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.

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 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 valid common-law marriage if you reside in a state that recognizes common-law marriages) and children as described 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 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31-day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy).

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 information about your coverage choices, https://www.opm.gov/healthcare- insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request 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 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 FEHB Program 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 at (888) 865-5813 or visit our website at www.kp.org/feds.

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. Providers may request photo identification together with your ID card to verify identity. 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 Member Services at 404-261-2590 (locally in the metropolitan Atlanta area) or 888-865-5813 (long distance), (TTY: 711), or write to us at: Member Services Department, Nine Piedmont Center, 3495 Piedmont Road, NE, Atlanta, GA 30305-1736. After registering on our website at www.kp.org/feds, you may also request replacement cards electronically.

You get care from “Plan providers” and “Plan facilities”. You will only pay cost-sharing as described in Section 4. Your Cost for Covered Services.

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. Services by Plan Providers are covered when acting within the scope of their license or certification under applicable state law. We contract with The Southeast Permanente Medical Group, Inc. (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.

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area.

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 Services Department at (404) 261-2590 (locally) or 888-865-5813 (long distance) (TTY: 711). The list is also on our website at www.kp.org/feds.

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 services (404) 261-2590 (locally) or 888-865-5813 (long distance) (TTY: 711).

Plan facilities are hospitals, medical offices, and other facilities in our service area that we own or 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 provider 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 Services Department at (404) 261-2590 (locally) or 888-865-5813 (long distance) (TTY: 711). The list is also on our website at
www.kp.org/feds.

You must receive your health services at Plan facilities, except if you have an emergency, authorized referral, or out-of-area urgent care. If you are visiting another Kaiser Permanente or allied plan service area, you may receive healthcare services at those Kaiser Permanente facilities. See Section 5(h), Special features, for more details. Under the circumstances specified in this brochure, you may receive follow-up or continuing care while you travel anywhere. 

It depends on the type of care you need. First, you and each covered family member should choose a primary care provider. This decision is important since your primary care provider delivers or arranges for most of your healthcare.

To choose or change your primary care provider, you can either select one from our Provider Directory, from our website, www.kp.org/feds, or you can call our Member Services Department at 404-261-2590 (locally in the metropolitan Atlanta area) or 888-865-5813 (long distance) (TTY: 711).

We encourage you to choose a Medical Group physician as your primary care provider when you enroll. You may select a primary care provider from any of our available Plan providers who practice in these specialties: internal medicine, pediatrics or family practice. If you do not select a primary care provider, one will be selected for you. You may choose any primary care Plan physician who is available to accept you. Parents may choose a pediatrician as the Plan physician for their child. Your primary care provider will provide most of your healthcare, or give you a referral to see a specialist.

Please notify us of the primary care provider you choose. If you need help choosing a primary care provider, call us or visit our website at www.kp.org/feds. You may change your primary care provider at any time. You are free to see other Plan physicians if your primary care provider is not available, and to receive care at other Kaiser Permanente facilities.

Specialty care is care you receive from providers other than a primary care provider.  When your primary care provider believes you may need specialty care, they will request authorization from the Plan to refer you to a specialist for an initial consultation and/or for a certain number of visits. If the Plan approves the referral, you may seek the initial consultation from the specialist to whom you were referred. You must then return to your primary care provider after the consultation, unless your referral authorizes a certain number of additional visits without the need to obtain another referral. The primary care provider must provide or obtain authorization for a specialist to provide all follow-up care. Do not go to the specialist for return visits unless your primary care provider gives you a referral that has been approved by us. However, you may see Plan gynecologists, obstetricians, dermatologists, optometrists, ophthalmologists, mental health, and substance use providers without a referral. You may make appointments directly with these providers.

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

• Keep in mind that your primary care provider choice determines which specialists are available to you. Your primary care provider has an established relationship with a specific group of specialty care doctors. By referring only to a certain group of specialists, your primary care provider is better able to ensure that you receive quality care.
• If you change primary care provider, you must check with your new primary care provider to determine if you can continue seeing your current specialist or if you need a new referral.
• If you receive specialty care services outside the Medical Group for which a referral was not obtained, is no longer valid or is beyond the level of care authorized by us, you will be responsible for all charges associated with those services.
• If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care provider in consultation with you and your attending specialist may develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care provider will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand). 
• If you are seeing a specialist when you enroll in our Plan, talk to your primary care provider. Your primary care provider will decide what treatment you need. If they decide to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care provider, who will arrange for you to see another specialist. You may receive approved services from your current specialist until we can make arrangements for you to see a Plan specialist. 
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for a reason 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.

Your Plan primary care provider 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 at 404-261-2590 (TTY: 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 92^nd day after you become a member of this Plan, whichever happens first.

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

Copayments, deductibles and coinsurance for services are due at the time of your visit. We reserve the right to reschedule non-urgent care if you do not pay at the time of your visit.

Your primary care provider arranges most referrals to specialists. For certain services your Plan provider must obtain approval from us. Before we approve a referral, we may consider if the service or item is medically necessary and meets other coverage requirements. We call this review and approval process “prior authorization".  Once the referral is approved, we will notify you that we have authorized your referral.

When you receive medical services for which you do not have prior authorization from us, we will not pay for them except in an emergency. Charges for these medical services will be your financial responsibility.

Your Plan provider must obtain prior authorization from us for:

• Inpatient hospital care services, surgery and procedures
• Outpatient surgery, related services and procedures
• Ambulance transport (non-emergency)
• Bariatric surgery and related services
• Gender reassignment surgery
• Clinical trials
• Dental services covered under the medical plan and temporomandibular joint treatment
• Certain prescription medications as identified on our formulary
• The following diagnostic services:
  • Sleep studies
  • Neuropsychological testing
  • Video capsule endoscopy
• Applied Behavior Analysis (ABA)
• Durable medical equipment (DME) and orthopedic and prosthetic devices
• Feeding disorder treatment 
• Growth hormone therapy (GHT)
• Home health services and hospice care
• Infertility diagnosis and treatment
• Injections/infusions 
• Organ/tissue transplants and related services
• Outpatient multidisciplinary rehabilitation
• Post-stabilization care
• Speech therapy
• The following radiology services:
  • CT scans
  • CT angiography 
  • MRI
  • MRA
  • PET
  • SPECT
  • Specialty imaging
• Skilled nursing care
• The following treatment therapies:
  • Biofeedback
  • Hyperbaric oxygen (HBO) treatment
  • Pain management services
  • Sclerotherapy or other varicose vein treatment
  • Uterine artery embolization
• Wound care services
• Services or items from a non-Plan provider or at non-Plan facilities

To confirm if your referral has been approved for a service or item that requires prior authorization, please call our Member Services Department at 404-261-2590 (TTY: 711).

Your Plan provider submits the request for the services above with supporting documentation. You should call your Plan provider’s office if you have not been notified of the outcome of the review within 5 working days. If your request is not approved, you have the right to ask us in writing to reconsider our initial decision (see Section 8, The disputed claims process).

Prior authorization determinations are made based on the information available at the time the service or item is requested. We will not cover the service or item unless you are a Plan member on the date you receive the service or item.

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 at 404-261-2590 (locally) or 888-865-5813 (long distance) (TTY: 711). You may also call OPM’s FEHB 3 at (202) 606-0755 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 at 404-261-2590 (locally) or 888-865-5813 (long distance) (TTY: 711). 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.

Emergency services do not require preauthorization. However, if you are admitted to a facility, you or your family member must notify the Plan within 48 hours, or as soon as reasonably possible, or your claims may be denied.

You must obtain preauthorization from us for post-stabilization care you receive from non-Plan providers.

See Section 5(d), Emergency services/accidents for more information.

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.

You must receive your health services at Plan facilities, except if you have an emergency, authorized referral, or out-of-area urgent care.  Your primary care provider will provide most of your healthcare or give you a referral to see a specialist.  If you do not obtain a referral from us for services or items that require a referral, we will not pay any amount for those services or items, and you may be liable for the full price of those services or items.  This also includes any residual amounts, such as deductibles, copayments or coinsurance that are not covered or not paid by any other insurance plan you use to pay for those services or items. 

Under 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 prior approval decision, you may request a review in accord with the procedures detailed below.  If your claim is in reference to a contraceptive, call 404-261-2590 (locally in the metropolitan Atlanta area) or 888-865-5813 (long distance) (TTY: 711).

If you have already received the service, 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 do one of the following:

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, or supply.

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 was 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 request for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services. The amount of copayment will depend upon whether you are enrolled in the High Option, Standard Option or Prosper, the type of provider, and the service or supply that you receive.

