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

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

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

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

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

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

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

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

Once enrolled in your FEHB Program Plan, you should contact your carrier directly for address updates and questions about your benefit coverage.

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

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

Contact your employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family.  If you have a Self and Family enrollment, you may contact us to add a family member.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26.  We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26^th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

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

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

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

Natural children, adopted children, and stepchildren

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

Foster children

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

Children Incapable of self-support

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

Married children

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

Children with or eligible for employer-provided health insurance

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

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

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

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

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

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

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

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

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or Plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2025 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2024 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

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

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

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

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

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

If you are an enrollee, and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment.

You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof. In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you.

However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get additional information about your coverage choices. You can also visit OPM's website at https://www.opm.gov/healthcare- insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

If you leave Federal service, tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered child and you turn 26.

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

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

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

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

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

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

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

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

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

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

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

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

FEHB Carriers must have clauses in their plan provider agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the plan provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If a plan provider bills you for covered services over your normal cost share (deductible, copay, co-insurance), contact your Carrier to enforce the terms of its provider contract

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

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

This plan recognizes that transgender, non-binary, and other gender diverse members require health care delivered by healthcare providers experienced in gender affirming health. Benefits described in this brochure are available to all members meeting medical necessity guidelines regardless of race, color, national origin, age, disability, religion, sex or gender.

Kaiser Permanente primary care providers provide care coordination for complex conditions, for assistance please contact your provider or Member Service at 888-901-4636 (TTY: 711).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Note: The list is not all inclusive and is subject to change upon notification to physicians. Please call Member Services at 888-901-4636 to verify if your procedure/services require preauthorization.

• Bariatric Surgery
• Certain prescription medications as indicated on our formulary
• Clinical trials
• Cochlear implants
• High end radiology services, such as CAT scan, MRI, PET and SPECT scans
• Inpatient facility services, such as hospital, rehabilitation, skilled nursing, mental health and substance use disorder treatment facilities
• Non-emergent air transportation
• Organ transplants
• Reconstructive breast surgery
• Gender Affirming services
• Surgeries for sleep disorders
• Temporomandibular joint (TMJ) surgery
• Infusion therapy

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

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

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

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

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

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

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us toll-free at 888-901-4636. You may also call OPM's FEHB 3 at (202) 606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us toll-free at 888-901-4636. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

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

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

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

Maternity care does not require preauthorization. 

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

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

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

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

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 888-901-4636.

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

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

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

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

2. Ask you or your provider for more information.

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

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

3. Write to you and maintain our denial.

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

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

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

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

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

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

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

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

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

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

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

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

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

Example:

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

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

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

• The Standard Option calendar year deductible is $350 per person.
• Under Standard Option Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses for in- and out-of-network services applied to the calendar year deductible reach $350.
• Under Standard Option Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses for in- and out-of-network services applied to the calendar year deductible for your enrollment reach $700.
• Under Standard Option Self and Family Enrollment, the deductible is considered satisfied for all family members when their combined covered expenses for in- and out-of-network services applied to the calendar year deductible for family members reach $700.
• The Standard Option deductible is waived for preventive care.
• The High Deductible Health Plan (HDHP) calendar year deductible is $1,650 for Self Only enrollment and $1,650 per person for Self Plus One or Self and Family enrollment not to exceed a total family deductible of $3,300 (each applies separately for services received from Plan providers and non-Plan providers).

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

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

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

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

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

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

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

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

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

You should also see section Important Notice About Surprise Billing – Know Your Rights below that describes your protections against surprise billing under the No Surprises Act.

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

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

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

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

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

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

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

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

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services.

A surprise bill is an unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by non-Plan providers with respect to patient visits to Plan health care facilities, or for
• air ambulance services furnished by non-Plan providers of air ambulance

Balance billing happens when you receive a bill from the non-Plan provider, facility, or air ambulance service for the difference between the non-Plan provider's charge and the amount payable by your health plan. 

Your health plan must comply with the NSA protections that hold you harmless from surprise bills.

In addition, your health plan complies with the surprise billing laws of Washington and RCW 48.49.030(2).

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.kp.org/feds or contact the health plan at 888-901-4636.

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

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
• 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

• Breast imaging

In-network: Nothing (No deductible)
Out-of-network: Nothing (No deductible)

• 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:

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as for breast cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal. For a complete list of screenings go to the website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, medically necessary postpartum visits, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. Well-women visits also include prepregnancy, prenatal, postpartum, and interpregnancy visits. For a complete list of preventive care benefits for women please visit the Health and Human Services (HHS) website at https://www.hrsa.gov/womens-guidelines
• 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

In-network: Nothing

Out-of-network: Nothing (No deductible)

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/ 

In-network: Nothing

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

(No deductible)

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy.
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.

Notes:

• See Section 5(h) for additional optional programs under Wellness and Other Special Features
• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines, see Section 5(f) for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity, see section 5(b) for surgery requirements and cost share.

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.

All Charges

• 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
• Children's immunizations endorsed by the Centers for Disease Control (CDC) including DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the website at www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• 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

Note:

• Any procedure, injection, diagnostic service, laboratory, or X-ray service done in conjunction with a routine examination and is not included in the preventive recommended listing of services will be subject to the applicable member copayments, coinsurance, and deductible.

In-network: Nothing

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

(No deductible)

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy.
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.

Notes: 

• There are no frequency/visit limitations, services are based on medical necessity
• See Section 5(h) for additional optional programs under Wellness and Other Special Features
• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines, see Section 5(f) for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity, see section 5(b) for surgery requirements and cost share.

