Professional services of physicians and other healthcare 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 healthcare 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 healthcare 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

Professional services of physicians and other healthcare 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)

Tests, such as:

• Blood test
• Urinalysis
• Non-routine Pap test
• Pathology
• X-ray
• Non-routine mammogram
• CT/CAT Scan
• 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

• Urine drug screening

In-network: Nothing (no deductible) for the first 2 tests per year, then 20% of Plan allowance after the deductible

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

• One annual routine physical 
• One annual routine eye exam

The following preventive services are covered at the time interval recommended at each of the links below:

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. 
• We cover other preventive services required by federal healthcare reform legislation (the Affordable Care Act and implementing regulations) and additional services that we include in our preventive services benefit. For a complete list of Kaiser Permanente preventive services visit our website at www.kp.org/prevention
• To build your personalized list of preventive services go to www.health.gov/myhealthfinder

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)

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. 

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 not included in the preventive recommended listing of services
• You should consult with your physician to determine what is appropriate for you.

Applies to this benefit

Not covered:

• Physical exams and immunizations required for obtaining or continuing employment or insurance, attending camp, athletic exams or travel.

• 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
• We cover other preventive services required by federal healthcare reform legislation (the Affordable Care Act and implementing regulations) and additional services that we include in our preventive services benefit. For a complete list of Kaiser Permanente preventive services visit our website at www.kp.org/prevention
• To build your personalized list of preventive services go to www.health.gov/myhealthfinder

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 not included in the preventive recommended listing of services.

Applies to this benefit

Not covered:

• Physical exams and immunizations required for obtaining or continuing employment or insurance, attending camp, athletic exams or travel.

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

In-network: Nothing

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

(No deductible)

• Breastfeeding support, supplies and counseling for each birth

Note: We cover breastfeeding pumps and supplies under Durable Medical Equipment (DME). 

In-network: Nothing

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

(No deductible)

  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.
• Your Plan provider does not have to obtain prior approval from us for your vaginal delivery. See Section 3, You need prior Plan approval for certain services, for prior approval guidelines.
• 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 their 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).

Applies to this benefit

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.

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 contraceptives (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

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

Standard fertility preservation for iatrogenic infertility, such as:

• Retrieval of sperm and eggs
• Cryopreservation
• Storage for preserved specimen for 1 year after a covered preservation procedure even if your enrollment ends

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
• Any charges associated with donor eggs or donor sperm
• Any charges associated with cryopreservation, unless listed as covered above for iatrogenic infertility
• Any charges associated with thawing and storage of frozen sperm, eggs and embryos, unless listed as covered above for iatrogenic infertility
• Fertility drugs 

• 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

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.

• 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 
• Infusion therapy in a medical office or outpatient hospital facility: Professional services of physicians and other healthcare professionals, equipment and supplies
• Ultraviolet light treatments

Notes:

• Growth hormone therapy (GHT) 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 Section 3, 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)

• Infusion therapy in a medical office or outpatient hospital facility: Medication

In-network: 20% of Plan allowance

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

• Infusion therapy at home: Professional services of physicians and other healthcare professionals, equipment and supplies

In-network: Nothing (No deductible)

Out-of-network: All Charges

• Infusion therapy at home: Medication

In-network: 20% of Plan allowance 

Out-of-network: All Charges

• Enteral and parenteral supplements and formula when it is the sole source, or an essential source, of nutrition

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

• Amino acid modified products for the treatment of inborn errors of metabolism, such as phenylketonuria (PKU)

In-network: Nothing

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

(No 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)

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

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

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 

• 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

Notes:

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

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:

• Hearing services that are not shown as covered
• Replacement parts and batteries, repair of hearing aids, and replacement of lost or broken hearing aids
  

• 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

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)

• 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

• 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).

Applies to this benefit

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

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

• One breastfeeding pump and supplies per delivery, including equipment that is required for pump functionality

• Ultraviolet light treatment equipment

In-network: Nothing (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.

Applies to this benefit

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

• Home healthcare 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.

• 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

• 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

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 cessation.
  
  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

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.

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
• 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)
• Services for the promotion, prevention or other treatment of hair loss or hair growth
• Cosmetic surgery, any surgery procedure (or any portion of the procedure) performed primarily to improve physical appearance through change in bodily form
• Services not listed above as covered

• 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.

• Gender reassignment surgery
  • Assigned female at birth: hysterectomy, oophorectomy, metoidioplasty, phalloplasty, vaginectomy, scrotoplasty, erectile prosthesis, urethral extension, bilateral mastectomy with chest reconstruction, breast reduction
  • Assigned male at birth: penectomy, vaginoplasty, clitoroplasty, labiaplasty, orchiectomy, tracheal shave, breast augmentation, facial hair removal, facial feminization

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
• Gender reassignment surgery not listed above

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;
• Medical and surgical treatment of temporomandibular joint (TMJ) disorder (non-dental); 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)
• Correction of any malocclusion not listed above

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 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 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.
• We cover medically necessary routine dental services in preparation for chemotherapy, radiation therapy, and transplants. Covered services may include a routine oral examination, cleaning (prophylaxis), extractions, and X-rays. You pay cost-sharing listed in Section 5(a) for services performed during an office visit.

