible of $3,000 (each applies separately for services received from Plan providers and non-Plan providers) each calendar year. The deductible applies to all benefits in this Section.
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts and copayments for eligible medical expenses and prescriptions.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how
    cost-sharing works. Also, read Section 9, Coordinating benefits with Medicare and other coverage.



What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action. 

What to do in case of emergency:

Emergencies within our service area: If you are in an emergency situation, please call your doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e.g., the 911 phone system) or go to the nearest hospital emergency room.

If you need to be hospitalized, you or a family member must notify us unless it is not reasonably possible to do so. If you are hospitalized in a non-Plan facility, we will work with your doctor to determine when and if it is medically feasible to transfer you to a Plan hospital. You will be transferred when medically feasible with any ambulance charges covered in full.

Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, you or a family member must notify us unless it is not reasonably possible to do so. If you are hospitalized in a non-Plan facility, we will work with your doctor to determine when and if it is medically feasible to transfer you to a Plan hospital. You will be transferred when medically feasible with any ambulance charges covered in full.

Follow-up care received from non-Plan providers and/or at a non-Plan facility when the care could be received from a Plan provider and/or at a Plan facility, will be covered at the out-of-network benefit level.




Benefit Description : Emergency within our service areaHDHP (You pay After the calendar year deductible… )
  • Emergency care at a doctor’s office
  • Emergency care at an urgent care center
  • Emergency care as an outpatient or inpatient in a hospital, including doctors’ services
20% of Plan allowance

Not covered:

  • Elective care or non-emergency care
All Charges
Benefit Description : Emergency outside our service areaHDHP (You pay After the calendar year deductible… )
  • Emergency care at a doctor’s office
  • Emergency care at an urgent care center
  • Emergency care as an outpatient or inpatient in a hospital, including doctors’ services
20% of Plan allowance

Not covered:

  • Elective care or non-emergency care
  • Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
All Charges
Benefit Description : AmbulanceHDHP (You pay After the calendar year deductible… )

Professional ambulance service when medically appropriate.

  • Ground transportation
  • Air transportation

In cases where the patient’s condition does not warrant air transportation, coverage will be based on the benefit or ground transportation.

Note: If you are hospitalized in a non-Plan facility and Plan doctors believe care can be provided in a Plan hospital, you may ask to be transferred to a Plan provider when medically feasible with any ambulance charges covered in full.

See Section 5(c), for non-emergency service.

20% of Plan allowance

Not covered:

  • The use of any type of ambulance transportation for personal convenience.
All Charges



Section 5(e). Mental Health and Substance Use Disorder Benefits (HDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • The calendar year deductible is $1,500 for Self Only enrollment, $1,500 per person for Self Plus One or Self and Family enrollment not to exceed a total family deductible of $3,000 (each applies separately for services received from Plan providers and non-Plan providers). The deductible applies to all benefits in this Section.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how
    cost-sharing works. Also, read Section 9, Coordinating benefits with Medicare and other coverage.
  • YOU MUST GET PREAUTHORIZATION FOR INPATIENT SERVICES. Benefits are payable only when we determine the care is clinically appropriate to treat your condition and only when you receive the care as part of a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure. To be eligible to receive full benefits, you must follow the preauthorization process and get Plan approval of your treatment plan:
  • All inpatient stays must be preauthorized by the Plan. You or your mental health or substance use disorder treatment provider must obtain preauthorization by calling 800-223-6114 before services are provided except as required by state law. If preauthorization is not obtained, a retro-review may be done to determine if the services are covered and if they were medically necessary. Services that are not preauthorized will be reduced by 20%. Please see Section 3, “What happens when you don’t follow the preauthorization rules.”

 We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required

Note: Preauthorization is not required for treatment rendered by a state hospital when the member has been involuntarily committed.

  • OPM will base its review of disputes about treatment plans on the treatment plan’s clinical appropriateness. 
  • OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.



Benefit Description : Professional servicesHDHP (You pay After the calendar year deductible...)

We cover professional services by licensed professional mental health and substance use disorder treatment practitioners when acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or marriage and family therapists.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Diagnosis and treatment of psychiatric conditions, mental illness, or mental disorders.  Services include:

  • Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
  • Crisis intervention and stabilization for acute episodes
  • Medication evaluation and management  (pharmacotherapy)
  • Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
  • Treatment and counseling (including individual or group therapy visits)
  • Diagnosis and treatment of alcoholism and drug use, including detoxification, treatment and counseling
  • Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
  • Electroconvulsive therapy
  • Applied Behavioral Analysis (ABA) therapy - for the treatment of autism spectrum disorder or a developmental disability

In-network: 20% of Plan allowance

Nothing for group sessions

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Nothing for group sessions

Benefit Description : DiagnosticsHDHP (You pay After the calendar year deductible...)
  • Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility
  • Inpatient diagnostic tests provided and billed by a hospital or other covered facility

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Inpatient hospital or other covered facilityHDHP (You pay After the calendar year deductible...)

Inpatient services provided and billed by a hospital or other covered facility

  • Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
  • Professional services of physicians

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Outpatient hospital or other covered facilityHDHP (You pay After the calendar year deductible...)

Outpatient services provided and billed by a hospital or other covered facility

  • Services such as partial hospitalization, half-way house, residential treatment, full-day hospitalization, or facility-based intensive outpatient treatment

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Physical, Occupational and Speech TherapiesHDHP (You pay After the calendar year deductible...)

Services must be provided by qualified physical, occupational, or speech therapists.

In-Network: 20% of Plan allowance


Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount

Benefit Description : Not CoveredHDHP (You pay After the calendar year deductible...)
  • Services that, upon review, are determined to be inappropriate to treat your condition or are Plan exclusions.
  • Long-term rehabilitative therapy
  • Exercise programs
All Charges



Section 5(f). Prescription Drug Benefits (HDHP)

Important things you should keep in mind about these benefits:

  • We cover prescribed drugs and medications, as described in the chart on page (Applies to printed brochure only).
  • Please remember that all benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • Federal law prevents the pharmacy from accepting unused medications.
  • Members must make sure their physicians obtain prior approval/authorizations for certain prescription drugs and supplies before coverage applies.  Prior approval/authorizations must be renewed periodically.
  • The deductible is $1,500 for Self Only enrollment, $1,500 per person for Self Plus One or Self and Family enrollment not to exceed a total family deductible of $3,000 (each applies separately for services received from Plan providers and non-Plan providers) each calendar year. The deductible applies to all benefits in this Section.
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts and copayments for eligible prescriptions.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how
    cost-sharing works. Also, read Section 9, Coordinating benefits with Medicare and other coverage.



