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

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

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

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

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

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

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

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

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

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

Contact your carrier to add a family member when there is already family Coverage.

Contact your employing or retirement office if you are changing from Self to Self Plus One or Self and Family or to add a family member if you currently have a Self Only plan.

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

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

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

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described in the chart below.  A Self Plus One enrollment covers you and your spouse, or one 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 on 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 2023 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 2022 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.

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

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

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

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

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be  eligible for a tax credit that lowers your monthly premiums.  Visit www.HealthCare.gov to compare plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll.  Finally, if you qualify for coverage under another group health plan (such as your spouse's plan), you may be able to enroll in that plan, as long as you apply within 30 days of losing 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 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 800-464-4000 (TTY: 711) 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 our Member Service Call Center at 800-464-4000 (TTY: 711). 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. We contract with the Southern California Permanente Medical Group (Medical Group) to provide or arrange covered services for our members. Medical care is provided through physicians, nurse practitioners, physician assistants, and other skilled medical personnel. Specialists in most major specialties are available as part of the medical teams for consultation and treatment. We credential Plan providers according to national standards. 

We list Plan providers in the provider directory, which we update periodically. Directories are available at the time of enrollment or upon request by calling our Member Service Call Center at 800-464-4000 (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 physicians provide care coordination for complex conditions, for assistance please contact your provider or Member Service Call Center at 800-464-4000 (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 facility directory, with their locations and phone numbers. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling our Member Service Call Center at 800-464-4000 (TTY: 711).The list is also on our website at www.kp.org/feds.

You must receive your health services at Plan facilities, except if you have an emergency, authorized referral, or out-of-area urgent care. If you are visiting another Kaiser Permanente or allied plan service area, you may receive 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 physician. This decision is important since your primary care physician provides or arranges for most of your healthcare.

To choose or change your primary care physician, you can either select one from our Provider Directory, from our website, www.kp.org/feds, or you can call our Member Services Call Center at 800-464-4000 (TTY: 711).

We encourage you to choose a primary care physician when you enroll. You may select a primary care physician from any of our available Plan providers who practice as generalists in these specialties: internal medicine, pediatrics, or family practice. If you do not select a primary care physician, one may 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 physician will provide most of your healthcare, or give you a referral to see a specialist.

Please notify us of the primary care physician you choose. If you need help choosing a primary care physician, call us. You may change your primary care physician at any time. You are free to see other Plan physicians if your primary care physician 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 physician. When your primary care physician 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 physician after the consultation, unless your referral authorizes a certain number of additional visits without the need to obtain another referral. The primary care physician 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 physician gives you an approved referral. However, you may see Plan gynecologists, obstetricians, optometrists, audiologists, urologists (limited to vasectomies), and health education, or mental health and substance use disorder treatment providers without a referral. You may make appointments directly with these providers.

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

• If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician, 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 physician 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 physician. Your primary care physician 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 physician, 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 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 pregnant 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. If you are being treated for a maternal mental health condition, you can continue to see your specialist for up to 12 months from the diagnosis or from the end of pregnancy, whichever occurs later.

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

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Member Service Call Center immediately at 800-464-4000 (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 92nd day after you become a member of this Plan, whichever happens first.

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

Your primary care physician arranges most referrals to specialists. For certain services your Plan physician must obtain approval from Medical Group. 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.

Your Plan physician must obtain prior authorization for:

• Certain prescription medications as identified on our formulary
• Durable medical equipment (DME)
• Home health services (If your Plan Physician makes a written referral for at least eight continuous hours of home health nursing or other care, the Medical Group's designee Plan Physician or committee will authorize the Services if the designee determines that they are Medically Necessary and that they are not the types of Services that an unlicensed family member or other layperson could provide safely and effectively in the home setting after receiving appropriate training)
• Organ/tissue transplants and related services
• Orthopedic and prosthetic devices
• Outpatient surgery and procedures
• Services or items from non-Plan providers or at non-Plan facilities (we cover these services and items only if they are not available from Plan providers)
• Gender Affirming surgery

To confirm if a referral has been approved for a service or item that requires prior authorization, please call our Member Service Call Center at 800-464-4000 (TTY: 711).

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 at least 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 800-464-4000 (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 800-464-4000 (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 prior authorization. However, if you are admitted to a non-Kaiser Permanente 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 prior authorization 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 treatement 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 physician 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 our Member Service Call Center at 800-464-4000 (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.

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

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

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services. 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 or a $25 copayment when you receive diagnostic and treatment services from a specialty care provider.
• Under the Standard Option, you pay a $30 copayment when you receive diagnostic and treatment services from a primary care provider or a $40 copayment when you receive diagnostic and treatment services from a specialty care provider.
• Under Prosper, you pay a $30 copayment when you receive diagnostic and treatment services from a primary care provider or a $40 copayment when you receive diagnostic and treatment services from a specialty care provider.