You pay a primary care provider copayment when you visit any primary care provider as described in Section 3, How you get care. You pay a specialist copayment when you receive care from a specialist as described in Section 3.

For example, for diagnostic and treatment services as described in Section 5(a): 

• Under the High Option, you pay a $15 copayment when you receive diagnostic and treatment services from a primary care provider and a $30 copayment when you receive these services from a specialty care provider.
• Under the Standard Option, you pay a $20 copayment when you receive diagnostic and treatment services from a primary care provider and a $40 copayment when you receive these services from a specialty care provider.
• Under Prosper, you pay a $20 copayment when you receive diagnostic and treatment services from a primary care provider and a $40 copayment when you receive these services from a specialty care provider.

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them. Cost-sharing does not accrue toward the deductible. Certain other benefits, such as infertility, also do not accrue to the deductible.

• The High and Standard Option do not have a deductible.
• The calendar year deductible for Prosper is $300 per person. Under a Self Plus One or Self and family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $600 under Prosper.

Any payment you make toward the deductible for services you receive during the last three months of a calendar year will apply toward the deductible for the next calendar year.

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 old option to the deductible of your new option.

Coinsurance is the percentage of our allowance that you must pay for your care.

Example: In our High Option, Standard Option and Prosper, you pay 50% of our allowance for infertility services and 20% of our allowance for durable medical equipment.

After your cost-sharing total is $4,000 per person up to $8,000 per family enrollment (High Option), $5,000 per person up to $10,000 per family enrollment (Standard Option) or $6,500 per person up to $13,000 per family enrollment (Prosper) 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 $4,000 per person up to $8,000 per family maximum out-of-pocket limit. If you or one of your covered family members has out-of-pocket qualified medical expenses of $4,000 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 $8,000 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.

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:

• Chiropractic services
• Dental services 
• Health education services
• Hearing aids
• Infertility services
• Travel benefit
• Payments for services under the Student Out-of-Area Coverage

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 Georgia and OCGA 33-20E-8.

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 888-865-5813.

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 member FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse you eligible out-of-pocket expense based on the claim information it receives from your plan.

Professional services of physicians and other healthcare professionals

• In physician’s office
• Office medical consultations
• Second surgical opinion

$15 per primary care office visit (nothing for children through age 17)

$30 per specialty care office visit

$20 per primary care office visit (nothing for children through age 17)

$40 per specialty care office visit

$20 per primary care office visit

$40 per specialty care office visit

Professional services of physicians and other healthcare professionals

• To receive injections
• Advanced care planning

$15 per primary care office visit

$30 per specialty care office visit 

$20 per primary care office visit

$40 per specialty care office visit

$20 per primary care office visit

$40 per specialty care office visit

• During a hospital stay
• In a skilled nursing facility
• At home

Nothing

Nothing

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

•  Interactive video visit
•  Phone visits
•  Email

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

Nothing

Nothing

Nothing

Tests, such as:

• Blood test
• Urinalysis
• Non-routine Pap test
• Pathology
• X-rays
• Non-routine mammograms
• Ultrasound
• Electrocardiogram and EEG

Nothing

Nothing

• CT/CAT scan
• MRI
• Nuclear medicine
• PET scan

$100 per office visit

10% of our allowance after the deductible

One routine physical exam per calendar year.

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 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, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at
  https://www.hrsa.gov/womens-guidelines
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Nothing

Nothing

Nothing

• Routine mammogram

Nothing

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

Nothing

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:

• 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.

Nothing

Nothing

Nothing

Notes:

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

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Immunizations, boosters, and medications for travel or work-related exposure.

All charges

All charges

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 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 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 https://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.
• Hearing screenings are provided by a primary care provider as part of a well-child care visit. For other hearing exams or tests, see Section 5(a), Diagnostic and treatment services or Section 5(a), Hearing services.

Nothing

Nothing

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: 

• 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.

Nothing

Nothing

Nothing

Not covered:

• Physical exams and immunizations required for:
  • Obtaining or continuing employment
  • Insurance or licensing
  • Attending schools, sports or camp
  • Athletic exams 
  • Participating in employee programs
  • Court ordered parole or probation
  • Travel
  • Work related exposure 
• All other hearing testing, except as may be covered in Section 5(a), Diagnostic and treatment services and Section 5(a), Hearing services

All charges

All charges

All charges

Complete maternity (obstetrical) care, such as:

• Prenatal and postpartum care
• Screening for gestational diabetes 
• Screening and counseling for prenatal and postpartum depression

Nothing

Nothing

• Breastfeeding and lactation support, supplies, and counseling for each birth

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

Nothing

Nothing

Nothing

• All other visits during pregnancy (such as visits to genetics counselors and perinatologists)

$40 per office visit

$40 per office visit

• Delivery

Nothing for inpatient professional delivery services

Nothing for inpatient professional delivery services

• 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.

Nothing

Nothing

Nothing

Notes:

• Routine maternity care is covered after confirmation of pregnancy.
• 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 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 benefits Section 5(b).
• 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.
• You pay cost-sharing for other services, including:
  
  • Diagnostic and treatment services for illness or injury received during a non-routine maternity care as described in this section
  • Lab, X-ray and other diagnostic tests (including ultrasounds), Durable medical equipment as described in this section
  • Surgical services (including circumcision of an infant if performed at the mother’s discharge from the hospital) as described in Section 5(b):Outpatient hospital or ambulatory surgical center
  • Hospitalization (including room and board and delivery) as described in Section 5(c). Inpatient hospital

Applies to this benefit

Applies to this benefit

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 female sterilization 
• Surgically implanted contraceptive drugs
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Family planning counseling
• Contraceptives counseling
• Male family planning services are covered in Primary and Specialty office visits. See Section 5(a), Diagnostic and treatment services.

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 other 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.

Nothing

Nothing

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

All charges

$40 per office visit

$40 per office visit

Treatment of infertility, such as:

• Artificial insemination:
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• Semen analysis
• Hysterosalpingogram
• Hormone evaluation

50% of our allowance

50% of our allowance

Standard fertility preservation for iatrogenic infertility

• Retrieval of sperm and eggs
• Cryopreservation storage for preserved specimen for 1 year after a covered preservation procedure or when your enrollment ends, whichever is sooner 

Notes: 

• See Section 5(f), Prescription drug benefits, for coverage of fertility drugs.
• 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. See Section 3, You need prior Plan approval for certain services, for more information.
• A Plan physician will determine the appropriate treatment and number of attempts for infertility treatment.

50% of our allowance

50% of our allowance

50% of our allowance

Not covered:

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

• Assisted reproductive technology (ART) procedures, including related services and supplies, such as:
  • in vitro fertilization (IVF)
  • embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)            
• Ovum transplants
• Infertility services when either member of the family has been voluntarily surgically sterilized.
• Services to reverse voluntary, surgically induced infertility
• Any charges associated with donor eggs, donor sperm, or donor embryos
• Any charges associated with cryopreservation or with thawing and storage of frozen sperm, eggs, and embryos, unless listed as covered above for iatrogenic infertility
• Services related to surrogate arrangements

All charges

All charges

All charges

• Testing and treatment

$40 per office visit

$40 per office visit

• Injections

$15 per primary care office visit

$30 per specialty care office visit

$20 per primary care office visit

$40 per specialty care office visit

$20 per primary care office visit

$40 per specialty care office visit

• Serum

Nothing

Nothing

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

All charges

• Chemotherapy and radiation therapy

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

$40 per office visit

$40 per office visit

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 12 weeks or 36 visits, whichever comes first
• Growth hormone therapy (GHT)
• Ultraviolet light treatments

Note: Growth hormone requires our prior approval and is covered under the prescription drug benefit. See Section 3, You need prior Plan approval for certain services and Section 5(f), Prescription drug benefits.

$40 per office visit

$40 per office visit

• Applied Behavioral Analysis (ABA) for children through age 20 for the treatment of autism spectrum disorder

Note: Applied Behavioral Analysis treatment requires prior authorization. See section 3. You need prior plan approval for certain services, for more information.

Nothing

Nothing

Nothing

• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy

Nothing at home

Nothing at home

Nothing at home

• Dialysis - hemodialysis and peritoneal dialysis

 $30 per office visit

 $40 per office visit

 $40 per office visit

• Up to 20 visits combined per condition per calendar year for:
  • Physical habilitative and rehabilitative therapy by qualified physical therapists to attain or restore bodily function when you have a total or partial loss of bodily function due to illness or injury
  • Occupational habilitative and rehabilitative therapy by occupational therapists to assist you in attaining or resuming self-care and improved functioning in other activities of daily life when you have a total or partial loss of bodily function due to illness or injury.