There are important features you should be aware of. These include:

  • Who can write your prescription. A licensed physician or dentist, and in states allowing it, licensed/certified providers with prescriptive authority prescribing within their scope of practice must prescribe your medication.

Note: Some drugs require prior authorization and may be limited to a specific quantity or day supply (see Section 3. Other services, regarding prior approval.

  • Where you can obtain them. You must fill the prescription at a Plan retail pharmacy or through a Plan mail order program, except for emergencies. If you have any questions regarding your pharmacy benefit, please call Member Services toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711
  • Mail Order Program. Covered prescription drugs are available through the mail order program. Prescriptions ordered through this program are subject to the same copayments, guidelines, and limitations set forth above. Mail order issues up to a 90-day supply per fill.  To begin using mail order, or to transfer an existing prescription from a retail pharmacy, ask your prescriber to send the prescription directly to the mail order pharmacy.

                                   Kaiser Permanente 
                                   Mail Order Pharmacy
                                   P.O. Box 34383
                                   Seattle, WA 98124-1383

                                   Phone: 800-245-7979
                                   Fax: 206-901-4443

  • These are the dispensing limitations. Prescription drugs will be dispensed for up to a 30-day supply per fill, except for certain drugs, which may be dispensed on a 90-day supply basis with two (2) copayments. For prescribed hormonal contraceptives, you may obtain up to a 12-month supply at a Plan pharmacy or through our mail-delivery program. If a drug is a Tier 4 or Tier 5 drug, you will pay the applicable coinsurance. Refills for any prescription drug cannot be obtained until at least 75% of the drug has been used. Drugs designated as specialty may be covered for up to a 30-day supply per fill. If you have a new prescription for a chronic condition, you may request a coordination of medications so that medications for chronic conditions are refilled on the same schedule (synchronized).  Cost-shares for the initial fill of the medication will be adjusted if the fill is less than the standard quantity. Most drugs can be mailed from our mail order pharmacy. Some drugs (for example, drugs that are extremely high cost, require special handling, have standard packaging or requested to be mailed outside of the state of Washington) may not be eligible for mailing and/or a mail order discount. The pharmacy may reduce the day supply dispensed to a 30-day supply in any 30-day period if the pharmacy determines that the item is 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).
  • A generic equivalent will be dispensed if it is available. If your physician believes that a name brand product is medically necessary, or if there is no generic equivalent available, your physician may prescribe a name brand drug.  If you elect to purchase a name brand drug instead of the generic equivalent you are responsible for paying the difference in cost in addition to the prescription drug cost share.

Plan members called to active military duty (or members in the time of national emergency) who need to obtain prescribed medications should Call Member Services toll-free at 888-901-4636.

We have an open Drug Formulary.  Drug Formulary (approved drug list) is defined as a list of preferred pharmaceutical products the Pharmacy & Therapeutic Committee (made up of pharmacists and physicians) have developed to assure that you receive quality prescription drugs at a reasonable price. This means we classify MOST drugs into one of five “tier” categories:

      • Tier 1 generally includes generic drugs, but may include some brand formulary or preferred brands. Usually represents the lowest copays. 
      • Tier 2 generally includes brand formulary and preferred brand drugs, but may include some generics and brands not included in Tier 1. Usually represents brand or middle-range copays.
      • Tier 3 may include all other covered drugs not on tiers 1 and 2 (i.e., non-formulary or non-preferred).
      • Tier 4 includes preferred specialty drugs.
      • Tier 5 includes non-preferred specialty drugs.

Because of their lower cost to you, we recommend that you ask your provider to prescribe preferred drugs as the first choice of therapy. To order a Drug Formulary, call us toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711. You may also access the Drug Formulary on our website at
www.kp.org/feds/wa-options.

Preferred drugs are branded, single source or multi-source agents, or generic drugs that are determined to be preferred by us.

Non-preferred drugs are branded, single source or multi-source agents, or generic drugs that are determined to be
non-preferred by us.

Note: The Drug Formulary is continually reviewed and revised. We reserve the right to update this list at any time. For the most up-to-date information about our Drug Formulary, visit our website at www.kp.org/feds/wa-options.

  • Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic name of a drug is its chemical name; the name brand is the name under which the manufacturer advertises and sells a drug. They must contain the same active ingredient and must be equivalent in strength and dosage to the original brand name product. Under Federal law, generic and name brand drugs must meet the same standards for safety, purity, strength, and effectiveness. A generic drug costs you – and us – less than a name brand drug.
  • When you do have to file a claim. When you use a Plan pharmacy, you will not be responsible for submitting a claim form to the Plan. In the event of an accidental injury or medical emergency, you may utilize the services of a non-Plan pharmacy. For reimbursement of pharmacy claims, please submit an itemized claim form with the following information:
    • Member's name and ID#
    • Drug name, quantity, prescription number
    • Cost of drug and amount you paid
    • NDC number
    • Drug strength
    • Pharmacy name
    • Pharmacy address
    • Pharmacy NABP number

 Submit your request for reimbursement to:

                              Member Claims
                              P.O. Box 30766
                              Salt Lake City, UT 84130-0766

  • For additional information on your pharmacy benefits, call Member Services at 888-901-4636.
  • Specialty medications. Certain medications must be ordered only through our specialty drug pharmacy program.  Your physician must obtain preauthorization for these medications. For a list of specialty drugs, please go to Drug Lists on our website at www.kp.org/feds/wa-options or call Member Services toll-free at 888-901-4636 prior to receiving services.