In-network: Nothing

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

(No deductible)

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 and postpartum care
• Screening for gestational diabetes
• Delivery (including home births)
• Screening and counseling for prenatal and postpartum depression

In-network: Nothing

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

(No deductible)

• Breastfeeding and lactation 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:

• As part of your coverage, you have access to in-network certified nurse midwives and board-certified lactation specialists during the prenatal and post-partum period.
• 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. We cover routine circumcision under Preventive care, children.
• When a newborn requires definitive treatment during or after the mother’s hospital stay, 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. . In addition, circumcision is covered at the same rate as for regular medical or surgical benefits.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital costs, see Section 5(c) and Surgical benefits Section 5(b).

Applies to this benefit

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the HRSA list. This list includes::

• Voluntary sterilization
• Surgically implanted contraceptives 
• Injectable contraceptives (such as Depo Provera)  
• Intrauterine devices (IUDs)
• Contraceptive methods and counseling

Notes:

• See additional Family Planning and Prescription drug coverage Section 5(f).
• See Section 5(b), Surgical and Anesthesia Services for coverage of voluntary sterilization for males and females and section 5(f), Prescription Drug Benefits for oral contraceptives and devices such as diaphragms.
• Your plan offers some type of voluntary female sterilization surgery coverage at no cost to members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exceptions process described below.
• Kaiser Permanente physicians prescribe the appropriate level of medically necessary medications to FEHB members. To ensure physicians can make appropriate exceptions, they have the authority to prescribe brand-name or non-formulary drugs for members without administrative review if their opinion is that a particular drug is medically necessary and would be more beneficial for an individual member. Members pay their regular prescription drug copayment for medically necessary brand-name drugs.
• If you are having difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov. For more information about contraception, you can visit the OPM website at Contraception Coverage (www.opm.gov) or email contraception@opm.gov.

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)
• Semen analysis
• Hysterosalpingogram
• Hormone evaluation

Notes:

• Infertility is the inability of an individual to conceive or produce conception during a period of 1 year if the female is age 35 or younger, or during a period of 6 months if the female is over the age of 35, or having a medical or other demonstrated condition that is recognized by a Plan physician as a cause of infertility.
• For coverage of fertility drugs, see Section 5(f), Covered medications and supplies.

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: These exclusions apply to fertile as well as infertile individuals or couples:

• Services related to surrogate arrangements
• 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

• 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

Note: You must obtain infusion medications for the home setting at a preferred specialty Plan pharmacy, and a Plan provider we identify must administer the medications.

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:

• 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 

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., audiologist, or other provider in a physician's office.
• Testing and examinations for hearing aids.

Note: For coverage of hearing screenings, see Section 5(a), Preventive care, children, and for any other hearing testing, see Section 5(a), Diagnostic and treatment services.

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, including auditory osseointegrated implants/bone anchored hearing systems (BAHS).

Notes:

• For audible prescription reading and speech generating devices, see Section 5(a), Durable medical equipment.
• Covered hearing aids will include bone conduction hearing devices but will not include over-the-counter hearing aids.
• Coverage for minors under the age of 18 is available after they have received medical clearance within the last six (6) months from either an otolaryngologist for an initial evaluation of hearing loss or from a licensed physician when it is determined there has not been a significant change in clinical status after the initial evaluation by an otolaryngologist.

All charges in excess of $3,000 for one hearing aid per ear every 36 months

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
• Over-the-counter 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 orthoptic
• 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. Covered items include:

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

Note: 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.

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 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 severe obesity.

Notes:

• Visit www.kp.org/feds to get a list of criteria you must meet to qualify for bariatric surgery. 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.
• For female surgical family planning procedures see Family Planning Section 5(a)
• For male surgical family planning procedures see Family Planning Section 5(a)

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:

• 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 Affirming 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: 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

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. Refer to Section 3, How you get care, for authorization procedures. Solid organ tissue transplants are limited to:

• 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: All charges

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: All charges

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

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous [myeloid]) leukemia
  • Hodgkin’s lymphoma (relapsed)
  • Non-Hodgkin’s lymphoma (relapsed)
  • Advanced neuroblastoma
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hematopoietic stem cell transplant (HSCT)
  • Hemoglobinopathies (e.g., thalassemias, Sickle cell disease)
  • Infantile malignant osteopetrosis
  • Kostmann’s syndrome
  • Leukocyte adhesion deficiencies
  • Marrow Failure and Related Disorders (i.e., Fanconi's, Pure Red Cell Aplasia)
  • Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler's syndrome, Sanfilippo’s syndrome, Maroteaux Lamy syndrome variants)
  • Myelodysplasia/Myelodysplastic syndromes
  • Myeloproliferative disorders
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe Aplastic Anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for:
  • Hodgkin’s lymphoma (relapsed)
  • Non-Hodgkin’s lymphoma (relapsed)
  • Amyloidosis
  • Ewing sarcoma
  • Hematopoietic stem cell transplant (HSCT)
  • Immune deficiency diseases other than SCID (e.g., Wiskott-Aldrich syndrome, Kostmann’s Syndrome, Leukocyte Adhesion Deficiencies) not amenable to more conservative treatments
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Phagocytic/Hemophagocytic deficiency diseases
  • Pineoblastoma
  • Testicular, mediastinal, retroperitoneal, and ovarian germ cell tumors
  • Waldenstrom’s macroglobulin

In-network: 20% of Plan allowance

Out-of-network: All charges

Limited benefits The following autologous blood or bone marrow stem cell transplants may be provided in a National Cancer Institute (NCI) or National Institutes of Health (NIH)-approved clinical trial at a Plan-designated Center of Excellence. These limited benefits are not subject to medical necessity.

• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Beta Thalassemia Major
• Breast cancer
• Childhood rhabdomyosarcoma
• Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
• Chronic lymphocytic leukemia
• Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL) relapsed/refractory disease
• Chronic myelogenous leukemia
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Epithelial ovarian cancer
• High-grade (Aggressive) non-Hodgkin’s lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms)
• High-risk Ewing sarcoma
• High risk childhood kidney cancers
• Hodgkin’s lymphoma
• Multiple myeloma
• Multiple sclerosis
• Myeloproliferative Disorders
• Myelodysplasia/Myelodysplastic Syndromes
• Non-Hodgkin’s lymphoma
• Sarcomas
• Sickle Cell
• Systemic lupus erythematosus
• Systemic sclerosis
• Scleroderma
• Scleroderma-SSc (severe, progressive)

In-network: 20% of Plan allowance

Out-of-network: All charges

Mini-transplants performed in a Clinical Trial Setting (non-myeloblative, reduced intensity conditioning).

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • 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 nonlymphocytic (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: All charges

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
• Donor human milk provided through a milk bank

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/Accidents

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, 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, 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
$60 per 90-day supply

Tier 2 – Preferred
$40 per prescription/refill
$120 per 90-day supply

Tier 3 – Non-Preferred
$60 per prescription/refill
$180 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

(No deductible)

Notes:

• You pay no more than $35 for up to a 30-day supply of insulin.
• You pay no more than $35 for up to a 30-day supply of corticosteroid or corticosteroid combination inhalers.
• You pay no more than $35 per prescription of epinephrine autoinjector products that contain at least two autoinjectors.

• Opioid rescue agents such as naloxone when obtained from a Plan pharmacy in prescription form 

For more information consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/

Nothing

(No deductible)

• Fertility drugs, including drugs for in vitro fertilization 

Note: For in vitro fertilization only, we cover fertility drugs prescribed by non-Plan providers when obtained at a Plan pharmacy.

50% of our allowance after the deductible (If it is medically necessary to administer medication during an office visit, the medication is included in the office visit copayment.)

Post-exposure prophylaxis (PEP) drugs

• One regimen of human immunodeficiency virus post-exposure prophylaxis

Nothing

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines. Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below.  

• Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.
• We cover contraceptive drugs and devices, including implanted contraceptive devices, diaphragms, contraceptive gels, hormonal contraceptive methods, and prescribed FDA approved over-the-counter women's contraceptives and devices.
• We cover non-preferred contraceptives if they would otherwise be covered, and a Plan provider receives an approved drug formulary exception.
• Providers may prescribe non-formulary, contraceptive drugs for their patients if they determine it is medically necessary and would be clinically appropriate for an individual patient. Members pay no cost share for non-formulary contraceptive drugs when determined medically necessary. For more information on contraceptive coverage and the prescription exception process, please go to kp.org/feds under Member Resources. 
• We cover prescribed FDA approved over-the-counter women’s contraceptives and devices when prescribed by a Plan provider and obtained at a Plan pharmacy.
• If you have difficulty accessing contraceptive coverage or other reproductive healthcare you can contact contraception@opm.gov.
• Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7 by filing a claim for covered services.

Note: For additional Family Planning benefits see Section 5(a)

Nothing    

(No deductible)

Note: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation Educational Classes and Programs in Section 5(a)

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

(No deductible)

Mail order not available for specialty drugs

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
• Over-the-counter (nonprescription) medications, except certain over-the-counter substances approved by the Plan
• Medical supplies such as dressings and antiseptics
• Drugs to enhance athletic performance
• Drugs prescribed to treat any non-covered service, except as stated above
• Drugs obtained at a non-Plan pharmacy, except for emergencies
• 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

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from a Plan pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections.

For more information consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/

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 A and B recommendations. 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: when prescribed by a healthcare professional and filled by a network pharmacy.

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 
• Over-the-counter 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

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

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

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

Early intervention is a hallmark of Kaiser Permanente’s prenatal care program. Prenatal care screenings can help detect or prevent many adverse health outcomes and identify members with high-risk pregnancies. In Kaiser Permanente’s patient-centered model of care, the care plan for patients with high-risk pregnancies is determined based on the patient’s unique needs and condition.  This may include ultrasounds, fetal monitoring, and/or additional in-person prenatal visits, and supportive touchpoints with nurses or other care coordinators. 

When you visit a different Kaiser Foundation Health Plan service area, you can receive visiting member services from designated providers in that area. Visiting member services are subject to the terms, conditions, and cost-sharing described in this FEHB brochure. Certain services are not covered as a visiting member. Visiting member services are described in our visiting member brochure. For more information about receiving visiting member services, including provider and facility locations in other Kaiser Permanente services areas, please call our Washington Visiting Member Services at 800-466-4296 or visit wa.kaiserpermanente.org/html/public/services/traveling.

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

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

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

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

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

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

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

Kaiser Permanente is committed to investing in the total health of our members. Exercise, nutrition, and weight management resources such as wellness coaching and online Healthy Lifestyle Programs are all available at no cost. We offer our members the tools and resources they need to actively participate in their health at home, online, with their smartphone, and at our facilities. Our members can enroll in a variety of programs that are designed to help them take an active role in their health and make desired lifestyle changes. Unless otherwise noted, most of these programs are available at no additional costs to members because they are embedded within our integrated care delivery model as part of our core offerings. Examples of our wellness programs aimed at weight and nutrition are:

• Nutrition counseling (such as weight loss and a healthy diet)
• Stress reduction programs
• Chronic disease self-management programs
• Exercise counseling and cardiovascular fitness programs
• Smoking cessation program
• Health risk assessments

Members can access our Health and Wellness Programs at kp.org/healthyliving.