$30 per visit

$40 per visit

$40 per visit

Comprehensive outpatient rehabilitation facility services

$30 per visit

$40 per visit

$40 per visit

Not covered:

• Long-term therapy
• Exercise programs
• Maintenance therapy
• Cognitive rehabilitation programs, except in cases of traumatic brain injury
• Vocational rehabilitation programs
• Therapies done primarily for educational purposes
•  Services provided by local, state and federal government agencies, including schools

All charges

$30 per visit

$40 per visit

$40 per visit

Not covered:

• Long-term speech therapy
• Therapies done primarily for educational purposes
• Therapy for tongue thrust in the absence of swallowing problems
• Training or therapy to improve articulation in the absence of injury, illness, or medical condition affecting articulation
• Voice therapy for occupation or performing arts
• Services provided by local, state, and federal government agencies including schools

All charges

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

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

$15 per primary care office visit

$30 per specialty care office visit

$20 per primary care office visit

$40 per specialty care office visit

$20 per primary care office visit

$40 per specialty care office visit

Hearing aids for children through age 18, including testing and examinations

Notes:

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

All charges in excess of $3,000 for each hearing impaired ear every 48 months

All charges in excess of $3,000 for each hearing impaired ear every 48 months

All charges in excess of $3,000 for each hearing impaired ear every 48 months

Not covered:

• All other hearing testing, except as may be covered in Section 5(a), Diagnostic and treatment services and Section 5(a), Preventive care, children
• Hearing aids, including testing and examinations for them, for all persons age 19 and over
• Batteries for hearing aids and replacement of lost hearing aids

All charges

• Diagnosis and treatment of diseases of the eye
• Routine eye exam with a Plan optometrist to determine the need for vision correction and provide a prescription for eyeglasses

$40 per office visit

$40 per office visit

Not covered:

• Eyeglasses and frames
• Contact lenses, examinations for contact lenses or the fitting of contact lenses
• Eye surgery solely for the purpose of correcting refractive defects of the eye 
• Vision therapy, including orthoptics, visual training and eye exercises
• Low vision aids

All charges

$15 per primary care office visit

$20 per primary care office visit

$40 per specialty care office visit

$20 per primary care office visit

$40 per specialty care office visit

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges

External prosthetic and orthotic devices, such as:

• 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
• Ostomy and urological supplies
• Therapeutic shoes required for conditions associated with diabetes
• Braces
• Scoliosis braces

20% of our allowance

20% of our allowance after the deductible

Internal prosthetic devices, such as:

• Artificial joints
• Pacemakers
• Cochlear implants
• Surgically implanted breast implants following mastectomy
• Intraocular implant following cataract removal

Note: See 5(b), Surgery benefits, for coverage of the surgery to insert the device and Section 5(c), Hospital benefits, for inpatient hospital benefits.

Nothing

Nothing

Notes:

• Orthopedic and prosthetic equipment or services must be prescribed by a Plan physician; obtained through sources designated by the Plan; consistent with Medicare guidelines; and primarily and customarily used to serve a medical or therapeutic purpose in the treatment of an illness or injury.
• We cover only those standard items that are adequate to meet the medical needs of the member.
• For coverage of hearing aids, see Section 5(a), Hearing services.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

• Orthopedic and prosthetic devices and corrective shoes, except as described above
• Foot orthotics and podiatric use devices, such as arch supports, heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Dental prostheses, devices, and appliances, except oral devices or appliance used to reduce upper airway collapsibility
• Repairs, adjustments, or replacements due to misuse, theft or loss

All charges

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Covered items include:

• Oxygen and oxygen dispensing equipment
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Speech generating devices
• Blood glucose monitors
• Insulin pumps
• Infant apnea monitors

20% of our allowance 

10% of our allowance after the deductible

• One breastfeeding pump per delivery, including any equipment and supplies that are required for pump functionality. 

20% of our allowance for hospital-grade pump

Nothing for retail-grade pump and breastfeeding supplies

20% of our allowance for hospital-grade pump

Nothing for retail-grade pump and breastfeeding supplies

 20% of our allowance after the deductible for hospital-grade pump

 Nothing for retail-grade pump and breastfeeding supplies

• Home phototherapy equipment for the treatment of psoriasis and atopic dermatitis
• Enteral and parenteral elemental dietary formulas and amino acid modified product for the treatment of inborn errors of metabolism

Nothing

Nothing

Nothing

Notes:

• We only provide DME in the Plan’s service area.
• We cover only those standard items that are adequate to meet the medical needs of the member.
• We may require you to return the equipment to us, or pay us the fair market price of the equipment, when it is no longer prescribed.
• Durable medical equipment (DME) is equipment that is prescribed a Plan physician; obtained through sources designated by the Plan; consistent with our Plan DME formulary guidelines; intended for repeated use; primarily and customarily used to serve a medical or therapeutic purpose in the treatment of an illness or injury; designed for prolonged use; and appropriate for use in the home.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered: 

• Audible prescription reading devices
• Comfort, convenience or luxury equipment or features
• Non-medical items such as sauna baths or elevators
• Exercise and hygiene equipment
• Electronic monitors of the heart, lungs, or other bodily functions, except for infant apnea monitors
• Devices to perform medical testing of bodily fluids, excretions or substances
• Modifications to the home or vehicle
• Dental appliances
• More than one piece of durable medical equipment serving essentially the same function
• Spare or alternate use equipment
• Disposable supplies
• Replacement batteries
• Repairs, adjustments, or replacements due to misuse, theft or loss

All charges

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), home health aide, physical or occupational therapist, and speech and language pathologist.
• Services include oxygen therapy, intravenous therapy and medications.

Notes:

• We only provide these services in the Plan's service areas.
• These services are covered only if you are homebound and a Plan physician determines that it is feasible to maintain effective supervision and control of your care in your home.

Nothing

Nothing

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
• Custodial care
• Private duty nursing
• Personal care and hygiene items
• Care that a Plan provider determines may be appropriately provided in a Plan facility, hospital, skilled nursing facility or other facility we designate and we provide

All charges

Up to 20 visits per calendar year, limited to:

• Diagnosis and treatment of neuromusculoskeletal disorders
• Laboratory tests, pathology and plain film X-rays associated with diagnosis and treatment (not to exceed 4 views)
• Adjunctive therapies such as ultrasound, electrical muscle stimulation, and vibratory therapy, not to exceed 2 per visit

Notes:

• You may only self-refer to a participating chiropractor. The participating chiropractor must provide, arrange or prescribe your care.

• For a list of participating chiropractors, contact our Member Services Department at 404-261-2590 (TTY: 711).

$40 per office visit

$40 per office visit

Not covered:

• Hypnotherapy, behavior training, sleep therapy and weight programs 
• Thermography
• Any radiological exam other than plain film studies such as magnetic resonance imaging, CT scans, bone scans, nuclear radiology
• Treatment for non-neuromusculoskeletal disorders
• Chiropractic appliances, except as covered in Section 5(a), Durable medical equipment and Prosthetics and orthotic devices

All charges

Not covered, including acupuncture

All charges

Health education classes, including:

• Stress reduction
• Chronic conditions, such as diabetes and asthma

$20 per office visit

$20 per office visit

• Tobacco Cessation programs, including individual/group/telephone counseling, and for over-
  the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence.

Nothing

Nothing

• General health education not addressed to a specific condition, as well as Lamaze classes and weight control

Charges vary

Charges vary

• Childhood obesity Screening programs and treatment interventions

Nothing - $10/program

Nothing - $10/program

Notes:

• Please call Member Services at 404-261-2590 for information on cost and classes near you.
• See Section 5(f), Prescription drug benefits, for important information about coverage of tobacco cessation and other drugs.

Applies to this benefit

Applies to this benefit

Applies to this benefit

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)

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

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

Nothing

Nothing

Nothing

• Surgical treatment of severe obesity (bariatric surgery). 

Notes:

• Visit kp.org/feds to get a list of criteria you must meet to qualify for bariatric surgery.  This program may refer you to other Plan providers to determine if you meet the additional criteria necessary for bariatric surgery, including:
  • nutritional,
  • psychological,
  • medical; and
  • social readiness for surgery.
• Final approval for surgical treatment will be required from The Southeast Permanente Medical Group’s designated physician. See Section 3, You need prior Plan approval for certain services, for more information.