Benefit Description : Covered medications and suppliesHDHP (You pay After the calendar year deductible… )

We cover the following medications and supplies prescribed by a physician and obtained from a Plan retail pharmacy or through the mail order program:

  • Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered
  • Insulin
  • Diabetic supplies limited to:
    • Disposable needles and syringes for the administration of covered medications
    • Lancets, test strips and control solution
  • Drugs for sexual dysfunction limited to eight (8) pills per prescription per month
  • Preauthorized compounded drugs
  • Hormone therapy

Tier 1
$20 per prescription/refill
$40 per 90-day supply

Tier 2 – Preferred
$40 per prescription/refill
$80 per 90-day supply

Tier 3 – Non-Preferred
$60 per prescription/refill
$120 per 90-day supply

Tier 4 – Preferred Specialty
25% up to a maximum out of pocket of $200 per 30-day supply

Tier 5 – Non-Preferred Specialty
35% up to a maximum out of pocket of $300 per 30-day supply

Note: Deductible waived for the following diabetic supplies lancets, test strips and control solution.

Women's contraceptive drugs and devices

Note: Over-the-counter contraceptive drugs and devices, including emergency contraceptives, approved by the FDA require a written prescription by an approved provider. Contraceptive drugs purchased at a non-Plan pharmacy are not covered, except emergencies.

Nothing

(No deductible)

Male’s contraceptive drugs and devices

Note: Over-the-counter contraceptive drugs and devices, including emergency contraceptives, approved by the FDA require a written prescription by an approved provider. Contraceptive drugs purchased at a non-Plan pharmacy are not covered, except emergencies.

Nothing 

Mail Order Drug Program

  • Prescription medications mailed to your home by the Kaiser Permanente Washington mail order pharmacy (mail order issues up to a 90-day supply per fill.)

Tier 1
$20 per prescription/refill
$40 per 90-day supply

Tier 2 – Preferred
$40 per prescription/refill
$80 per 90-day supply

Tier 3 – Non-Preferred
$60 per prescription/refill
$120 per 90-day supply

Mail order not available for specialty drugs

Limited benefits

  • Drugs to aid in tobacco cessation when prescribed and dispensed as part of the Plan's tobacco cessation program
  • Over-the-counter tobacco cessation drugs when obtained through the Kaiser Permanente Washington mail order pharmacy and Plan retail pharmacy
Nothing

Not covered:

  • Drugs and supplies for cosmetic purposes
  • Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them, except treatment of phenylketonuria (PKU) as described elsewhere in this brochure
  • Non-prescription medications, except certain over-the-counter substances approved by the Plan
  • Medical supplies such as dressings and antiseptics
  • Fertility drugs
  • Drugs to enhance athletic performance
  • Drugs prescribed to treat any non-covered service
  • Drugs obtained at a non-Plan pharmacy, except for out-of-area emergencies
  • Compounded drugs for hormone replacement therapy
  • Drugs that are not medically necessary according to accepted medical, dental or psychiatric practice as determined by the Plan
  • Lost or stolen medications
  • Non-self administered medications (e.g., intramuscular, intravenous, intrathecal)
  • Weight loss medications

Note: Over-the-counter and prescription drugs authorized by the Quit For Life® program and approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation programs benefit (see Educational classes and programs).

All Charges
Benefit Description : Preventive Care MedicationsHDHP (You pay After the calendar year deductible… )

The following are covered: 

  • Aspirin to reduce the risk of heart attack

  • Oral fluoride for children to reduce the risk of tooth decay
  • Folic acid for women to reduce the risk of birth defects

  • Liquid iron supplements for children age 0-1 year

  • Medications to reduce the risk of breast cancer

  • Statins for adults at risk of cardiovascular disease

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a health care professional and filled by a network pharmacy. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients. For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Nothing

(No deductible)

Not covered:

  • Drugs and supplies for cosmetic purposes
  • Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them, except treatment of phenylketonuria (PKU) as described elsewhere in this brochure
  • Non-prescription medications, except certain over-the-counter substances approved by the Plan
  • Medical supplies such as dressings and antiseptics
  • Fertility drugs
  • Drugs to enhance athletic performance
  • Drugs prescribed to treat any non-covered service
  • Drugs obtained at a non-Plan pharmacy, except for out-of-area emergencies
  • Compounded drugs for hormone replacement therapy
  • Drugs that are not medically necessary according to accepted medical, dental or psychiatric practice as determined by the Plan
  • Lost or stolen medications
  • Non-self administered medications (e.g., intramuscular, intravenous, intrathecal)
  • Weight loss medications

Note: Over-the-counter and prescription drugs authorized by the Quit For Life® program and approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation program benefit (see Educational classes and programs).

All Charges




Section 5(g). Dental Benefits (HDHP)

Important things you should keep in mind about these benefits:

  • Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
  • If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) dental plan, your FEHB Plan will be the first/primary payor of any benefit payments and your FEDVIP plan is secondary to your FEHB Plan. See Section 9, Coordinating benefits with Medicare and other coverage.
  • The deductible is $1,500 for Self Only enrollment, $1,500 per person for Self Plus One or Self and Family enrollment not to exceed a total family deductible of $3,000 (each applies separately for services received from Plan providers and non-Plan providers) each calendar year. The deductible applies to all benefits in this Section.
  • After you have satisfied your deductible, your Traditional medical coverage begins.
  • Under your Traditional medical coverage, you will be responsible for your coinsurance amounts and copayments for eligible medical expenses and prescriptions.
  • We cover hospitalization for dental procedures only when a non-dental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c), 
    for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
  • Be sure to read Section 4, Your costs for covered services, for valuable information about how
    cost-sharing works. Also, read Section 9, Coordinating benefits with Medicare and other coverage.



TermDefinition

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. Sound natural teeth are those that do not have any restoration. (See Section 10, Definitions of terms we use in this brochure.) The need for these services must result from an accidental injury (not biting or chewing). All services must be performed and completed within 12 months of the date of injury.

Note: This benefit is not part of the Dental preventive care benefit.

In-network: 20% of Plan allowance

Out-of-network: 40% of Plan allowance and any difference between our allowance and the billed amount




TermDefinition

See Dental preventive care.

We have no other dental benefits.




Section 5(h). Wellness and Other Special Features (HDHP)

TermDefinition

Flexible benefits option

In certain cases, Kaiser Permanente Washington Options Federal, at its sole discretion, may choose to authorize coverage for benefits
or services that are not otherwise included as covered under this Plan. Such authorization is done on a case-by-case basis if a particular benefit or service is judged to be medically necessary, beneficial and cost effective. However, our decision to authorize services in one instance does not commit us to cover the same or similar services for you in other instances, or to cover the same or similar services in any other instance for any other enrollee. Our decision to authorize services does not constitute a waiver of our right to enforce the provisions, limitations and exclusions of this Plan.