The Plan may allow you to designate a specialist as the physician who provides most of your healthcare (including services that primary care physicians provide, such as referrals to specialists). If you choose to receive most of your healthcare from a physician designated as a specialist, the specialty care office visit copayment, rather than the primary care office visit copayment, will apply.

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

• The High and Standard Options have no deductible. 
• The calendar year deductible is $100 per person under Prosper. 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 $200.

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.

Cost-sharing is due when you receive the services, except for the following:

Before starting or continuing a course of infertility services, you may be required to pay one or more deposits toward some or the entire course of services. Any unused portion of your deposit will be returned to you. When a deposit is not required, before you can schedule an infertility procedure, you must pay the copayment or coinsurance for the procedure.

For items ordered in advance, you pay the copayment or coinsurance in effect on the order date (although we will not cover the item unless you still have plan coverage for it on the date you receive it) and you may be required to pay the copayment or coinsurance before the item is ordered.

After your cost-sharing total is $2,000 per person up to $4,000 per family enrollment (High Option), $3,000 per person up to $6,000 per family enrollment (Standard Option), or $5,000 per person up to $10,000 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 $2,000 per person up to $4,000 per family maximum out-of-pocket limit. If you or one of your covered family members has out-of-pocket qualified medical expenses of $2,000 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 $4,000 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
• Durable medical equipment, except the following items: blood glucose monitors and their supplies; infusion pumps and supplies to operate the pump; standard curved handle or quad cane and replacement supplies; standard or forearm crutches and replacement supplies; dry pressure pad for a mattress; nebulizer and supplies; peak flow meters; IV pole; bone stimulator; cervical traction (over door); and, phototherapy blankets for treatment of jaundice in newborns
• Hearing aids
• Infertility services and fertility drugs
• Travel benefit

Be sure to keep accurate records and receipts of your cost-sharing, since you are responsible for informing us when you reach the maximum.

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” under certain circumstances. A surprise bill is an unexpected bill you receive from a non-Plan healthcare provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at plan facilities, but you receive some care from non-Plan providers.

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 unexpected bills.

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 800-464-4000.

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

Professional services of physicians and other healthcare professionals

• In a physician’s office
• Office medical consultations
• Second surgical opinions
• Advanced care planning
• At home

$15 per primary care office visit

$25 per specialty care office visit

$30 per primary care office visit (nothing for children through age 17)

$40 per specialty care office visit (nothing for children through age 17)

$30 per primary care office visit

$40 per specialty care office visit

Professional services of physicians and other healthcare professionals

• During a hospital stay
• In a skilled nursing facility

Nothing after the deductible

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

• Interactive video visits
• Phone visits
• Email

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

Nothing

Tests, such as:

• Blood test
• Urinalysis
• Non-routine Pap test
• Pathology
• X-rays
• Non-routine mammogram
• Ultrasound
• Electrocardiogram and EEG
• Nuclear medicine

Nothing

$10 per office visit after the deductible

• Routine laboratory tests to monitor the effectiveness of dialysis

Nothing after the deductible

• CT/CAT scan
• MRI 
• PET scan

$50 per procedure after the deductible

• Procedures requiring licensed staff to monitor your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort.

$300 per procedure after the deductible

Routine physical exam, including hearing exams to determine the need for hearing correction.

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

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/DTaP, and human papillomavirus (HPV). For a complete list of immunizations visit the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules
• Screenings such as for breast cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. For a complete list of A and B recommended screenings visit the U.S. Preventive Services Task Force (USPSTF) website at www.uspreventiveservicestaskforce.org
• Individual counseling on prevention and reducing health risks
• 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 www.healthcare.gov/preventivecare-women
• Services such as routine prostate specific antigen (PSA) test and retinal photography screening
• We cover other preventive services required by federal healthcare reform legislation (the Affordable Care Act and implementing regulations) and additional services that we include in our preventive services benefit. For a complete list of Kaiser Permanente preventive services visit our website at www.kp.org/prevention  
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Nothing

• Routine mammogram covered 

Nothing

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

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 preventive 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
  - Insurance or licensing
  - Participating in employee programs
  - Court ordered parole or probation

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 https://brightfutures.aap.org
• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of
  immunizations go to the Centers for Disease Control (CDC) website at www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of A and B recommended preventive care services under the U.S. Preventive Services Task Force (USPSTF) online at www.uspreventiveservicestaskforce.org
• We cover other preventive services required by federal healthcare reform legislation (the Affordable Care Act and implementing regulations) and additional services that we include in our preventive services benefit. For a complete list of Kaiser Permanente preventive services visit our website at www.kp.org/prevention
• To build your personalized list of preventive services go to 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 physician 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

Not covered:

• Physical exams required for:
  - Obtaining or continuing employment
  - Insurance or licensing
  - Participating in employee program
  - Court ordered parole or probation
• 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

Routine maternity (obstetrical) care, such as:

• Prenatal care visits
• Screening for gestational diabetes 
• First postpartum care visit

Nothing

• Breastfeeding support, supplies and counseling for each birth

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

Nothing

Nothing

Nothing

• Delivery

Nothing for inpatient professional delivery services after the deductible

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 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.
• When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• 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 after 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, limited to:

• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Contraceptive counseling
• Family planning counseling

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. 