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

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

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

Covered services include:

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

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

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

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

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

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

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

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

By law, HSAs are available to members who:

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

In 2025, for each month you are eligible for an HSA premium pass through, we will contribute to your HSA $62.50 per month for a Self Only enrollment or $125 per month for a Self Plus One or Self and Family enrollment. In addition to our monthly contribution, you have the option to make additional tax-free contributions to your HSA, so long as total contributions do not exceed the limit established by law, which is $3,600 for an individual and $7,200 for a family. See maximum contribution information on page (Applies to printed brochure only).  You can use funds in your HSA to help pay your health Plan deductible. You own your HSA, so the funds can go with you if you change plans or employment.

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

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

HSA features include:

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

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

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

In 2025, we will give you an HRA credit of $750 per year for a Self Only enrollment and $1,600 per year for a Self Plus One or Self and Family enrollment (these amounts may be prorated the first year you are enrolled in this HDHP). You can use funds in your HRA to help pay your Plan deductible and/or for certain expenses that do not count toward the deductible. 

HRA features include:

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

  NOTE: If your enrollment in this HDHP becomes effective other than the first day of a month, your HRA credit will be available to you the first of the following month.

• The tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP.
• Unused credit carries over from year to year.
• The HRA credit does not earn interest.
• The HRA credit is forfeited if you leave Federal employment or switch health insurance plans.
• An HRA does not affect your ability to participate in an FSAFEDS Healthcare Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility requirements.

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

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

Health Savings Account (HSA)

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

You must:

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

You must:

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

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

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

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

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

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

For 2025, a monthly premium pass through of $62.50 will be made by the HDHP directly into your HSA each month.

For 2025, a monthly premium pass through of $62.50 will be made by the HDHP directly into your HRA each month.

For 2025, a monthly premium pass through of $125 will be made by the HDHP directly into your HSA each month.

For 2025, a monthly premium pass through of $125 will be made by the HDHP directly into your HRA each month.

For 2025, a monthly premium pass through of $125 will be made by the HDHP directly into your HSA each month.

For 2025, a monthly premium pass through of $125 will be made by the HDHP directly into your HRA each month.

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

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

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

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

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

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

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

Additional contributions are discussed on page (Applies to printed brochure only).

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

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

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

You cannot contribute to the HRA.

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

You cannot contribute to the HRA.

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

You cannot contribute to the HRA.

You can access your HSA by the following methods:

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

You can access your HRA by the following methods:

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

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

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

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

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

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

See IRS Publications 502 and 969 for information on eligible medical expenses. Over-the-counter drugs and Medicare premiums are also reimbursable. Most other types of medical insurance premiums are not reimbursable. 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

If you are age 55 or older, the IRS permits you to make additional contributions to your HSA. The allowable additional contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the U.S. Department of Treasury website at www.irs.gov or request a copy of IRS Publication 969 by calling 1-800-829-3676.

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

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

For detailed information of IRS-allowable expenses, request a copy of IRS Publications 502 and 969 by calling 800-829-3676, or visit the IRS website at www.irs.gov and click on “Forms and Publications.” Note: Although over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA. Also, insurance premiums are reimbursable under limited circumstances.

See information below

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

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

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

• 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:

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as for breast cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. For a complete list of screenings go to the website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, medically necessary postpartum visits, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. Well-women visits also include prepregnancy, prenatal, postpartum, and interpregnancy visits. For a complete list of preventive care benefits for women please visit the Health and Human Services (HHS) website at https://www.hrsa.gov/womens-guidelines
• 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

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

Nothing

• Routine mammogram

Nothing

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/

Nothing

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy.
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.

Notes:

• See Section 5(h) for additional optional programs under Wellness and Other Special Features
• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines, see Section 5(f) for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity, see section 5(b) for surgery requirements and cost share.

Nothing

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/Tdap, 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 may also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• 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

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.

Nothing

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:
• Intensive nutrition and behavioral weight-loss counseling therapy.
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.

Notes: 

• See Section 5(h) for additional optional programs under Wellness and Other Special Features
• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines, see Section 5(f) for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity, see section 5(b) for surgery requirements and cost share.

Nothing

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 $1,650 per person for Self Only enrollment or $1,650 per person for Self Plus One or Self and Family enrollment, not to exceed a total family deductible of $3,300 (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
• 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

• Breast imaging

In-network: Nothing
Out-of-network: Nothing

• 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 and postpartum care
• Screening and counseling for prenatal and postpartum depression
• Screening for gestational diabetes 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 and lactation support 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:

• As part of your coverage, you have access to in-network certified nurse midwives and board-certified lactation specialists during the prenatal and post-partum period.
• 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. 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 hospital stay, 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. In addition, circumcision is covered at the same rate as for regular medical or surgical benefits.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefit under Section 5(b).

Applies to this benefit

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the HRSA list. This list includes:

• Contraceptive methods and counseling
  • Surgically implanted contraceptives 
  • Injectable contraceptives (such as Depo Provera)  
  • Intrauterine devices (IUDs)

Notes:

• See additional Family Planning and Prescription drug coverage Section 5(f)
• See Section 5(b), Surgical and Anesthesia Services for coverage of voluntary sterilization for males and females and section 5(f), Prescription Drug Benefits for oral contraceptives and devices such as diaphragms.