Under the flexible benefits option, we determine the most effective way to provide services.

  • We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
  • Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
  • By approving an alternative benefit, we do not guarantee you will get it in the future.
  • The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
  • If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
  • Our decision to offer or withdraw alternative benefits is not subject to OPM review
    under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

Consulting Nursing Service

For urgent care information and after hours care 24 hours a day, 7 days a week, call toll-free 800-297-6877.

Services for deaf, hard of hearing or speech impaired

We provide a TTY/text phone number at: 711. Sign language services are also available.

Travel benefit/services overseas

If you are on Temporary Duty Assignment or reside temporarily outside of Washington state you are covered for all of the benefits described in this brochure.  You pay the applicable cost-share per visit for services.  For non-urgent and non-emergent services you should receive care from a Plan provider; in Idaho, Oregon, Montana and Alaska, a Plan provider is a First Choice Health Network provider and in all other states a Plan provider is a First Health Network provider.  Medications obtained at a participating pharmacy in connection with non-urgent, non-emergent services will also be covered. See also Section 1. "How we pay providers".

If you need assistance while anywhere in the world call Member Services toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington State’s relay line by dialing either 800-833-6388 or 711.

Filing Overseas Claims for Urgent or Emergent Care
Most overseas providers are under no obligation to file claims on behalf of our members. You may need to pay for the services at the time you receive them and then submit a claim to us for reimbursement. To file a claim for urgent or emergent care received outside the United States, send a completed Overseas Claim Form and itemized bills to:

Member Claims
P.O. Box 30766
Salt Lake City, UT 84130-0766

We will do the translation and currency conversion for you. You may obtain the Overseas Claim Form by calling Member Services toll-free at 888-901-4636 or from our website at www.kp.org/feds/wa-options, Members/Forms and Information.




Section 5(i). Health Education Resources and Account Management Tools (HDHP)

TermDefinition

Health education resources

Through our website at www.kp.org/feds/wa-options you will find information on:

  • General health topics
  • Links to health care news
  • Cancer and other specific diseases
  • Drugs/medication interactions
  • Kids’ health
  • Patient safety information
  • Helpful website links
Account management tools

For each HSA and HRA account holder, complete payment history and balance information can be found online at www.MyHealthEquity.com.

This information is also available by calling the HealthEquity® customer service line toll-free at 866-346-5800.

You may view monthly statements, year-end statements and tax statements online at healthequity.com.

If you have an HSA, you may also change your investment options online at www.MyHealthEquity.com.

Consumer choice information

As a member of this HDHP, you may choose any provider. However, you will pay less out-of-pocket when using a network provider. Directories are available online at www.kp.org/feds/wa-options by clicking on Members/Find a Provider. See pages (Applies to printed brochure only) and (Applies to printed brochure only) for further information.

Pricing information for prescription drugs and a link to our online pharmacy are available at www.kp.org/feds/wa-options by clicking on Pharmacy.

Educational materials regarding HSAs and HRAs are available at www.myhealthequity.com.

Care support

Patient safety information is available online at

www.kp.org/feds/wa-options.




Non-FEHB Benefits Available to Plan Members

The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. These programs and materials are the responsibility of the Plan, and all appeals must follow their guidelines.  For additional information contact the Plan at 888-901-4636 or visit our website at www.kp.org/feds/wa-options.

Eyewear Discount - Member Services: 888-901-4636 www.kp.org/wa/eyecare

Vision hardware discount members get discounts on vision hardware including eyeglasses, prescription sunglasses and contact lenses once per year. Call Member Services at 888-901-4636 or go online to kp.org/wa/eyecare for more information. 

Health classes and programs - www.kp.org/classes

You can sign up for wellness programs and classes designed to help you achieve your health goals. All sessions are taught by our team of experts who walk you through how to make actionable lifestyle changes.

Fitness deals - www.kp.org/exercise

  • ClassPass makes it easier for you to work out from anywhere. ClassPass partners with 30,000 gyms and studios around the world and offers a range of classes including yoga, dance, cardio, boxing, Pilates, boot camp, and more. You can get unlimited on-demand video workouts at no cost and reduced rates on livestream and in-person fitness classes.
  • Active&Fit Direct®. As a Kaiser Permanente member, get access to more than 11,000 gyms with one membership. When Kaiser Permanente members sign up for an Active&Fit Direct gym membership, they can visit any of the 11,000 participating fitness centers in the nationwide Active&Fit Direct network.
  • ChooseHealthy® provides reduced rates on a variety of fitness, health, and wellness products. This includes activity trackers, workout apparel and exercise equipment.

Emotional Wellness Apps - www.kp.org/selfcareapps

Kaiser Permanente provides wellness apps at no cost that can help you navigate life’s challenges and make small changes to improve your sleep, mood, relationships and more.

  • Calm is an app for meditation and sleep designed to lower stress, reduce anxiety and more. Member can access great features at no cost including the Daily Calm (mindful theme each day), more than 100 guided medications, Sleep Stories (soothe you into deeper and better sleep) and video lessons on mindful movement and gentle stretching.
  • myStrength is a personalized program that helps you improve your awareness and change behaviors. You can explore interactive activities, in-the-moment coping tools, community support, and more.



Section 6. General Exclusions – Services, Drugs and Supplies We Do Not Cover

The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for specific services, such as transplants, see Section 3 You need prior Plan approval for certain services.

We do not cover the following:

  • When a service is not covered, all services, drugs, or supplies related to the non-covered service are excluded from coverage, except services we would otherwise cover to treat complications of non-covered service. 
  • Fees associated with non-payment (including interest), missed appointments and special billing arrangements.
  • Services, drugs, or supplies you receive while you are not enrolled in this Plan.
  • Services, drugs, or supplies not medically necessary as determined by the Plan.
  • Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.
  • Experimental or investigational procedures, treatments, drugs or devices as determined by the Plan (see specifics regarding transplants).
  • Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term, or when the pregnancy is the result of an act of rape or incest.
  • Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program.
  • Services, drugs, or supplies you receive without charge while in active military service.
  • Research costs for clinical trials (see Section 9, and Section 10).
  • Services provided by a person who is related to you by blood or marriage.
  • Services or supplies we are prohibited from covering under the Federal Law.