Nothing

• Genetic counseling

$15 per primary care office visit

$25 per specialty care office visit

$30 per primary care office visit (nothing for children through age 17)

$40 per specialty care office visit (nothing for children through age 17)

$30 per primary care office visit

$40 per specialty care office visit

Not covered:

• Reversal of voluntary surgical sterilization

All charges

Diagnosis and treatment of infertility, such as:

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

Notes:

• See Section 5(a) Lab, X-ray, and other diagnostic tests, for coverage of diagnostic prescreening testing associated with infertility services, such as an Electrocardiogram (EKG).
• 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.
• Infertility services are covered for individuals over the age of 18.
• 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

Standard fertility preservation for iatrogenic infertility, such as:

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

Note: You pay cost-sharing for other services associated with fertility preservation for iatrogenic infertility, including:

• Lab, X-ray and other diagnostic tests, as described in Section 5(a)
• Surgical services as described in Section 5(b)
• Outpatient hospital or ambulatory surgical center as described in Section 5(c)
• Prescription drugs as described in Section 5(f)

$25 per specialty care office visit

$40 per specialty care office visit

$40 per specialty care office visit

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)
• Any charges associated with donor eggs, donor sperm or donor embryos
• Any charges associated with cryopreservation, unless listed as covered above for iatrogenic infertility
• Any charges associated with thawing and storage of frozen sperm, eggs and embryos, unless listed as covered above for iatrogenic infertility
• Ovum transplants
• Infertility services when either member of the family has been voluntarily, surgically sterilized
• Services to reverse voluntary, surgically induced infertility

All charges

• Testing and treatment

$40 per specialty care office visit

$40 per specialty care office visit

• Injections

$5 per office visit

• Serum

Nothing after the deductible

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

All charges

• Chemotherapy

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

• Intravenous (IV)/Infusion therapy— Home IV and antibiotic therapy
• Radiation therapy

$25 for services provided by a physician

Nothing for services provided by a non-physician provider

$40 for services provided by a physician

Nothing for services provided by a non-physician provider

$40 for services provided by a physician

Nothing for services provided by a non-physician provider

• Cardiac rehabilitation following a qualifying event/condition

$15 per primary care office visit

$25 per specialty care office visit

$30 per primary care office visit

$40 per specialty care office visit

$30 per primary care office visit

$40 per specialty care office visit

• Respiratory and inhalation therapy

$25 per specialty care office visit

Nothing for services provided by a non-physician provider

$40 per specialty care office visit

$10 per office visit for services provided by a non-physician provider

$40 per specialty care office visit

$10 per office visit for services provided by a non-physician provider after the deductible

• Outpatient dialysis performed in a doctor’s office or facility - hemodialysis and peritoneal dialysis

$40 per specialty care office visit after the deductible

• Ultraviolet light treatments
• Home dialysis – hemodialysis and peritoneal dialysis

Nothing

Notes:

• After you receive appropriate training at a dialysis facility we designate, we also cover equipment and medical supplies required for home hemodialysis and home peritoneal dialysis inside our service area. Coverage is limited to the standard item of equipment or supplies that adequately meets your medical needs. We decide whether to rent or purchase the equipment and supplies, and we select the vendor. You must return the equipment and any unused supplies to us or pay us the fair market price of the equipment and any unused supplies when we are no longer covering them.
• See Section 5(e), Professional services, for coverage of Applied Behavior Analysis (ABA).
• Note: Growth hormone is covered under the prescription drug benefit. See Section 5(f), Prescription drug benefits.

Applies to this benefit

Applies to this benefit

Applies to this benefit

• 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.
• Multidisciplinary outpatient rehabilitation includes diagnostic and restorative services comprising a program of physical, speech, occupational, and respiratory therapy, as well as certain other items and services that are medically necessary for rehabilitation.

$15 per visit

$30 per visit

$30 per visit after the deductible

Not covered:

• Exercise programs

All charges

Habilitative and rehabilitative services for:

• Visits to a speech therapist

$15 per visit

$30 per visit

$30 per visit after the deductible

Not covered:

• Services to treat social, behavioral, or cognitive delays in speech or language development, unless medically necessary.