• Your plan offers some type of voluntary female sterilization surgery coverage at no cost to members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exceptions process described below.

• Kaiser Permanente physicians prescribe the appropriate level of medically necessary medications to FEHB members. To ensure physicians can make appropriate exceptions, they have the authority to prescribe brand-name or non-formulary drugs for members without administrative review if their opinion is that a particular drug is medically necessary and would be more beneficial for an individual member. Members pay their regular prescription drug copayment for medically necessary brand-name drugs.
• If you are having problems accessing contraceptive coverage or reproductive healthcare, you can contact contraception@opm.gov. For more information about contraception, you can visit the OPM website at Contraception Coverage (opm.gov) or email contact contraception@opm.gov

In-network: Nothing          

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

Voluntary male sterilization

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) 
• Semen analysis
• Hysterosalpingogram
• Hormone evaluation

Notes:

• Infertility is the inability of an individual to conceive or produce conception during a period of 1 year if the female is age 35 or younger, or during a period of 6 months if the female is over the age of 35, or having a medical or other demonstrated condition that is recognized by a Plan physician as a cause of infertility.
• For coverage of fertility drugs, see Section 5(f), Covered medications and supplies.

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:  These exclusions apply to fertile as well as infertile individuals or couples:

• Services related to surrogate arrangements
• 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

• 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

Note: You must obtain infusion medications for the home setting at a preferred specialty Plan pharmacy, and a Plan provider we identify must administer the medications.

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., audiologist, or other provider in a physician's office. 
• Testing and examinations for hearing aids.

Note: For coverage of hearing screenings, see Section 5(a), Preventive care, children, and for any other hearing testing, see Section 5(a), Diagnostic and treatment services.

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, including auditory osseointegrated implants/bone anchored hearing systems (BAHS).

Note:

• For audible prescription reading and speech generating devices, see Section 5(a), Durable medical equipment.

All charges in excess of $3,000 for one hearing aid per ear every 36 months

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
• Over-the-counter hearing aids

• 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
• 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

• 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. Covered items include:

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

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.

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 or certified acupuncture practitioner for:
  • anesthesia
  • pain relief 
  • substance use disorder - unlimited
  • dry needling
• 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 severe obesity.

Notes: Visit kp.org/feds to get a list of criteria you must meet to qualify for bariatric surgery.  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.

For female surgical family planning procedures see Family Planning Section 5(a)

For male surgical family planning procedures see Family Planning Section 5(a)

In-network: 20% of Plan allowance

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

Voluntary sterilization (tubal ligation and vasectomy)

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 Affirming 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: 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

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: All charges

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: All charges

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)
  • Hematopoietic stem cell transplant (HSCT)
  • 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
  • Hematopoietic stem cell transplant (HSCT)
  • Medulloblastoma
  • Multiple myeloma
  • Pineoblastoma 
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

In-network: 20% of Plan allowance

Out-of-network: All charges

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: All charges

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: All charges

National Transplant Program (NTP)

In-network: 20% of Plan allowance

Out-of-network: All charges

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 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
• Donor human milk provided through a milk bank
• 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, 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, 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
• Medications prescribed to treat obesity

Tier 1
$20 per prescription/refill
$60 per 90-day supply

Tier 2 – Preferred
$40 per prescription/refill
$120 per 90-day supply

Tier 3 – Non-Preferred
$60 per prescription/refill
$180 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

Notes:

• You will not be subject to the deductible for insulin, lancets, test strips, and control solution.
• You pay no more than $35 for up to a 30-day supply of insulin and the cost-sharing you pay counts toward the deductible.
• You will not be subject to the deductible for corticosteroid or corticosteroid combination inhalers.
• You pay no more than $35 for up to a 30-day supply of corticosteroid or corticosteroid combination inhalers and the cost-sharing you pay counts toward the deductible.
• You pay no more than $35 per prescription for epinephrine autoinjector products that contain at least two autoinjectors and the cost-sharing you pay counts toward the deductible.

• Opioid rescue agents such as naloxone when obtained from a Plan pharmacy in prescription form

For more information consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/.

Nothing

(No deductible)

• Fertility drugs, including drugs for in vitro fertilization

Note: For in vitro fertilization only, we cover fertility drugs prescribed by non-Plan providers when obtained at a Plan pharmacy.

50% of our allowance after the deductible (If it is medically necessary to administer medication during an office visit, the medication is included in the office visit copayment.)

Post-exposure prophylaxis (PEP) drugs

• One regimen of human immunodeficiency virus post-exposure prophylaxis

Nothing after the deductible

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines. Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below.

• Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.
• If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.
• Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7 by filing a claim for covered services.
• We cover contraceptive drugs and devices, including implanted contraceptive devices, diaphragms, contraceptive gels, hormonal contraceptive methods, and prescribed FDA approved over-the-counter women's contraceptives and devices.
• We cover non-preferred contraceptives if they would otherwise be covered, and a Plan provider receives an approved drug formulary exception.
• Providers may prescribe non-formulary, contraceptive drugs for their patients if they determine it is medically necessary and would be clinically appropriate for an individual patient. Members pay no cost share for non-formulary contraceptive drugs when determined medically necessary. For more information on contraceptive coverage and the prescription exception process, please go to kp.org/feds under Member Resources. 
• We cover prescribed FDA approved over-the-counter women’s contraceptives and devices when prescribed by a Plan provider and obtained at a Plan pharmacy.