Section 7. Filing a Claim for Covered Services

This Section primarily deals with post-service claims (claims for services, drugs, equipment, or supplies you have already received). See Section 3 for information on pre-service claims procedures (services, drugs, equipment, or supplies requiring prior Plan approval), including urgent care claims procedures. When you see Plan providers, receive services at Plan hospitals and facilities, or obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment, coinsurance, or deductible (if applicable).

You will only need to file a claim when you receive emergency services from non-Plan Provider. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:




TermDefinition

Medical and hospital benefits

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing 800-833-6388 or 711, or at our website at www.kp.org/feds/wa-options.

When you must file a claim such as for services you receive outside the Plan's service area - submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

  • Covered member's name, date of birth, address, phone number and ID number
  • Name and address of the provider or facility that provided the service or supply
  • Dates you received the services or supplies
  • Diagnosis
  • Type of each service or supply
  • The charge for each service or supply
  • A copy of the explanation of benefits, payments, or denial from any primary payor such as the Medicare Summary Notice (MSN)
  • Receipts, if you paid for your services.

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:

Kaiser Permanente Washington Options Federal
Member Claims
PO Box 30766
Salt Lake City, UT 84130-0766

Prescription drugs

When you must file a claim – such as for prescriptions you receive from an out-of-state non-Plan pharmacy due to an emergency – submit it on a claim form that includes the information shown below. Bills and receipts should be itemized and show:

  • Member’s name and ID number
  • Drug name, quantity, prescription number
  • Cost of drug and amount you paid
  • NDC number
  • Drug strength
  • Pharmacy name
  • Pharmacy address
  • Pharmacy NABP number 

 

Submit your claims to: 

Claim Reimbursement
P.O. Box 30766
Salt Lake City,  UT 84130-0766 

Deadline for filing your claim

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

Post-service claims procedures

We will notify you of our decision within 30 days after we receive your post-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

If we need an extension because we have not received necessary information from you, our notice will describe the specific information required and we will allow you up to 60 days from the receipt of the notice to provide the information.

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

Authorized RepresentativeYou may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, we will permit a health care professional with knowledge of your medical condition to act as your authorized representative without your express consent. For the purposes of this section, we are also referring to your authorized representative when we refer to you.

Notice Requirements

If you live in a county where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language.  The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the health care provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.




Section 8. The Disputed Claims Process

You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes. For more information or to make an inquiry about situations in which you are entitled to immediate appeal to OPM, including additional requirements not listed in Sections 3, 7 and 8 of this brochure, please call Member Services at the phone number found on your ID card, Plan brochure, or Plan website.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs, equipment or supplies have already been provided). In Section 3, If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs, equipment or supplies that must have prior Plan approval, such as inpatient hospital admissions.

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make your request, please contact our Member Services Department by writing to Kaiser Permanente Washington Options Federal, P.O. Box 34593, Seattle, WA 98124-1593 or calling 888-901-4636.

Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.

When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.

Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or his/her subordinate, who made the initial decision.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.

Disagreements between you and the HDHP fiduciary regarding the administration of an HSA or HRA are not subject to the disputed claims process.




StepDescription

1

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at:

Kaiser Permanente Washington Options Federal
Appeals Department
PO Box 34593
Seattle, WA 98124-1593

or fax your request to: 206-901-7340; and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB)

e) Include your email address (optional), if you would like to receive our decision via email. Please note that by giving us your email, we may be able to provide our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

2

 

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a)     Pay the claim; or

b)     Write to you and maintain our denial; or

c)     Ask you or your provider for more information. 

        You or your provider must send the information so that we receive it within 60 days of our request. We 
         will then decide within 30 more days.

        If we do not receive the information within 60 days, we will decide within 30 days of the date the
        information was due. We will base our decision on the information we already have. We will write to 
        you with our decision.

3

 

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

  • 90 days after the date of our letter upholding our initial decision; or
  • 120 days after you first wrote to us - if we did not answer that request in some way within 30 days; or
  • 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 2, 1900 E Street NW, Washington, DC 20415-3620.

Send OPM the following information:

  • A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
  • Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
  • Copies of all letters you sent to us about the claim;
  • Copies of all letters we sent to you about the claim; and
  • Your daytime phone number and the best time to call.
  • Your email address, if you would like to receive OPM's decision via email. Please note that by providing your email address, you may receive OPM's decision more quickly.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

4

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied preauthorization or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.




Note: If you have a serious or life-threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 877-828-4514.  We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal.  You may call OPM’s FEHB 2 at (202) 606-3818 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about Plan eligibility issues.  For example, we do not determine whether you or a dependent is covered under this Plan.  You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.




Section 9. Coordinating Benefits with Medicare and Other Coverage

TermDefinition

When you have other health coverage

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays health care expenses without regard to fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.kp.org/feds/wa-options.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance. When we are the secondary payor, we will coordinate benefits with the primary payor allowing up to our Plan's benefit visit maximum.




TermDefinition
  • TRICARE and CHAMPVA

TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

  • Workers' Compensation

We do not cover services that:

  • You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
  • OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

  • Medicaid

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

When other Government agencies are responsible for your care

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

When others are responsible for injuries

Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provision of benefits under our coverage.

If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party’s insurance policies, your own insurance policies, or a workers’ compensation program or policy, you must reimburse us out of that payment.  Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness.  However, we will cover the cost of treatment that exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned.  Our right of reimbursement is not subject to reduction based on attorney fees or costs under the “common fund” doctrine and is fully enforceable regardless of whether you are “made whole” or fully compensated for the full amount of damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverageSome FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 877-888-3337, (TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

Clinical Trials

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trial, this health Plan will provide related care as follows, if it is not provided by the clinical trial:

  • Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy. These costs are covered by this Plan.
  • Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial but not as part of the patient’s routine care. This Plan covers some of these costs, providing the Plan determines the services are medically necessary. For more specific information, we encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.
  • Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials, this Plan does not cover these costs.



TermDefinition

When you have Medicare

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" please contact Medicare at 800-MEDICARE (800-633-4227), (TTY 877-486-2048) or at www.medicare.gov.

  • The Original Medicare Plan (Part A or Part B)

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan- You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711, or see our website at www.kp.org/feds/wa-options.

We waive some cost-sharing if Original Medicare Plan is your primary payor and you use a provider who accepts Medicare assignment.