Applies to this benefit

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

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

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

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

• 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.
• 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

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

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

Local licensed ambulance services when medically necessary

Note: See Section 3 You need prior Plan approval for certain services and Section 5(d), Emergency Services/Accident

Not covered: 

• Transportation by car, taxi, bus, gurney van, wheelchair van, and any other type of transportation (other than a licensed ambulance), even if it is the only way to travel to a Plan provider

• 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

• 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.

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

Licensed ambulance service when medically necessary

Note: See Section 5(c), Services Provided by a Hospital or Other Facility and Ambulance Services for non-emergency service.

Not covered:

• Transportation by car, taxi, bus, gurney van, wheelchair van, and any other type of transportation (other than a licensed ambulance), even if it is the only way to travel to a Plan provider
• Air and sea ambulance when not medically necessary

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.

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 substance use disorders, 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)

• 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

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

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

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)

• Services that, upon review, are determined to be inappropriate to treat your condition or are Plan exclusions.
• Long-term rehabilitative therapy
• Exercise programs

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
• Sexual dysfunction drugs
• Preauthorized compounded drugs
• Hormone therapy
• Drugs to treat gender dysphoria, including hormones and androgen blockers

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

• 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

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

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).

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 healthcare 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

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

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

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 – single film (twice per calendar year)

D0270

$20.00

Bitewing X-rays – two films (twice per calendar year)

D0272

$31.00

Bitewing X-rays – four films (twice per calendar year)

D0274

$45.00

Full mouth or panorex X-rays: panoramic film (full mouth or panorex series limited to once every 3 calendar years)

D0330

$77.00

Full mouth or panorex X-rays: intraoral complete series including bitewings (full mouth or panorex series limited to once every 3 calendar years)

D0210

$95.00

Periodic oral exam (twice per calendar year)

D0120

$41.00

Limited oral evaluation – problem focused

D0140

$58.00

Comprehensive oral evaluation

D0150

$57.00

 Pulp vitality tests

D0460

$38.00

Prophylaxis (cleaning) – through age 13 (twice per calendar year)

D1120

$51.00

Prophylaxis (cleaning) – after age 13 (twice per calendar year)

D1110

$88.00

Fluoride – topical application of fluoride (twice per calendar year through age 17; prophylaxis not included)

D1208

$32.00

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

D1351

$28.00

Space Maintenance - fixed - unilateral (Passive Appliances) 

D1510

No benefit

• One annual routine physical 
• One annual routine eye exam

The following preventive services are covered at the time interval recommended at each of the links below:

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. 

• We cover other preventive services required by federal healthcare reform legislation (the Affordable Care Act and implementing regulations) and additional services that we include in our preventive services benefit. For a complete list of Kaiser Permanente preventive services visit our website at www.kp.org/prevention
• To build your personalized list of preventive services go to www.health.gov/myhealthfinder

Nothing

• Routine mammogram - covered for women.

Nothing

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. 

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 not included in the preventive recommended listing of services
• You should consult with your physician to determine what is appropriate for you

   

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

• 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
• We cover other preventive services required by federal healthcare reform legislation (the Affordable Care Act and implementing regulations) and additional services that we include in our preventive services benefit. For a complete list of Kaiser Permanente preventive services visit our website at www.kp.org/prevention
• To build your personalized list of preventive services go to www.health.gov/myhealthfinder

Nothing

Note: 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 not included in the preventive recommended listing of services.

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

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).

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.

Professional services of physicians and other healthcare 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

Professional services of physicians and other healthcare 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

Tests, such as:

• Blood test
• Urinalysis
• Non-routine Pap test
• Pathology
• X-ray
• Non-routine mammogram
• CT/CAT Scan
• 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

• Urine drug screening

In-network: Nothing for the first 2 tests per year, then 20% of Plan allowance

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

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

• Prenatal care (see Preventive care, adult)
• Postnatal care
• 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

• Delivery (including home births)

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

Note: We cover breastfeeding pumps and supplies under Durable Medical Equipment (DME). 