Notes: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation Educational Classes and Programs in Section 5(a). For additional Family Planning benefits see Section 5(a) 

Nothing

(No deductible)

Mail Order Drug Program

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

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

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

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

Mail order not available for specialty drugs

• 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
• Over-the-counter (nonprescription) medications, except certain over-the-counter substances approved by the Plan
• Medical supplies such as dressings and antiseptics
• Drugs to enhance athletic performance
• Drugs prescribed to treat any non-covered service, except as stated above
• Drugs obtained at a non-Plan pharmacy, except for out-of-area emergencies
• Drugs that are not medically necessary according to accepted medical, dental or psychiatric practice as determined by the Plan
• Lost or stolen medications

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

Preventive Medications with USPSTF A or B recommendations. 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: when prescribed by a healthcare professional and filled by a network pharmacy.

(No deductible)

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from a Plan pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections..

For more information consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/

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
• Over-the-counter (nonprescription) 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)

All Charges

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 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

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

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

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

For urgent care information and after hours care 24 hours a day, 7 days a week, call toll-free 800-297-6877.

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

If you are on Temporary Duty Assignment or reside temporarily outside of Washington state you are covered for all of the benefits described in this brochure.  You pay the applicable cost-share per visit for services.  For non-urgent and non-emergent services you should receive care from a Plan provider; in Idaho, Oregon, Montana and Alaska, a Plan provider is a First Choice Health Network provider and in all other states a Plan provider is a First Health Network provider.  Medications obtained at a participating pharmacy in connection with non-urgent, non-emergent services will also be covered. See also Section 1. "How we pay providers".

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

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

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

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

Early intervention is a hallmark of Kaiser Permanente’s prenatal care program. Prenatal care screenings can help detect or prevent many adverse health outcomes and identify members with high-risk pregnancies. In Kaiser Permanente’s patient-centered model of care, the care plan for patients with high-risk pregnancies is determined based on the patient’s unique needs and condition.  This may include ultrasounds, fetal monitoring, and/or additional in-person prenatal visits, and supportive touchpoints with nurses or other care coordinators. 

When you visit a different Kaiser Foundation Health Plan service area, you can receive visiting member services from designated providers in that area. Visiting member services are subject to the terms, conditions, and cost-sharing described in this FEHB brochure. Certain services are not covered as a visiting member. Visiting member services are described in our visiting member brochure. For more information about receiving visiting member services, including provider and facility locations in other Kaiser Permanente services areas, please call our Washington Visiting Member Services at 800-466-4296 or visit wa.kaiserpermanente.org/html/public/services/traveling.

Kaiser Permanente is committed to investing in the total health of our members. Exercise, nutrition, and weight management resources such as wellness coaching and online Healthy Lifestyle Programs are all available at no cost. We offer our members the tools and resources they need to actively participate in their health at home, online, with their smartphone, and at our facilities. Our members can enroll in a variety of programs that are designed to help them take an active role in their health and make desired lifestyle changes. Unless otherwise noted, most of these programs are available at no additional costs to members because they are embedded within our integrated care delivery model as part of our core offerings. Examples of our wellness programs aimed at weight and nutrition are:

• Nutrition counseling (such as weight loss and a healthy diet)
• Stress reduction programs
• Chronic disease self-management programs
• Exercise counseling and cardiovascular fitness programs
• Smoking cessation program
• Health risk assessments

Members can access our Health and Wellness Programs at kp.org/healthyliving.

Through our website at www.kp.org/feds/wa-options you will find information on:

• General health topics
• Links to healthcare news
• Cancer and other specific diseases
• Drugs/medication interactions
• Kids’ health
• Patient safety information
• Helpful website links

For each HSA and HRA account holder, complete payment history and balance information can be found online at www.MyHealthEquity.com.

This information is also available by calling the HealthEquity^® customer service line toll-free at 866-346-5800.

You may view monthly statements, year-end statements and tax statements online at healthequity.com.

If you have an HSA, you may also change your investment options online at www.MyHealthEquity.com.

As a member of this HDHP, you may choose any provider. However, you will pay less out-of-pocket when using a network provider. Directories are available online at www.kp.org/feds/wa-options by clicking on Members/Find a Provider. See page (Applies to printed brochure only) for further information.

Pricing information for prescription drugs and a link to our online pharmacy are available at www.kp.org/feds/wa-options by clicking on Pharmacy.

Educational materials regarding HSAs and HRAs are available at www.myhealthequity.com.

Patient safety information is available online at

www.kp.org/feds/wa-options.

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing 800-833-6388 or 711, or at our website at www.kp.org/feds/wa-options.

When you must file a claim such as for services you receive outside the Plan's service area - submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

• Covered member's name, date of birth, address, phone number and ID number
• Name and address of the provider or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payor such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services.

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:

Kaiser Permanente Washington Options Federal
Member Claims
PO Box 30766
Salt Lake City, UT 84130-0766

When you must file a claim – such as for prescriptions you receive from an out-of-state non-Plan pharmacy due to an emergency – submit it on a claim form that includes the information shown below. Bills and receipts should be itemized and show:

• Member’s name and ID number
• Drug name, quantity, prescription number
• Cost of drug and amount you paid
• NDC number
• Drug strength
• Pharmacy name
• Pharmacy address
• Pharmacy NABP number 

Submit your claims to: 

Claim Reimbursement
P.O. Box 30766
Salt Lake City,  UT 84130-0766 

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

We will notify you of our decision within 30 days after we receive your post-service claim.  If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you before the expiration of the original 30-day period.  Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

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

If you do not agree with our initial decision, you may ask us to review it by following the disputed claims process detailed in Section 8 of this brochure.

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, we will permit a healthcare professional with knowledge of your medical condition to act as your authorized representative without your express consent. For the purposes of this section, we are also referring to your authorized representative when we refer to you.