When you have Medicare Parts A and B, Medicare is primary payor and you receive care from a provider that accepts Medicare, we waive some out-of-pocket costs as follows:

Benefit Description: Deductible
Standard Option without Medicare You pay: $350
Standard Option with Medicare You pay: $0

Benefit Description: Out-of-Pocket Maximum
Standard Option without Medicare You pay: $5,000 per person up to $10,000 per family
Standard Option with Medicare You pay: $5,000 per person up to $10,000 per family

Benefit Description: Primary Care Physician
Standard Option without Medicare You pay: $25
Standard Option with Medicare You pay: $0

Benefit Description: Specialist
Standard Option without Medicare You pay: $35
Standard Option with Medicare You pay: $0

Benefit Description: Inpatient Hospital
Standard Option without Medicare You pay: 20% 
Standard Option with Medicare You pay: $0

Benefit Description: Outpatient Hospital
Standard Option without Medicare You pay: 20% 
Standard Option with Medicare You pay: $0

Benefit Description: RX
Standard Option without Medicare You pay: Tier 1 - $20, Tier 2 - $40, Tier 3 - $60. Tier 4 - Preferred Specialty 25% to $200, Tier 5 - Non-preferred Specialty 35% to $300
Standard Option with Medicare You pay: $0Tier 1 - $20, Tier 2 - $40, Tier 3 - $60, Tier 4 - Preferred Specialty 25% to $200, Tier 5 - Non-preferred Specialty 35% to $300

Benefit Description: Rx - Mail order (90-day supply)
Standard Option without Medicare You pay: 2x retail copay
Standard Option with Medicare You pay: 2x retail copay

If you have Medicare Part A only, and Original Medicare is your primary payor, we will waive deductible, coinsurance, and copayments for Part A services only (such as inpatient hospital care, home health, hospice, or skilled nursing care).

If you have Medicare Part B only, and Original Medicare is your primary payor, we will waive deductible, coinsurance, and copayments for Part B services only (such as outpatient medical or surgical care).

We will not waive the following:

- Cost-sharing for members who do not have Medicare Parts A or B, or, for whom Medicare is secondary payor
- Prescription drug cost-sharing
- Cost-sharing for HDHP members

  • Tell us about your Medicare coverage
You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.
  • Medicare Advantage (Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs and regional PPOs) in some areas of the country.

To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227), (TTY 800-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB Plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers). However,  we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

  • Medicare prescription drug coverage
    (Part D)
When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB Plan.



Primary Payor Chart

A. When you – or your covered spouse are age 65 or over and have Medicare and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant
3) Have FEHB through your spouse who is an active employee
4) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #3 above
5) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and...
  • You have FEHB coverage on your own or through your spouse who is also an active employee
  • You have FEHB coverage through your spouse who is an annuitant
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #3 above
7) Are enrolled in Part B only, regardless of your employment status ✓ for Part B services ✓ for other services
8) Are a Federal employee receiving Workers' Compensation disability benefits for six months ✓ *


B. When you or a covered family member...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have Medicare solely based on end stage renal disease (ESRD) and..
  • It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)
  • It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
  • This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)
  • Medicare was the primary payor before eligibility due to ESRD
3) Have Temporary Continuation of Coverage(TCC) and...
  • Medicare based on age and disability
  • Medicare based on ESRD (for the 30-month coordination period)
  • Medicare based on ESRD (after the 30-month coordination period)


C. When either you or a covered family member are eligible for Medicare solely due to disability and you...The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee
2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant
D. When you are covered under the FEHB Spouse Equity provision as a former spouse

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




Section 10. Definitions of Terms We Use in This Brochure

TermDefinition
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Clinical Trials Cost Categories

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded, conducted under an investigational new drug application reviewed by the Food and Drug Administration, or is a drug trial that is exempt from the requirement of an investigational new drug application.

    • Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy.
    • Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.
    • Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials.  This plan does not cover these costs.

Coinsurance

See Section 4, page (Applies to printed brochure only).

Copayment

See Section 4, page (Applies to printed brochure only).

Cost-sharing

See Section 4, page (Applies to printed brochure only).

Covered services Care we provide benefits for, as described in this brochure.

Custodial care

(1) Assistance with activities of daily living, for example, walking, getting in and out of bed, dressing, feeding, toileting, and taking medication. (2) Care that can be performed safely and effectively by people who, in order to provide the care, do not require medical licenses or certificates or the presence of a supervising licensed nurse. Custodial care that lasts 90 days or more is sometimes known as long-term care.

Deductible

See section 4, page (Applies to printed brochure only).

Experimental or investigational services

We do not cover a service, supply, item or drug that we consider experimental, except for the limited coverage specified in Section 9. Clinical trials. We consider a service, supply, item or drug to be experimental when the service, supply, item or drug: 
  1. has not been approved by the FDA; or
  2. is the subject of a new drug or new device application on file with the FDA; or
  3. is part of a Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial; or is intended to evaluate the safety, toxicity, or efficacy of the service; or
  4. is available as the result of a written protocol that evaluates the service’s safety, toxicity, or efficacy; or
  5. is subject to the approval or review of an Institutional Review Board; or
  6. requires an informed consent that describes the service as experimental or investigational. 

We carefully evaluate whether a particular therapy is safe and effective or offers a reasonable degree of promise with respect to improving health outcomes. The primary source of evidence about health outcomes of any intervention is peer-reviewed medical or dental literature

Health care professionalA physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.
Medical necessity

Medical services or hospital services which are determined by the Plan Medical Director or designee to be:

  • Rendered for the treatment or diagnosis of an injury or illness; and
  • Appropriate for the symptoms, consistent with diagnosis, and otherwise in accordance with sufficient scientific evidence and professionally recognized standards; and
  • Not furnished primarily for the convenience of the Member, the attending physician, or other provider of service.

Whether there is “sufficient scientific evidence” shall be determined by the Plan based on the following: peer-reviewed medical literature; publications, reports, evaluations, and regulations issued by state and federal government agencies; Medicare local carriers, and intermediaries; and such other authoritative medical sources as deemed necessary by the Plan.