Nothing

Nothing

Nothing

• Insertion of internal prosthetic devices. See 5(a), Orthopedic and prosthetic devices, for device coverage information
• Male voluntary sterilization (e.g., vasectomy)
• Treatment of burns

Notes:

• 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.

Nothing

Nothing

Nothing

• Female voluntary sterilization, including anesthesia and confirmation testing following tubal occlusion
• Surgically implanted time-released contraceptives and insertion of intrauterine devices (IUDs)

Nothing

Nothing

Notes:

• We cover the cost of these surgically implanted time-release contraceptive drugs and intrauterine devices under the prescription drug benefit (see Section 5(f)).

Nothing

Nothing

Nothing

Not covered:

• Reversal of voluntary sterilization
• Services for the promotion, prevention, or other treatment of hair loss or hair growth
• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form

All charges

• 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.

Note: We cover orthodontia services as a result of cleft lip and/or cleft palate.

• Surgery for treatment of a form of congenital hemangioma known as port wine stains on the face
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery and reconstruction on the other breast to produce a symmetrical appearance;
  • treatment of any physical complications, such as lymphedemas;
  • breast prostheses and surgical bras and replacements (see Prosthetic devices)

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

• Gender Affirming Surgery

Notes:

• Visit kp.org/feds to get a list of criteria you must meet to qualify for gender affirming surgery and the surgeries available. You should consult with your primary care physician to determine what is appropriate for you.
• Your primary care physician will introduce you to specialists and other caregivers familiar with the unique challenges of transitioning. Care teams collaborate to provide medical, psychological, and emotional support throughout the process.

Nothing

Nothing

Nothing

Not covered:

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

All charges

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, except extraction of the teeth to prepare the jaw for radiation treatment of neoplastic disease.

Nothing

Nothing

Nothing

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
• Shortening of the mandible or maxillae for cosmetic purposes 
• Correction of any malocclusion not listed above
• Dental services associated with medical treatment such as surgery, except for services related to accidental injury of teeth (See Section 5(g))

All charges

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 preauthorization 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 

Nothing

Nothing

Nothing

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)

Nothing

Nothing

Nothing

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

Nothing

Nothing

Nothing

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)

Nothing

Nothing

Nothing

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

Nothing

Nothing

Nothing

Notes:

• We cover related medical and hospital expenses of the donor when we cover the recipient.
• We cover donor screening tests for potential donors for solid organ transplants. We cover human leukocyte antigen (HLA) typing for potential donors for a bone marrow/stem cell transplant only for parents, children and siblings of the recipient.
• We cover computerized national and international search expenses for prospective unrelated bone marrow/stem cell transplant donors conducted through the National Marrow Donor Program, and the testing of blood relatives of the recipient.
• Please refer to Section 5(h), Special features, for information on our Centers of Excellence.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

All charges

Professional services provided in –

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

Nothing

Nothing

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.

$500 per admission

$250 per admission maternity care

$750 per admission

Nothing per admission for maternity care

10% of our allowance after deductible

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Blood and blood products
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services

Note: You may receive covered hospital services for certain dental procedures if a Plan physician determines you need to be hospitalized for reasons unrelated to the dental procedure. The need for anesthesia, by itself, is not such a condition.

Nothing

Nothing

Nothing

• Medical supplies and equipment, including oxygen, and any covered items billed by a hospital for use at home

According to the benefit of the specific item you take home (i.e., hospital bed, pharmacy items, etc.)

Not covered:

• Custodial care and care in an intermediate care facility
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as phone, television, barber services, and guest meals and beds
• Private nursing care, except when medically necessary
• Inpatient dental procedures
• Cord blood procurement and storage for possible future need or for a yet-to-be determined member recipient

All charges

• Operating, recovery, and other treatment rooms
• Observation care
• Prescribed drugs and medications
• Lab, X-ray, and other diagnostic tests
• Blood and blood products
• Pre-surgical testing
• Dressings, casts, and sterile trays
• Medical supplies and equipment, including oxygen
• Anesthetics and anesthesia service

Notes:

• For observation care associated with an emergency room visit, see Section 5(d) Emergency services/Accidents.

$200 per visit

10% of our allowance after the deductible

• 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(g) for dental information.

$150 per visit

$200 per visit

10% of our allowance after the deductible

Not covered:

• Cord blood procurement and storage for possible future need or for a yet-to-be determined member recipient

All charges

All charges

All charges

Up to 100 days per calendar year when you need full-time nursing care.

All necessary services are covered, including:

• Room and board
• General nursing care
• Medical social services
• Prescribed drugs, biologicals, supplies, and equipment, including oxygen, ordinarily provided or arranged by the skilled nursing facility

Nothing

10% of our allowance after the deductible

Not covered:

• Custodial care and care in an intermediate care facility
• Personal comfort items, such as phone, television, barber services, and guest meals and beds

All charges

Supportive and palliative care for a terminally ill member:

• You must reside in the service area
• Services are provided in the home, when a Plan physician determines that it is feasible to maintain effective supervision and control of your care in your home.

Services include inpatient care under limited circumstances, outpatient care, and family counseling. A Plan physician must certify that you have a terminal illness, with a life expectancy of approximately six months or less.

Nothing

Nothing

Nothing

Not covered:

• Independent nursing (private duty nursing)
• Homemaker services

All charges

• Local licensed ambulance service when medically necessary

Note: See Section 5(d) for emergency services

$125 per trip

$150 per trip

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

All charges

• Urgent care at a Plan urgent care center

$40 per office visit

$40 per visit

• Emergency care at an urgent care center not designated by the Plan
• Emergency care as an outpatient at a hospital, including physicians’ services
• Urgent care at a Plan emergency room 

Notes:

• If you receive emergency care and then are transferred to an observation bed or status, 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.

$200 per visit

$200 per visit

$250 per visit

Not covered:

• Elective care or non-emergency care
• Urgent care at a non-Plan urgent care center or emergency 

All charges

• Urgent care at an urgent care center

$30 per visit

$40 per visit

$40 per visit

• Emergency care at an urgent care center not designated by the Plan
• Emergency care as an outpatient at a hospital, including physicians’ services
• Urgent care at an emergency room 

Notes:

• If you receive emergency care and then are transferred to an observation bed or status, 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.
• See Section 5(h) for travel benefit coverage of continuing or follow-up care.

$200 per visit

$200 per visit

$250 per visit

Not covered:

• Elective care or non-emergency care
• Follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges

Licensed ambulance service when medically necessary.

Notes:

• See Section 5(c) for non-emergency service.
• Trip means any time an ambulance is summoned on your behalf.

$125 per trip

$150 per trip

Not covered:

• Trips we determine are not medically necessary
• Transportation by car, taxi, bus, gurney van, wheelchair van, minivan and any other type of transportation, even if it is the only way to travel to a provider or facility

All charges

We cover professional services recommended by a Plan mental health or substance use disorder treatment provider that are covered services, drugs, and supplies described in this brochure.

Notes:

• We cover the services only when we determine the care is clinically appropriate to treat your condition.

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

• Diagnosis and treatment of psychiatric conditions, mental illness, or disorders. Services include:
  • Crisis intervention and stabilization for acute episodes
  • Medication evaluation and management (pharmacotherapy)

$15 per individual therapy office visit

$15 per individual therapy office visit (Nothing for children through age 17)

$20 per individual therapy office visit

$20 per individual therapy office visit (Nothing for children through age 17)

$20 per individual therapy office visit

$20 per individual therapy office visit

• Treatment and counseling (including group and individual therapy visits)

$7 per group therapy office visit 

(Nothing for children through age 17)

$10 per group therapy office visit

(Nothing for children through age 17)

$10 per group therapy office visit

• Diagnosis and treatment of substance use disorders. Services include:
  • Detoxification (medical management of withdrawal from the substance)
  • Treatment and counseling (including individual and group therapy visits)
  • Rehabilitative care

$15 per individual therapy office visit

$7 per group therapy office visit

(Nothing for children through age 17)

$20 per individual therapy office visit

$10 per group therapy office visit

(Nothing for children through age 17)

$20 per individual therapy office visit

$10 per group therapy office visit

• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Electroconvulsive therapy

$15 per office visit

(Nothing for children through age 17)

$20 per office visit

(Nothing for children through age 17)

$20 per office visit

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility

Your cost-sharing responsibilities are no greater than for other illness or condition. See Section 5(a) Lab, X-ray and other diagnostic tests. 

Your cost-sharing responsibilities are no greater than for other illness or condition. See Section 5(a) Lab, X-ray and other diagnostic tests. 