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at:

Kaiser Permanente Washington Options Federal
Appeals Department
PO Box 34593
Seattle, WA 98124-1593

or fax your request to: 206-901-7340; and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB)

e) Include your email address (optional), if you would like to receive our decision via email. Please note that by giving us your email, we may be able to provide our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4.

In the case of a post-service claim, we have 30 days from the date we receive your request to:

a)     Pay the claim; or

b)     Write to you and maintain our denial; or

c)     Ask you or your provider for more information. 

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

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

If you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us - if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employees Insurance Operations, FEHB 2, 1900 E Street NW, Washington, DC 20415-3620.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM's decision via email. Please note that by providing your email address, you may receive OPM's decision more quickly.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision or notify you of the status of OPM’s review within 60 days. There are no other administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied preauthorization or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault. This is called "double coverage."

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners' (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.kp.org/feds/wa-options.

When we are the primary payor, we will pay the benefits described in this brochure.

When we are the secondary payor, we will determine our allowance. After the primary plan processes the benefit, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance. When we are the secondary payor, we will coordinate benefits with the primary payor allowing up to our Plan's benefit visit maximum.

TRICARE is the healthcare program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium. (OPM does not contribute to any applicable plan premiums.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

Every job-related injury or illness should be reported as soon as possible to your supervisor. Injury also means any illness or disease that is caused or aggravated by the employment as well as damage to medical braces, artificial limbs and other prosthetic devices. If you are a federal or postal employee, ask your supervisor to authorize medical treatment by use of form CA-16 before you obtain treatment. If your medical treatment is accepted by the Dept. of Labor Office of Workers’ Compensation (OWCP), the provider will be compensated by OWCP. If your treatment is determined not job-related, we will process your benefit according to the terms of this plan, including use of in-network providers. Take form CA-16 and form OWCP-1500/HCFA-1500 to your provider, or send it to your provider as soon as possible after treatment, to avoid complications about whether your treatment is covered by this plan or by OWCP.

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• OWCP or a similar agency pays for through a third-party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws.

When you have this Plan and Medicaid, we pay first.

Suspended FEHB coverage to enroll in Medicaid or a similar state-sponsored program of medical assistance: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these state programs, eliminating your FEHB premium. For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under the state program.

We do not cover services and supplies when a local, state, or federal government agency directly or indirectly pays for them.

Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of benefits or benefit payments and on the provision of benefits under our coverage.

If you have received benefits or benefit payments as a result of an injury or illness and you or your representatives, heirs, administrators, successors, or assignees receive payment from any party that may be liable, a third party’s insurance policies, your own insurance policies, or a workers’ compensation program or policy, you must reimburse us out of that payment. Our right of reimbursement extends to any payment received by settlement, judgment, or otherwise.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connection with your injury or illness. However, we will cover the cost of treatment that exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights of any other parties are honored) and is not impacted by how the judgment, settlement, or other recovery is characterized, designated, or apportioned. Our right of reimbursement is not subject to reduction based on attorney fees or costs under the “common fund” doctrine and is fully enforceable regardless of whether you are “made whole” or fully compensated for the full amount of damages claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a recovery from any liable party as successor to your rights.

If you do pursue a claim or case related to your injury or illness, you must promptly notify us and cooperate with our reimbursement or subrogation efforts.

Some FEHB plans already cover some dental and vision services. When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on www.BENEFEDS.com or by phone at 877-888-3337, (TTY 877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

If you are a participant in a clinical trial, this health Plan will provide related care as follows, if it is not provided by the clinical trial:

• Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy. These costs are covered by this Plan.
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial but not as part of the patient’s routine care. This Plan covers some of these costs, providing the Plan determines the services are medically necessary. For more specific information, we encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials, this Plan does not cover these costs.

For more detailed information on "What is Medicare?" and "Should I Enroll in Medicare?" please contact Medicare at 800-MEDICARE (800-633-4227), (TTY 877-486-2048) or at www.medicare.gov.

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share.

All physicians and other providers are required by law to file claims directly to Medicare for members with Medicare Part B, when Medicare is primary. This is true whether or not they accept Medicare.

When you are enrolled in Original Medicare along with this Plan, you still need to follow the rules in this brochure for us to cover your care.

Claims process when you have the Original Medicare Plan- You will probably not need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we process the claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711, or see our website at www.kp.org/feds/wa-options.

We waive some cost-sharing if Original Medicare Plan is your primary payor and you use a provider who accepts Medicare assignment.

When you have Medicare Parts A and B, Medicare is primary payor and you receive care from a provider that accepts Medicare, we waive some out-of-pocket costs as follows:

Benefit Description: Deductible
Standard Option without Medicare You pay: $350
Standard Option with Medicare You pay: $0

Benefit Description: Out-of-Pocket Maximum
Standard Option without Medicare You pay: $5,000 per person up to $10,000 per family
Standard Option with Medicare You pay: $5,000 per person up to $10,000 per family

Benefit Description: Primary Care Provider
Standard Option without Medicare You pay: $25
Standard Option with Medicare You pay: $0

Benefit Description: Specialist
Standard Option without Medicare You pay: $35
Standard Option with Medicare You pay: $0

Benefit Description: Inpatient Hospital
Standard Option without Medicare You pay: 20% 
Standard Option with Medicare You pay: $0

Benefit Description: Outpatient Hospital
Standard Option without Medicare You pay: 20% 
Standard Option with Medicare You pay: $0

If you have Medicare Part A only, and Original Medicare is your primary payor, we will waive deductible, coinsurance, and copayments for Part A services only (such as inpatient hospital care, home health, hospice, or skilled nursing care).