Never event/serious reportable event 

Certain Hospital Acquired Conditions, as defined by Medicare, including things like wrong-site surgeries, transfusion with the wrong blood type, pressure ulcers (bedsores), falls or trauma, and nosocomial infections (hospital-acquired infections) associated with surgeries or catheters, that are directly related to the provision of an inpatient covered service at a Plan provider.

Observation Care

Hospital outpatient services you get while your physician decides whether to admit you as an inpatient or discharge you. You can get observation services in the emergency department or another area of the hospital.

Plan allowance

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance as follows: the charges are consistent with those normally charged to others by the provider or organization for the same services or supplies; and the charges are within the general range of charges made by other providers in the same geographical area for the same services or supplies. You will be required to pay any difference between the non-Plan providers charge for services and the Allowed Amount. For non-emergency surgical or ancillary services performed at an in-Plan hospital or ambulatory
surgical facility in Washington, under Washington law a non-Plan provider may not charge you more than our allowance.

Post-service claimsAny claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.
Pre-service claimsThose claims (1) that require precertification or prior approval and (2) where failure to obtain precertification or prior approval results in a reduction of benefits.
ReimbursementA carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, and the terms of the carrier's health benefits plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.
Sound natural tooth A sound natural tooth is a tooth that is whole or properly restored (restoration with amalgams/resin-based composites only); is without impairment, periodontal, or other conditions; and is not in need of the treatment provided for any reason other than an accidental injury. A tooth previously restored with a crown, inlay, onlay, or porcelain restoration, or treated by endodontics is not considered a sound natural tooth.
SubrogationA carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.

Us/We

Us and We refer to Kaiser Foundation Health Plan of Washington Options, Inc., Kaiser Permanente Washington Options Federal, Options Federal or Kaiser Permanente.

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

Urgent care claims

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

  • Waiting could seriously jeopardize your life or health;
  • Waiting could seriously jeopardize your ability to regain maximum function; or
  • In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Member Services Department toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.




High Deductible Health Plan (HDHP) Definitions

TermDefinition

Calendar year deductible

The fixed amount of covered expenses you must incur during the calendar year for certain covered services and supplies before we start paying benefits for those services. See page (Applies to printed brochure only) for more information.

Catastrophic limit

The maximum amount you will have to pay in a calendar year towards copayments, coinsurance, and deductible for certain covered services. See page (Applies to printed brochure only) for more information.

Health Reimbursement Arrangement (HRA)

An HRA allows you to pay for certain medical expenses using funds contributed by the Plan. Money left at the end of the year may be rolled over to the following year as long as you remain with the Plan. See page (Applies to printed brochure only) for more information.

Health Savings Account (HSA)

An HSA allows you to pay for certain medical expenses using funds contributed by the Plan and/or yourself as long as you are covered only by a High Deductible Health Plan (HDHP). Money left at the end of the year may be rolled over to the following year and remains yours even if you leave the Plan. See page (Applies to printed brochure only) for more information.

Premium contribution to HSA/HRA

The amount of money from your premium payment that the Plan contributes to your HSA or HRA account. See page (Applies to printed brochure only) for more information.




Section 11

Index

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




Index Entry
(Page numbers solely appear in the printed brochure)
Accidental Injury
Acupuncture
Allergy care
Alternative treatments
Ambulance
Ambulatory surgical center
Anesthesia
Applied Behavioral Analysis (ABA)
Bariatric surgery
Biopsy
Blood and blood products
Cardiac rehabilitation
Casts
Catastrophic out-of-pocket max
Changes for 2021
Chemotherapy
Chiropractic
Cholesterol tests
Circumcision
Claims
Clinical Trials
Coinsurance
Colorectal cancer screening
Complementary care
Congenital anomalies
Contraceptive drugs and devices
Coordination of benefits
Copayment
Cost-sharing
CPAP machines
Deductible
Definitions
Dental benefits
Dental preventive care
Dental providers
Diagnostic services
Dialysis
Dressings
Educational classes and programs
Emergency
Experimental or investigational
Eyeglasses
Family planning
Fecal occult blood test
Federal Dental and Vision Insurance Program (FEDVIP)
Federal Flexible Spending Account Program (FSAFEDS)
Fraud
General exclusions
Generic drugs
Health Reimbursement Arrangements (HRA)
Health Savings Accounts (HSA)
Home health services
Hospice care
Hospital
Immunizations
Infertility
Insulin
Magnetic Resonance Imagings (MRIs)
Mail Order Program
Mammograms
Maternity benefits
Medicaid
Medical necessity
Medicare
Original Medicare
Mental Health/Substance Use Disorder Benefits
Naturopath
Neurodevelopmental therapies
Newborn care
Nurse
Licensed Practical Nurse (LPN)
Nurse Anesthetist (NA)
Nutritional guidance
Occupational therapy
Ocular injury
Oral and maxillofacial surgical
Out-of-network services
Out-of-pocket expenses
Overseas claims
Oxygen
Pap test
Phenylketonuria (PKU) formulas
Physical therapy
Plan allowance
Plan providers
Point of Service Benefits
Precertification
Prescription drugs
Preventive care, adult
Preventive care, children
Primary care providers
Prior approval
Prosthetic devices
Psychologist
Pulmonary rehabilitation
Radiation therapy
Room and board
Second surgical opinion
Skilled nursing facility care
Sleep disorders
Social worker
Specialty care
Speech therapy
Splints
Surgery
Oral
Outpatient
Reconstructive
Syringes
Temporary Continuation of Coverage (TCC)
Temporomandibular joint disorders (TMJ)
Tobacco cessation
Transgender services
Transplants
Treatment therapies
Vision services
Workers' Compensation
X-rays



Summary of Benefits for the Standard Option of Kaiser Permanente Washington Options Federal - 2021

  • Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at kp.org/feds/wa-options.
  • If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
  • Below, an asterisk (*) means the item is subject to the $350 per person ($700 per family) calendar year deductible.