Your cost-sharing responsibilities are no greater than for other illness or condition. See Section 5(a) Lab, X-ray and other diagnostic tests. 

Notes:

• You may see a Plan mental health or substance use provider for these services without a referral from your primary care provider. See Section 3, How you get care, for information about services requiring our prior approval.
• Your Plan mental health or substance use provider will develop a treatment plan to assist you in improving or maintaining your condition and functional level, or to prevent relapse and will determine which diagnostic and treatment services are appropriate for you.
• See Section 5(a), Treatment therapy for coverage of Applied Behavior Analysis (ABA).

Applies to this benefit

Applies to this benefit

Applies to this benefit

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
• 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

Your cost-sharing responsibilities are no greater than for other illness or condition. See Section 5(a) Lab, X-ray and other diagnostic tests.

Your cost-sharing responsibilities are no greater than for other illness or condition. See Section 5(a) Lab, X-ray and other diagnostic tests.

Your cost-sharing responsibilities are no greater than for other illness or condition. See Section 5(a) Lab, X-ray and other diagnostic tests.

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

Note: All inpatient admissions require approval by a Plan mental health or substance use physician.

$500 per admission

$750 per admission

10% of our allowance after deductible 

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

• Services in approved alternative care settings such as partial hospitalization, residential treatment, facility based intensive outpatient treatment

Note: All hospital alternative services treatment programs require approval by a Plan mental health or substance use physician.

$200 per visit 

$250 per visit after the deductible

Not covered:

• Care that is not clinically appropriate for the treatment of your condition
• Intelligence, IQ, aptitude ability, learning disorders or interest testing not necessary to determine the appropriate treatment of a psychiatric condition
• Evaluation or therapy on court order or as a condition of parole or probation, or otherwise required by the criminal justice system, unless determined by a Plan physician to be medically necessary and appropriate
• Services that are custodial in nature
• Marital, family or educational services
• Services rendered or billed by a school or a member of its staff
• Services provided under a federal, state or local government program
• Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms

All charges

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

• Drugs and medications that, by federal law, require a physician’s prescription for their purchase, except those listed as Not covered
• Insulin
• Diabetic supplies, limited to glucose test strips, home glucose monitoring supplies and acetone test tablets
• Disposable needles and syringes for the administration of covered medications
• Compound drugs
• Immunosuppressant drugs required as a result of a covered transplant
• Growth hormone therapy (GHT) - in limited circumstances for treatment of children with Turner’s syndrome or classical growth hormone deficiency, only with prior approval by Plan physicians
• Drugs to treat gender dysphoria, including hormones and androgen blockers
• Weight management drugs
• Medications prescribed to treat obesity

Notes:

• For information about mail order discounts, see "These are the dispensing limitations" in the introduction to Section 5(f).
• You will be charged your applicable generic or brand name drug copayment depending on the compound drug's main ingredient, whether the main ingredient is a generic drug or brand name drug.
• A compound drug is one in which two or more drugs or pharmaceutical agents are combined together. We limit coverage to products listed in our drug formulary or when one of the ingredients requires a prescription by law.
• Growth hormone requires our prior approval. See Section 3, Services requiring our prior approval.

Plan medical office pharmacy:

$5 for preferred generic drugs, $10 for non-preferred generic drugs, $45 for preferred and non-preferred brand name drugs, and $100 for specialty drugs up to a 30-day supply.

Plan participating community pharmacy:  

$15 for preferred generic drugs, $20 for non-preferred generic drugs, $55 for preferred and non-preferred brand name drugs and $100 for specialty drugs up to a 30-day supply.

Plan medical office pharmacy:

$5 for preferred generic drugs, $10 for non-preferred generic drugs, $45 for preferred brand name drugs, $55 for non-preferred brand name drugs, and $150 for specialty drugs up to a 30-day supply 

Plan participating community pharmacy:

$20 for preferred generic drugs, $25 for non-preferred generic drugs, $55 for preferred brand name drugs, $65 for non-preferred brand name drugs, and $150 for specialty drugs up to a 30-day supply

Plan medical office pharmacy:

$5 for preferred generic drugs, $10 for non-preferred generic drugs, $45 for preferred brand name drugs, $65 for non-preferred brand name drugs, and $200 for specialty drugs up to a 30-day supply 

Plan participating community pharmacy:

$20 for preferred generic drugs, $25 for non-preferred generic drugs, $55 for preferred brand name drugs, $75 for non-preferred brand name drugs, and $200 for specialty drugs up to a 30-day supply

• Intravenous fluids and medications for home use

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 PSHB 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 Filing a Claim for Covered Services.
• We cover contraceptive drugs, devices and products, including implanted contraceptive drugs, devices, and products, including implanted devices, diaphragms, contraceptive gels, hormonal contraceptive methods, and FDA approved over-the-counter contraceptive drugs, devices, and products.
• We cover non-preferred contraceptive drugs, devices, and products 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.

Nothing

Notes:

• For additional Family Planning benefits see Section 5(a) Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals.
• 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) Medical Services and Supplies Provided by Physicians and Other Healthcare Professionals.

• Sexual dysfunction drugs

All charges

• 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

50% of our allowance

50% of our allowance

• Prescribed tobacco cessation medications, including prescribed over-the-counter medications, approved by the FDA to treat tobacco dependence

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Prescriptions filled at a non-Plan pharmacy, except for out-of-area emergencies as described in Section 5(d), Emergency services/accidents
• Vitamins, nutrients and food supplements that can be purchased without a prescription, unless they are included in our drug formulary or listed as covered above or below 
• Over-the-counter (nonprescription) drugs, including prescription drugs for which there is an over-the-counter drug equivalent available, unless 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
• Medical supplies such as dressings and antiseptics, except as listed above
• Drugs that shorten the duration of the common cold
• Any requested packaging of drugs other than the dispensing pharmacy’s standard packaging
• Replacement of lost, stolen or damaged prescription drugs and accessories
• Drugs related to non-covered services, except as stated above
• Drugs for the promotion, prevention, or other treatment of hair loss or growth
• Contraceptive devices, except as listed above
• Infant formulas
• Immunizations and other drugs and supplies needed for travel

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
• Medication to reduce the risk of breast cancer
• 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.

Nothing when prescribed by a healthcare professional and filled by a network pharmacy.

Nothing when prescribed by a healthcare professional and filled by a network pharmacy.

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained in a clinical setting administered in a form such as 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/.

Nothing

Nothing

Nothing

Not covered:

• Prescriptions filled at a non-Plan pharmacy, except for emergencies as described in Section 5(d), Emergency services/accidents
• Vitamins, nutritional and herbal supplements that can be purchased without a prescription, unless they are included in our drug formulary or listed as covered above
• Over-the-counter drugs, unless 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 or damaged prescription drugs and accessories
• Drugs related to non-covered services, except as stated above

All charges

All charges

All charges

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury and all services must be completed within 365 days of the injury in order to be covered.

• damage is due to an accidental injury from trauma to the mouth from violent contact with an external object,
• the tooth has not been restored previously, except in a proper manner, and
• the tooth has not been weakened by decay, periodontal disease, or other existing dental pathology.

50% of our allowance

50% of our allowance

Not covered:

• Services for conditions caused by an accidental injury occurring before your eligibility date

All charges

Diagnostic and preventive dental services when provided by a Delta Dental PPO dentist, Delta Dental Premier or any licensed dentist:

• Routine oral examinations - twice per calendar year
• Cleaning (prophylaxis) - twice per calendar year (excluding periodontal prophylaxis)
• Topical application of fluoride - twice per calendar year
• Bitewing X-rays - twice per calendar year for children through age 17 and once per calendar year for adults age 18 and over
• Full mouth series X-rays - once every five years

Note: You may choose to receive preventive dental benefits from any licensed dentist. Delta Dental dentists agree to negotiated fee schedules as payment in full, and your coinsurance is based on a dentist's fee schedule. Your out-of-pocket costs may be lower if you choose a Delta Dental PPO dentist, rather than a Delta Premier or non-Delta dentist as well. For a list of Delta Dental PPO or Delta Dental Premier dentists, please call Delta Dental at 800-521-2651 or go to www.deltadentalins.com

30% of the dentist’s usual and customary fee schedule or the fee actually charged, whichever is less

All charges

50% of our allowance

50% of our allowance

General anesthesia and associated hospital or ambulatory surgery facility charges in conjunction with dental care are covered for members:

• 7 years of age or younger
• Who are developmentally disabled
• Who are not able to have dental care under local anesthesia due to a neurological or medically compromising condition
• Who have sustained extensive facial or dental trauma

Nothing

Nothing

See Section 5(c) for facility charges.