If you have Medicare Part B only, and Original Medicare is your primary payor, we will waive deductible, coinsurance, and copayments for Part B services only (such as outpatient medical or surgical care).

We will not waive the following:

• Cost-sharing for members who do not have Medicare Parts A or B, or, for whom Medicare is secondary payor
• Prescription drug cost-sharing
• Cost-sharing for HDHP members
  
  

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country.

To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227), (TTY 800-486-2048) or at www.medicare.gov.

If you enroll in a Medicare Advantage plan, the following options are available to you:

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB Plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers). However, we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

• 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)

An authorization by you (the enrollee or covered family member) that is approved by us (the Carrier), for us to issue payment of benefits directly to the provider.

• We reserve the right to pay you directly for all covered services. Benefits payable under the contract are not assignable by you to any person without express written approval from us, and in the absence of such approval, any assignment shall be void.
• Your specific written consent for a designated authorized representative to act on your behalf to request reconsideration of a claim decision (or, for an urgent care claim, for a representative to act on your behalf without designation) does not constitute an Assignment.
• OPM’s contract with us, based on federal statute and regulation, gives you a right to seek judicial review of OPM's final action on the denial of a health benefits claim but it does not provide you with authority to assign your right to file such a lawsuit to any other person or entity. Any agreement you enter into with another person or entity (such as a provider, or other individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf, does not constitute an Assignment, is not a valid authorization under this contract, and is void.

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is either Federally funded, conducted under an investigational new drug application reviewed by the Food and Drug Administration, or is a drug trial that is exempt from the requirement of an investigational new drug application.

• Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy.
• Extra care costs – costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care.
• Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This plan does not cover these costs.

See Section 4, page (Applies to printed brochure only).

See Section 4, page (Applies to printed brochure only).

See Section 4, page (Applies to printed brochure only).

(1) Assistance with activities of daily living, for example, walking, getting in and out of bed, dressing, feeding, toileting, and taking medication. (2) Care that can be performed safely and effectively by people who, in order to provide the care, do not require medical licenses or certificates or the presence of a supervising licensed nurse. Custodial care that lasts 90 days or more is sometimes known as long-term care.

See section 4, page (Applies to printed brochure only).

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

Hospice is a program for caring for the terminally ill patient that emphasizes supportive services, such as home care and pain and symptom control, rather than curative care. If you make a hospice election, you are not entitled to receive other healthcare services that are related to the terminal illness. If you have made a hospice election, you may revoke that election at any time, and your standard health benefits will be covered.

Medical services or hospital services which are determined by the Plan Medical Director or designee to be:

• Rendered for the treatment or diagnosis of an injury or illness; and
• Appropriate for the symptoms, consistent with diagnosis, and otherwise in accordance with sufficient scientific evidence and professionally recognized standards; and
• Not furnished primarily for the convenience of the Member, the attending physician, or other provider of service.

Whether there is “sufficient scientific evidence” shall be determined by the Plan based on the following: peer-reviewed medical literature; publications, reports, evaluations, and regulations issued by state and federal government agencies; Medicare local carriers, and intermediaries; and such other authoritative medical sources as deemed necessary by the Plan.

Certain Hospital Acquired Conditions, as defined by Medicare, including things like wrong-site surgeries, transfusion with the wrong blood type, pressure ulcers (bedsores), falls or trauma, and nosocomial infections (hospital-acquired infections) associated with surgeries or catheters, that are directly related to the provision of an inpatient covered service at a Plan provider.

Hospital outpatient services you get while your physician decides whether to admit you as an inpatient or discharge you. You can get observation services in the emergency department or another area of the hospital.

Our allowance is the amount we use to determine our payment and your coinsurance for covered services. We determine our allowance as follows:

• For services and items provided by Kaiser Permanente, the applicable charges in the Plan’s schedule of Kaiser Permanente charges for services and items provided to Plan
  members.
• For services and items for which a provider (other than Kaiser Permanente) is compensated on a capitation basis, the charges in the schedule of charges that Kaiser Permanente negotiates with the capitated provider.
• For items obtained at a pharmacy owned and operated by Kaiser Permanente, the amount the pharmacy would charge a Plan member for the item if a Plan member’s benefit plan did not cover the item. This amount is an estimate of: the cost of acquiring, storing, and dispensing drugs, the direct and indirect costs of providing Kaiser Permanente pharmacy services and items to Plan members, and the pharmacy program’s contribution to the net revenue requirements of the Plan.
• For services subject to federal or state surprise billing laws, the amount that we are required to pay (see Section 4 for more information about surprise billing).
• For all other services and items, the payments that Kaiser Permanente makes for the services and items, or if Kaiser Permanente subtracts cost-sharing from its payment, the amount the Kaiser Permanente would have paid if it did not subtract cost-sharing.

You should also see Important notice about surprise billing – know your rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

An unexpected bill you receive for:

• emergency care – when you have little or no say in the facility or provider from whom you receive care, or for
• non-emergency services furnished by non-Plan providers with respect to patient visits to Plan health care facilities, or for
• air ambulance services furnished by non-Plan providers of air ambulance services.

A claim for medical care or treatment is an urgent care claim if waiting for the regular time limit for non-urgent care claims could have one of the following impacts:

• Waiting could seriously jeopardize your life or health;
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim.

Urgent care claims usually involve Pre-service claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Member Services Department toll-free at 888-901-4636; for the deaf and hearing-impaired use Washington state's relay line by dialing either 800-833-6388 or 711. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.