TermDefinition 1Definition 2

Medical services provided by physicians:

Diagnostic and treatment services provided in the office

Office visit: $25 for primary care services or $35 for specialty care services

(Applies to printed brochure only)

Services provided by a hospital:

  • Inpatient & outpatient

20% of Plan allowance*

(Applies to printed brochure only)

Emergency benefits:

  • In-area/Out-of-area

Emergency Room: $150*

(Applies to printed brochure only)

Emergency benefits:

In-area/Out-of-area

Urgent Care: $25 for primary care services or $35 for specialty care services

Mental health and substance use disorder treatment:

Regular cost sharing*

(Applies to printed brochure only)

Prescription drugs:

  • Retail pharmacy

Tier 1: $20; Tier 2: $40; Tier 3: $60; Tier 4: 25% up to a maximum out of pocket of $200 per 30-day supply; Tier 5: 35% up to a maximum out of pocket of $300 per 30-day supply

(Applies to printed brochure only)

Prescription drugs:

  • 90-day supply

Tier 1: $40; Tier 2: $80; Tier 3: $120

(Applies to printed brochure only)

Dental care: Preventive dental care

All charges in excess of the fee schedule allowance.

(Applies to printed brochure only)

Vision care: Annual eye exam

Nothing

(Applies to printed brochure only)

Wellness and other special features:

See Section 5(h)

(Applies to printed brochure only)

Point of Service benefits:

See Section 5(i)

(Applies to printed brochure only)

Protection against catastrophic costs (out-of-pocket maximum):

Nothing after $5,000/person or $10,000/family per year. Some costs do not count toward this protection

(Applies to printed brochure only)




Summary of Benefits for the HDHP of Kaiser Permanente Washington Options Federal - 2021

Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can also obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at kp.org/feds/wa-options. If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form. 

In 2021, for each month you are eligible for a Health Savings Account (HSA), we will deposit $62.50 per month for Self Only enrollment or $125 per month for Self Plus One or Self and Family enrollment into your HSA. For the High Deductible Health Plan (HDHP), you may use your HSA or pay out of pocket to satisfy your calendar year deductible of $1,500 for Self Only enrollment and $1,500 per person for Self Plus One or Self and Family enrollment not to exceed a total family deductible of $3,000 (each applies separately for services received from Plan providers and non-Plan providers). Once you satisfy your calendar year deductible, Traditional medical coverage begins.

If you are not eligible for an HSA, we will establish a Health Reimbursement Arrangement (HRA) account for you with an annual credit of $750 for Self Only enrollment and $1,500 for Self Plus One or Self and Family enrollment.

Below, an asterisk (*) means the item is subject to the $1,500 per person Self Only ($1,500 per person Self Plus One or Self and Family, not to exceed a total family deductible of $3,000) calendar year deductible.




TermDefinition 1Definition 2

In-network medical preventive care:

Nothing

(Applies to printed brochure only)

Preventive dental care:

All charges in excess of the dental fee schedule allowance

(Applies to printed brochure only)

Medical services provided by physicians: Diagnostic and treatment services provided in the office

In-network: 20% of Plan allowance*
Out-of-network: 40% of Plan allowance*

(Applies to printed brochure only)

Services provided by a hospital: Inpatient & outpatient

In-network: 20% of Plan allowance*
Out-of-network: 40% of Plan allowance*

(Applies to printed brochure only)

Emergency benefits: In-area & out-of-area

20% of Plan allowance*

(Applies to printed brochure only)

Mental health and substance use disorder treatment:

In-network: 20% of Plan allowance*
Out-of-network: 40% of Plan allowance*

(Applies to printed brochure only)

Prescription drugs:

  • Retail pharmacy

Tier 1: $20*; Tier 2: $40*; Tier 3: $60*; Tier 4: 25% up to a maximum out of pocket of $200 per 30-day supply*; Tier 5: 35% up to a maximum out of pocket of $300 per 30-day supply*

(Applies to printed brochure only)

Prescription drugs:

  • 90-day supply

Tier 1: $40*; Tier 2: $80*; Tier 3: $120*

(Applies to printed brochure only)

Dental care - Accidental injury only:

In-network: 20% of Plan allowance*
Out-of-network: 40% of Plan allowance*

(Applies to printed brochure only)

Vision care: Annual eye exam

Nothing (included in Preventive Care)

(Applies to printed brochure only)

Wellness and other special features:

See Section 5(h)

(Applies to printed brochure only)

Protection against catastrophic costs (out-of-pocket maximum):

Nothing after $5,000/person or $10,000/family per year (each applies separately for services received from Plan providers and non-Plan providers). Some costs do not count toward this protection.

(Applies to printed brochure only)




2021 Rate Information for Kaiser Permanente Washington Options Federal

To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

To review premium rates for all FEHB health plan options please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium.

Non-Postal rates apply to most non-Postal employees. If you are in a special enrollment category, contact the agency that maintains your health benefits enrollment.

Postal rates apply to certain United States Postal Service employees as follows:

  • Postal Category 1 rates apply to career bargaining unit employees who are represented by the following agreement: NALC.
  • Postal Category 2 rates apply to career bargaining unit employees who are represented by the following agreement: PPOA.

Non-Postal rates apply to all career non-bargaining unit Postal Service employees and career bargaining unit employees who are represented by the following agreements: APWU, IT/AS, NPMHU, NPPN and NRLCA. Postal rates do not apply to non-career Postal employees, Postal retirees, and associated members of any Postal employee organization who are not career Postal employees.

If you are a Postal Service employee and have questions or require assistance, please contact:

USPS Human Resources Shared Service Center: 877-477-3273, option 5, Federal Relay Services: 800-877-8339

Premiums for Tribal employees are shown under the monthly non-Postal column. The amount shown under employee contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your Tribal Benefits Officer for exact rates.




Type of EnrollmentEnrollment CodeNon-Postal Premium
BiWeekly
Gov't Share
Non-Postal Premium
BiWeekly
Your Share
Non-Postal Premium
Monthly
Gov't Share
Non-Postal Premium
Monthly
Your Share
Postal Premium
BiWeekly
Category 1 Your Share
Postal Premium
BiWeekly
Category 2 Your Share
Standard Option Self OnlyL11$241.58$101.42$523.42$219.75$98.06$88.00
Standard Option Self Plus OneL13$517.46$244.00$1,121.16$528.67$236.81$215.25
Standard Option Self and FamilyL12$562.25$199.21$1,218.21$431.62$191.40$167.98
HDHP Option Self OnlyL14$229.06$76.35$496.29$165.43$73.30$63.37
HDHP Option Self Plus OneL16$508.49$169.50$1,101.74$367.24$162.72$140.68
HDHP Option Self and FamilyL15$508.49$169.50$1,101.74$367.24$162.72$140.68