Nothing

See Section 5(c) for facility charges.

• Extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease
• Extraction of bony impacted teeth

$200 per office visit

10% of our allowance after the deductible

Not covered:

• Other dental services not specifically shown as covered

All charges

The Centers of Excellence program began in 1987. As new technologies proliferate and become the standard of care, Kaiser Permanente refers members to contracted "Centers of Excellence" for certain specialized medical procedures.

We have developed a nationally contracted network of Centers of Excellence for organ transplantation, which consists of medical facilities that have met stringent criteria for quality care in specific procedures. A national clinical and administrative team has developed guidelines for site selection, site visit protocol, volume and survival criteria for evaluation and selection of facilities. The institutions have a record of positive outcomes and exceptional standards of quality.

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 claims 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. 

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.

Take steps to improve your well-being by completing the Kaiser Permanente Total Health Assessment and a biometric screening. FEHB subscribers and their enrolled spouses (age 18 and over) are eligible to receive $250 for completing a confidential, online, Total Health Assessment (available in English or Spanish) and being up to date on the following biometric screenings: blood glucose, blood pressure, Body Mass Index (BMI) and total cholesterol. To view and determine the status of your screenings, go to www.kp.org/feds. If you have not had these screenings recently, you may be required to contact your Kaiser Permanente doctor.  You will get a picture of your overall health and a customized action plan with tips and resources to improve your well-being.

You must accept the Wellness Program Agreement to be eligible to earn rewards. Please go to www.kp.org/feds to learn how to earn your reward and to view and track the status of your reward activities.

You must complete the Total Health Assessment and biometric screening during the plan year. We will issue you a Kaiser Permanente Health Payment Card 4-6 weeks after you complete both activities. We will send each eligible member their own debit card.

You may use your Health Payment Card to pay for certain qualified medical expenses, such as:

• Copayments for office visits, prescription drugs and other services at Kaiser Permanente or other providers
• Prescription eyeglasses or contacts
• Dental services
• Over-the-counter medication for certain diseases
• Other medical expenses, as permitted by the IRS

Please keep your card for use in the future. As you complete activities, we will add rewards to your card. We will not send you a new card until the card expires. Rewards you earn during this calendar year may be used until March 31 of the next calendar year. Funds are forfeited if you leave this plan.

For more information, please go to www.kp.org/feds. If you have questions about completing a Total Health Assessment or class, you may call us at 866-300-9867. If you have questions about your account balance or what expenses the Health Payment Card can be used for, you may call the phone number on the back of your Health Payment Card.

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

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.

For more information about receiving visiting member services, including provider and facility locations in other Kaiser Permanente service areas, please call our Away from Home Travel Line at 951-268-3900 or visit kp.org/travel.

We provide a limited benefit to eligible members who are full-time registered college students (at least 12 credit hours per semester) attending a recognized accredited institution outside Kaiser Permanente’s service areas and within the United States. These benefits are in addition to your emergency benefits and will be applied before your travel benefit.

• We cover routine, continuing and follow-up medical care.
• You pay 20% of the usual and customary charges.
• Your benefit is limited to $1,200 each calendar year.
• There is no deductible.
• You must certify the member’s student status annually.
• For more information about this benefit call our Member Services Department at 404-261-2590 (TTY: 711).
• File claims as shown in Section 7.

The following services are not included in your out-of-area student coverage benefit:

• Dental services
• Transplants and transplant follow-up care
• Services provided outside the United States

Kaiser Permanente offers smoking cessation classes as described under Educational classes and programs in Section 5(a). In addition to the classes we also offer the following:

• Kaiser Permanente’s "Great Start" Quit Line is free and available for pregnant women 24 hours a day.
• Free smoking cessation resources are available, including a self-help booklet for pregnant women, as well as brochures for adults and teens.
• Bookmark listing of smoking cessation resources
• Bi-Annual smoking cessation resource outreach mailings to all identified smokers

For more information or to order any of the above materials please call our Member Services Department at 404-261-2590 (TTY: 711).

Kaiser Permanente’s travel benefit for Federal employees provides you with outpatient follow-up and/or continuing medical and mental health and substance use care when you are temporarily (for example, on a temporary work assignment or attending school) outside your home service area by more than 100 miles and outside of any other Kaiser Permanente service area. These benefits are in addition to your emergency services/accident benefit and include:

• Outpatient follow-up care necessary to complete a course of treatment after a covered emergency. Services include removal of stitches, a catheter, or a cast.
• Outpatient continuing care for covered services for conditions diagnosed and treated within the previous 12 months by a Kaiser Permanente healthcare provider or affiliated Plan provider. Services include dialysis and prescription drug monitoring.

You pay $25 for each follow-up or continuing care office visit. This amount will be deducted from the reimbursement we make to you or to the provider. We limit our payment for this travel benefit to no more than $1,200 each calendar year. For more information about this benefit call our Member Services Department at 404-261-2590 (TTY: 711). File claims as shown in Section 7.

The following are a few examples of services not included in your travel benefits coverage:

• Non-emergency hospitalization
• Infertility treatments
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area
• Transplants 
• Durable medical equipment (DME )
• Prescription drugs 
• Home health services

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, call our Member Service Call Center at 404-261-2825 (TTY: 711).

When you must file a claim - such as for services you received 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
• Follow up services rendered out-of-area
• 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
Claims Administration
P.O. Box 190849
Atlanta, GA 31119-0849

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.

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 Foundation Health Plan of Georgia, Inc., Attention: Appeals Department, Nine Piedmont Center, 3495 Piedmont Road, NE, Atlanta, GA 30305-1736; 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) forms.

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 3, 1900 E Street, NW, Washington, DC 20415-3630.

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;
• Your daytime phone number and the best time to call; and
• 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 precertification or prior approval. This is the only deadline that may not be extended.

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

You may not 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 the NAIC website at www.kp.org/feds.

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, except Medicare-eligible members with Original Medicare as primary payor must pay cost-sharing described in this FEHB brochure (see Sections 4 and 5, members with Medicare should also see the Original Medicare Plan portion of this Section 9).  We will not pay more than our allowance. If we are the secondary payor, and you received your services from Plan providers, we may bill the primary carrier.

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.

When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.

If you obtain a judgment or settlement from or on behalf of a third party who allegedly caused or is responsible for an injury or illness for which you received covered healthcare services or benefits (“Services”), you must pay us Charges for those Services. “Charges” are: 1) for Services that we pay the provider on a fee-for-service basis, the payments that we made for the Services; and 2) for all other Services, the charges in the provider’s schedule of charges for Services provided to Members less any cost share payments that you made to the provider. Our payments for Services in these circumstances are expressly conditioned on your agreement to comply with these provisions. You are still required to pay cost-sharing to the provider, even if a third party has allegedly caused or is responsible for the injury or illness for which you received Services.

You must also pay us Charges for such Services if you receive or are entitled to receive a recovery from any insurance for an injury or illness alleged to be based on a third party’s or your own fault, such as from uninsured or underinsured motorist coverage, automobile or premises medical payments coverage, or any other first party coverage. You must also pay us Charges for such Services if you receive or are entitled to receive recovery from any Workers' Compensation benefits.

To secure our rights, we will have a lien on and reimbursement right to the proceeds of any judgment or settlement you or we obtain. The proceeds of any judgment or settlement that you or we obtain shall first be applied to satisfy our lien, regardless of whether the total amount of the proceeds is less than the actual losses and damages you incurred. We are entitled to full recovery regardless of whether any liability for payment is admitted by a person entity or insurer. We are entitled to full recovery regardless of whether settlement or judgment received by you identifies the medical benefits provided or purports to allocate any portion of the settlement or judgment to payment to expenses other than medical expenses. We are entitled to recover from any and all settlements, even those designated as for pain and suffering, non-economic damages and/or general damages only.

In order for us to determine the existence of any rights we may have and to satisfy those rights, you must complete and send us all consents, releases, authorizations, assignments, and other documents, including lien forms directing your attorney and any insurer to pay us directly. You may not agree to waive, release, or reduce our rights under this provision without our prior, written consent. You must cooperate in doing what is reasonably necessary to assist us with our right of recovery. You must notify us within 30 days of the date you or someone acting on your behalf notifies anyone, including an insurer or attorney, of  your intention to pursue or investigate a claim to recover damages or obtain compensation due to your injury or illness.  You must not take any action that may prejudice our right of recovery.