In-network: Nothing  (No deductible)     

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

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.
• Your Plan provider does not have to obtain prior approval from us for your vaginal delivery. See Section 3, You need prior Plan approval for certain services, for prior approval guidelines.
• 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 their 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)

Applies to this benefit

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

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 contraceptives (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

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

Standard fertility preservation for iatrogenic infertility, such as:

• Retrieval of sperm and eggs
• Cryopreservation
• Storage for preserved specimen for 1 year after a covered preservation procedure even if your enrollment ends

In-network: 50% of Plan allowance

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

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
• Any charges associated with donor eggs or donor sperm
• Any charges associated with cryopreservation, unless listed as covered above for iatrogenic infertility
• Any charges associated with thawing and storage of frozen sperm, eggs and embryos, unless listed as covered above for iatrogenic infertility
• Fertility drugs

• 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

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

• 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 
• Infusion therapy in a medical office or outpatient hospital facility: Professional services of physicians and other healthcare professionals, equipment, supplies and medication.
• Ultraviolet light treatments

Notes:

• Growth hormone therapy (GHT) 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 Section 3, 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

• Infusion therapy at home: Professional services of physicians and other healthcare professionals, equipment and supplies

In-network: Nothing

Out-of-network: All Charges

• Infusion therapy at home: Medication

In-network: 20% of Plan allowance

Out-of-network: All Charges

• Enteral and parenteral supplements and formula when it is the sole source, or an essential source, of nutrition

• Amino acid modified products for the treatment of inborn errors of metabolism, such as phenylketonuria (PKU)

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

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.

In-network: 20% of Plan allowance

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

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 

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

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

• 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
  

• 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 

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)

• 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

• 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

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

• One breastfeeding pump and supplies per delivery, including equipment that is required for pump functionality

• Ultraviolet light treatment equipment

In-network: Nothing

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.

Applies to this benefit

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

• Home healthcare 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.

• 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

• 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

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 cessation.
  
  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

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.

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
• 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)
• Services for the promotion, prevention or other treatment of hair loss or hair growth
• Cosmetic surgery, any surgery procedure (or any portion of the procedure) performed primarily to improve physical appearance through change in bodily form
• Services not listed above as covered

• 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.

• Gender reassignment surgery
  • Assigned female at birth: hysterectomy, oophorectomy, metoidioplasty, phalloplasty, vaginectomy, scrotoplasty, erectile prosthesis, urethral extension, bilateral mastectomy with chest reconstruction, breast reduction
  • Assigned male at birth: penectomy, vaginoplasty, clitoroplasty, labiaplasty, orchiectomy, tracheal shave, breast augmentation, facial hair removal, facial feminization

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
• Gender reassignment surgery not listed above

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;
• Medical and surgical treatment of temporomandibular joint (TMJ) disorder (non-dental); 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)
• Correction of any malocclusion not listed above

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 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 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.
• We cover medically necessary routine dental services in preparation for chemotherapy, radiation therapy, and transplants. Covered services may include a routine oral examination, cleaning (prophylaxis), extractions, and X-rays. You pay cost-sharing listed in Section 5(a) for services performed during an office visit.

Applies to this benefit

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

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

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

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

• 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

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

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

Local licensed ambulance services when medically necessary

Note: See Section 3 You need prior Plan approval for certain services and Section 5(d), Emergency Services/Accident

Not covered:

• Transportation by car, taxi, bus, gurney van, wheelchair van, and any other type of transportation (other than a licensed ambulance), even if it is the only way to travel to a Plan provider

• 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

Not covered:

• Elective care or non-emergency care

• 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

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

Licensed ambulance service when medically necessary

Note: See Section 5(c), Services Provided by a Hospital or Other Facility and Ambulance Services for non-emergency service.

Not covered:

• Transportation by car, taxi, bus, gurney van, wheelchair van, and any other type of transportation (other than a licensed ambulance), even if it is the only way to travel to a Plan provider 
• Air and sea ambulance when not medically necessary

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.

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 substance use disorders, 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

• 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

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

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

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

• Services that, upon review, are determined to be inappropriate to treat your condition or are Plan exclusions.
• Long-term rehabilitative therapy
• Exercise programs

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
• Sexual dysfunction drugs
• Preauthorized compounded drugs
• Hormone therapy
• Drugs to treat gender dysphoria, including hormones and androgen blockers

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: You will not be subject to the deductible for insulin, lancets, test strips, and control solution. You pay no more than $100 for up to a 30-day supply of insulin and the cost-sharing you pay count toward the deductible.

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

• 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

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

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).

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 healthcare 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)

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

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 - single film (twice per calendar year)

D0270

$20.00

Bitewing X-rays - two files (twice per calendar year)

D0272

$31.00

Bitewing X-rays - four films (twice per calendar year)

D0274

$45.00

Full mouth or panorex X-rays: panoramic film (full mouth or panorex series limited to once every 3 calendar years)

D0330

$77.00

Full mouth or panorex X-rays: intraoral - complete series including bitewings (full mouth or panorex series limited to once every 3 calendar years)

D0210

$95.00

Periodic oral exam (twice per calendar year)

D0120

$41.00

Limited oral evaluation - problem focused

D0140

$58.00

Comprehensive oral evaluation

D0150

$57.00

Pulp vitality tests

D0460

$38.00

Prophylaxis (cleaning) - through age 13 (twice per calendar year)

D1120

$51.00

Prophylaxis (cleaning) - after age 13 (twice per calendar year)

D1110

$88.00

Fluoride - Topical application of fluoride (twice per calendar year through age 17; prophylaxis not included)

D1208

$32.00

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

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.

Applies to this benefit

Applies to this benefit

• 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

• 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

• 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

• 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)