If your estate, parent, guardian, or conservator asserts a claim based on your injury or illness, that person or entity and any settlement or judgment recovered by that person or entity shall be subject to our liens and other rights to the same extent as if you had asserted the claim against the party. We may assign our rights to enforce our liens and other rights.

We have the option of becoming subrogated to all claims, causes of action, and other rights you may have against a third party or an insurer, government program, or other source of coverage for monetary damages, compensation, or indemnification on account of the injury or illness allegedly caused by the third party. We will be so subrogated as of the time we mail or deliver a written notice of our exercise of this option to you or your attorney, but we will be subrogated only to the extent of the total of Charges for the relevant Services.

Contact us if you need more information about recovery or subrogation.

If you enter into a Surrogacy Agreement, you must reimburse us for covered services you receive related to conception, pregnancy, delivery, or postpartum care in connection with the Surrogacy Agreement, except that the amount you must pay will not exceed the payments or other compensation you and any other payee are entitled to receive under the Surrogacy Agreement. A "Surrogacy Agreement" is one in which a person agrees to become pregnant and to surrender the baby (or babies) to another person or persons who intend to raise the child (or children), in exchange for payment or compensation for being a surrogate. The "Surrogacy Agreement" does not affect your obligation to pay your cost-sharing for services received, but we will credit any such payments toward the amount you must pay us under this paragraph. We will only cover charges incurred for any services when you have legal custody of the baby and when the baby is covered as a family member under your Self Plus One or Self and Family enrollment (the legal parents are financially responsible for any services that the baby receives).

By accepting services, you automatically assign to us your right to receive payments that are payable to you or any other payee under the Surrogacy Agreement, regardless of whether those payments are characterized as being for medical expenses. To secure our rights, we will also have a lien on those payments and on any escrow account, trust, or any other account that holds those payments. Those payments (and amounts in any escrow account, trust, or other account that holds those payments) shall first be applied to satisfy our lien. The assignment and our lien will not exceed the total amount of your obligation to us under the preceding paragraph.

Within 30 days after entering into a Surrogacy Agreement, you must send written notice of the Agreement, a copy of the Agreement, including the names, addresses, and phone numbers of all parties involved in the Agreement. You must send this information to:

Trover Solutions, Inc.
Kaiser Permanente Georgia Surrogacy Mailbox
9390 Bunsen Parkway
Louisville, KY 40220

You must complete and send us consents, releases, authorizations, lien forms, and other documents that are reasonably necessary for us to determine the existence of any rights we may have under this "Surrogacy Agreements" section and to satisfy those rights.

If your estate, parent, guardian, or conservator asserts a claim against a third party based on the Surrogacy Agreement, your estate, parent, guardian, or conservator and any settlement or judgment recovered by the estate, parent, guardian, or conservator shall be subject to our liens and other rights to the same extent as if you had asserted the claim against the third party. We may assign our rights to enforce our liens and other rights.

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 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. 

We will cover routine care costs and may cover some extra care costs not provided by the clinical trial in accordance with Section 5 when Plan physicians provide or arrange for your care. We encourage you to contact us to discuss specific services if you participate in a clinical trial.

• Routine care costs are 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. We cover routine care costs not provided by the clinical trial.
• Extra care costs are 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. We cover some extra care costs not provided by the clinical trial. We encourage you to contact us to discuss coverage for specific services if you participate in a clinical trial.

The Plan does not cover research costs.

• Research costs are 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 at 404-233-3700 (locally in the metropolitan Atlanta area) or 800-232-4404 (long distance) (TTY: 711), 8 a.m. to 8 p.m., 7 days a week, or visit our website at www.kp.org/feds.

We do not waive any costs if the Original Medicare Plan is your primary payor.

We offer a program designed to help members with their Medicare Part B premium. This program is called “Senior Advantage 2”. For each month you are enrolled in Senior Advantage 2, have Medicare Parts A and B and are enrolled in Senior Advantage for Federal Members, you will be reimbursed up to $200 (up to $2,400 per year) of your Medicare Part B monthly premium and extra charges added to the Part B premium (Part B Late Enrollment Penalty, or LEP, and Part B Income-Related Monthly Adjustment Amount, or IRMAA). In addition to reimbursing for the Part B premium, we will cover additional benefits, including lower copayments for office visits, outpatient surgery, inpatient hospital care, emergency care, generic and brand-name prescription drugs and the SilverSneakers® fitness program.

You may enroll in this program if:

• You enroll in Kaiser Permanente’s High Option or Standard Option,
• You live in our Medicare Advantage Service area,
• You enroll in Senior Advantage for Federal Members, and
• The FEHB subscriber completes an additional application for enrollment in Senior Advantage 2.

Reimbursement will begin on the first of the month following receipt of your additional application for enrollment in Senior Advantage 2 and verification of your Medicare Part B enrollment. During a calendar year, you may enroll in Senior Advantage 2 only once. If the FEHB subscriber enrolls in Senior Advantage 2, each family member who enrolls in Senior Advantage for Federal Members is required to participate in Senior Advantage 2. If, for any reason, you do not meet the enrollment requirements for Senior Advantage 2, you will no longer be eligible to participate in the program. Your reimbursements will end and your regular FEHB High Option or Standard Option benefits will resume. You may be required to repay any reimbursement paid to you in error.

To learn more about Senior Advantage 2 and how to enroll, call us at 404-233-3700 (locally in the metropolitan Atlanta area) or 800-232-4404 (TTY:711), 8 a.m. to 8 p.m., 7 days a week, or visit our website at kp.org/feds.

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: 877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage plan: We offer a Medicare Advantage plan known as Kaiser Permanente Senior Advantage for Federal Members. Senior Advantage for Federal Members enhances your FEHB coverage by lowering cost-sharing for some services and/or adding benefits.  High and Standard Option Members can choose between 1 Medicare Advantage plans:  "Senior Advantage 1" (richest benefits) and "Senior Advantage 2" (some rich benefits) and Part B premium reimbursement.  If you live in our Senior Advantage service area and you have Medicare Parts A and B, you can enroll in Senior Advantage for Federal Members.  Enrolling in Senior Advantage for Federal Members does not change your FEHB premium. Your enrollment is in addition to your FEHB High Option, Standard Option or Prosper enrollment; however, your benefits will be provided under the Kaiser Permanente Senior Advantage for Federal Members plan and are subject to all Medicare rules. If you have Medicare Parts A and B, you can enroll in Senior Advantage for Federal Members with no increase to your FEHB or Kaiser Permanente premium.

If you are considering enrolling in Senior Advantage for Federal Members, please call us at 404-233-3700 (locally in the metropolitan Atlanta area) or 800-232-4404 (long distance) (TTY: 711), 8 a.m. to 8 p.m., 7 days a week, or visit our website at www.kp.org/feds.

With Kaiser Permanente Senior Advantage for Federal Members, you will get more coverage, such as lower cost sharing and additional benefits. This 2025 benefit summary allows you to make a comparison of your choices:

Benefit Description: Deductible
High Option You Pay Without Medicare: None
High Option Senior Advantage 1 You Pay: None
High Option Senior Advantage 2 You Pay: None
Standard Option You Pay Without Medicare: None
Standard Option Senior Advantage 1 You Pay: None
Standard Option Senior Advantage 2 You Pay: None
Prosper You Pay Without Medicare: $300
Prosper Senior Advantage You Pay: None

Benefit Description: Primary Care
High Option You Pay Without Medicare: $15 (No charge for children through age 17)
High Option Senior Advantage 1 You Pay: $0 (No charge for children through age 17)
High Option Senior Advantage 2 You Pay: $10 (No charge for children through age 17)
Standard Option You Pay Without Medicare: $20 (No charge for children through age 17)
Standard Option Senior Advantage 1 You Pay: $10 (No charge for children through age 17)
Standard Option Senior Advantage 2 You Pay: $20 (No charge for children through age 17)
Prosper You Pay Without Medicare: $20
Prosper Senior Advantage You Pay: $20

Benefit Description: Specialty Care
High Option You Pay Without Medicare: $30
High Option Senior Advantage 1 You Pay: $20
High Option Senior Advantage 2 You Pay: $25
Standard Option You Pay Without Medicare: $40
Standard Option Senior Advantage 1 You Pay: $25
Standard Option Senior Advantage 2 You Pay: $30
Prosper You Pay Without Medicare: $40
Prosper Senior Advantage You Pay: $30

Benefit Description: Outpatient Surgery
High Option You Pay Without Medicare: $150
High Option Senior Advantage 1 You Pay: $20
High Option Senior Advantage 2 You Pay: $50
Standard Option You Pay Without Medicare: $200
Standard Option Senior Advantage 1 You Pay: $100
Standard Option Senior Advantage 2 You Pay: $120
Prosper You Pay Without Medicare: 10% of our allowance*
Prosper Senior Advantage You Pay: $150

Benefit Description: Inpatient Hospital Care
High Option You Pay Without Medicare: $500 per admission ($250 per admission for maternity)
High Option Senior Advantage 1 You Pay: $100 per admission, (No charge for maternity)
High Option Senior Advantage 2 You Pay: $250 per admission
Standard Option You Pay Without Medicare: $750 per admission (No charge for maternity)
Standard Option Senior Advantage 1 You Pay: $250 per admission
Standard Option Senior Advantage 2 You Pay: $400 per admission
Prosper You Pay Without Medicare: 10% of our allowance* per admission
Prosper Senior Advantage You Pay: $350 per admission

Benefit Description: Part B Reimbursement
High Option Without Medicare: Not Applicable
High Option Senior Advantage 1: None
High Option Senior Advantage 2: Up to $200 monthly
Standard Option Without Medicare: Not Applicable
Standard Option Senior Advantage 1: None
Standard Option Senior Advantage 2: Up to $200 monthly
Prosper Without Medicare: Not Applicable
Prosper Senior Advantage: None

Benefit Description: Additional Benefits Offered
High Option Without Medicare: Not applicable
High Option Senior Advantage 1: Eyeglasses and contact lenses allowance; Healthy Food Card Allowance; One Pass; OTC Allowance; Transportation Allowance
High Option Senior Advantage 2: One Pass; OTC Allowance; Transportation Allowance
Standard Option Without Medicare: Not applicable
Standard Option Senior Advantage 1: One Pass; OTC Allowance; Transportation Allowance
Standard Option Senior Advantage 2: One Pass; OTC Allowance; Transportation Allowance
Prosper Without Medicare: Not applicable
Prosper Senior Advantage: One Pass; OTC Allowance; Transportation Allowance

Benefit Description: Out-of-Pocket Maximum (2x per family)
High Option You Pay Without Medicare: $4,000 per person
High Option Senior Advantage 1 You Pay: $2,000 per person
High Option Senior Advantage 2 You Pay: $2,000 per person
Standard Option You Pay Without Medicare: $5,000 per person
Standard Option Senior Advantage 1 You Pay: $2,500 per person
Standard Option Senior Advantage 2 You Pay: $2,500 per person
Prosper You Pay Without Medicare: $6,500 per person
Prosper Senior Advantage You Pay: $3,250 per person

* You pay the deductible, then cost-sharing

This is a summary of the features of the Kaiser Permanente Senior Advantage for Federal Members. As a Senior Advantage member, you are still entitled to coverage under the FEHB Program. All benefits are subject to the definitions, limitations, and exclusions set forth in this FEHB brochure and the Kaiser Permanente Senior Advantage for Federal Members Evidence of Coverage.

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.

When we are the primary payor, we process the claim first. If you enroll in another plan's Medicare Part D plan and we are the secondary payor, when you fill your prescription at a Plan pharmacy that is not owned and operated by Kaiser Permanente we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan. Our Kaiser Permanente owned and operated pharmacies will not consider another plan's Medicare Part D benefits. These Kaiser Permanente pharmacies will only provide your FEHB Kaiser Permanente benefits.

You will still need to follow the rules in this brochure for us to cover your care. We will only cover your prescription if it is written by a Plan provider and obtained at a Plan pharmacy or through our Plan mail service delivery program, except in an emergency or urgent care situation.

If you enroll in our Kaiser Permanente Senior Advantage for Federal Members plan, you will get all of the benefits of Medicare Part D plus additional drug benefits covered under your FEHB plan.

• 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 whom, 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).

We do not cover a service, supply, item or drug that we consider experimental, except for the limited coverage specified in Section 9, Clinical trials. We consider a service, supply, item or drug to be experimental when the service, supply, item or drug:

(1) has not been approved by the FDA; or

(2) is the subject of a new drug or new device application on file with the FDA; or

(3) is part of a Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial; or is intended to evaluate the safety, toxicity, or efficacy of the service; or

(4) is available as the result of a written protocol that evaluates the service’s safety, toxicity, or efficacy; or

(5) is subject to the approval or review of an Institutional Review Board; or

(6) requires an informed consent that describes the service as experimental or investigational;

We carefully evaluate whether a particular therapy is safe and effective or offers a reasonable degree of promise with respect to improving health outcomes. The primary source of evidence about health outcomes of any intervention is peer-reviewed medical or dental literature.

Healthcare benefits that are available as a result of your employment, or the employment of your spouse, and that are offered by an employer or through membership in an employee organization. Healthcare coverage may be insured or indemnity coverage, self-insured or self-funded coverage, or coverage through health maintenance organizations or other managed care plans. Healthcare coverage purchased through membership in an organization is also “group health coverage.”

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.

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.

Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.

Those claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.

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 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 at 404-261-2590 (locally in the metropolitan Atlanta area) or 888-865-5813 (long distance). 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.

$15 per primary care office visit (Nothing for children through age 17)
$30 per specialty care office visit

(Applies to printed brochure only)

$500 per admission
$250 per admission for maternity

(Applies to printed brochure only)

$150 per visit

(Applies to printed brochure only)

$200 per visit

(Applies to printed brochure only)

Regular cost-sharing

(Applies to printed brochure only)

$5 copay preferred generic, $10 copay non-preferred generic, $45 copay preferred and non-preferred brand drugs, $100 copay specialty drugs
Up to a 90-day supply of most drugs for 2 copays through our mail order program

(Applies to printed brochure only)

$15 copay preferred generic, $25 copay non-preferred, $55 copay preferred and non-preferred brand drugs, $100 copay specialty drugs

(Applies to printed brochure only)

Various cost-shares based on procedure

(Applies to printed brochure only)

$30 per office visit

(Applies to printed brochure only)

See Section 5(h) for more information

(Applies to printed brochure only)

Nothing after $4,000 for Self Only enrollment or $8,000 for Self Plus One and Family enrollment. Some costs do not count toward this protection. 

(Applies to printed brochure only)

$20 per primary care office visit (Nothing for children through age 17)
$40 per specialty care office visit

(Applies to printed brochure only)

$750 per admission
Nothing per admission for maternity

(Applies to printed brochure only)

$200 per visit

(Applies to printed brochure only)

$200 per visit

(Applies to printed brochure only)

Regular cost-sharing

(Applies to printed brochure only)

$5 copay preferred generic, $10 copay non-preferred generic, $45 copay preferred brand drugs, $55 copay non-preferred brand drugs, $150 copay specialty drugs

Up to a 90-day supply of most drugs for 2 copays through our mail order program

(Applies to printed brochure only)

$20 copay preferred generic, $25 copay non-preferred generic, $55 copay preferred brand drug, $65 copay non-preferred brand drug, $150 copay specialty drugs

(Applies to printed brochure only)

Various cost-shares based on procedure

(Applies to printed brochure only)

$40 per visit

(Applies to printed brochure only)

See Section 5(h) for more information

(Applies to printed brochure only)

Nothing after $5,000 for Self Only enrollment or $10,000 for Self and Family enrollment. Some costs do not count toward this protection.

(Applies to printed brochure only)

$300 per person
$600 per family

(Applies to printed brochure only)

$20 per primary care office visit
$40 per specialty care office visit

(Applies to printed brochure only)

10% coinsurance after deductible

(Applies to printed brochure only)

10% coinsurance after the deductible

(Applies to printed brochure only)

$250 per visit

(Applies to printed brochure only)

Regular cost-sharing

(Applies to printed brochure only)

$20 copay preferred generic, $25 copay non-preferred generic, $55 copay preferred brand drugs, $75copay non-preferred drugs, $200 copay specialty drugs

(Applies to printed brochure only)

$5 copay preferred generic, $10 copay non-preferred generic, $45 copay preferred brand drugs, $65 copay non-preferred brand drugs, $200 copay specialty drugs
Up to a 90-day supply of most drugs for 2 copays through our mail order program

(Applies to printed brochure only)

Various cost-share based on procedure

(Applies to printed brochure only)

$40 per visit

(Applies to printed brochure only)

See Section 5(h) for more information

(Applies to printed brochure only)

Nothing after $6,500 for Self Only enrollment or $13,000 for Self Plus One and Family enrollment.  Some costs do not count toward this protection.

(Applies to printed brochure only)