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, for any other hearing testing, see Section 5(a), Diagnostic and treatment services.

$15 per primary care office visit

$25 per specialty care office visit

$30 per primary care office visit

$40 per specialty care office visit

$25 per primary care office visit

$35 per specialty care office visit

Hearing aids for children through age 17, including testing and examinations

Notes:

• We will cover hearing aids for both ears only if both aids are required to provide significant improvement that is not obtainable with only one hearing aid.
• Coverage is limited to the types and models of hearing aids furnished by the provider or vendor we select.
• For coverage of Audible prescription reading and speech generating devices, see Section 5(a), Durable medical equipment.

All charges in excess of $1,000 for each hearing impaired ear every 36 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 18 and over
• Internally implanted hearing aids
• Replacement parts and batteries, repair of hearing aids, and replacement of lost or broken hearing aids

All charges

• Diagnosis and treatment of diseases of the eye

$15 per primary care office visit

$25 per specialty care office visit

$30 per primary care office visit (nothing for children through age 17)

$40 per specialty care office visit (nothing for children through age 17)

$30 per primary care office visit

$40 per specialty care office visit

• Routine eye exam with a Plan optometrist to determine the need for vision correction and provide a prescription for eyeglasses
• Therapeutic contact lenses for the condition of aniridia for up to two lenses per eye, per calendar year
• Up to a total of six medically necessary aphakic contact replacement lenses per eye, per calendar year to treat aphakia (absence of the crystalline lens of the eye)

Nothing

Not covered:

• Eyeglass lenses or frames 
• Contact lenses, examinations for contact lenses or the fitting of contact lenses, except for the condition of aniridia or to treat aphakia
• Eye surgery solely for the purpose of correcting refractive defects of the eye

All charges

• Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes

$15 per primary care office visit

$25 per specialty care office visit

$30 per primary care office visit (nothing for children through age 17)

$40 per specialty care office visit (nothing for children through age 17)

$30 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 that are consistent with our Plan Soft Goods Formulary guidelines
• Podiatric devices (including footwear) to prevent or treat diabetes-related complications when prescribed by a Plan physician
• Special footwear for foot disfigurement due to disease, injury, or developmental disability
• Enteral formula for members who require tube feeding per Medicare guidelines
• Tracheostomy tube and supplies
• Enteral pump and supplies
• External devices used for the treatment of sexual dysfunction

Nothing

Nothing

Internal prosthetic devices, such as:

• Artificial joints
• Pacemakers
• Cochlear implants
• Osseointegrated external hearing devices
• Surgically implanted breast implants following a mastectomy
• Monofocal intraocular lenses following cataract removal
• Repairs and replacements resulting from normal use

Note: See Section 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 after the deductible

Notes:

• Orthopedic and prosthetic equipment or services must be prescribed by a Plan physician; obtained through sources designated by the Plan; 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.
• See Section 3 How you get care for services that need prior Plan approval.

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, except as described above
• Multifocal intraocular lenses and intraocular lenses to correct astigmatism
• Nonrigid supplies, such as elastic stockings and wigs
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Comfort, convenience, or luxury equipment or features
• 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
• Hospital beds
• Wheelchairs, including motorized wheelchairs when medically necessary
• Crutches
• Walkers
• Speech generating devices
• Blood glucose monitors and related supplies
• Insulin pumps
• Infant apnea monitors

50% of our allowance

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

Nothing

• During a covered stay in a Plan hospital or skilled nursing facility

Nothing after the deductible

Notes:

• Durable medical equipment (DME) is equipment that is prescribed by 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.
• 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.
• We only provide DME in the Plan's service areas, except we cover the following DME items if you live outside our service area when the item is dispensed at a Plan facility:
  • Standard curved handle cane 
  • Standard crutches
  • For diabetes blood testing, blood glucose monitors and their supplies from a Plan Pharmacy
  • Insulin pumps and supplies to operate the pump (but not including insulin or any other drugs), after completion of training and education on the use of the pump
  • Nebulizers and their supplies for the treatment of pediatric asthma
  • Peak flow meters from a Plan Pharmacy
• Diabetes urine-testing supplies and insulin-administration devices other than insulin pumps are covered under your prescription drug benefit. See Section 5(f), Prescription drug benefits.
• See Section 3 How you get care for services that need prior Plan approval.

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, except diabetic blood testing equipment and supplies
• 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
• 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.), physical or occupational therapist, speech therapist or home health aide
• Services include oxygen therapy, intravenous therapy, and medications

Notes:

• We only provide these services in the Plan's service areas.
• The 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.
• Services of a home health aide must be part of covered home healthcare and home health aide services are not covered unless you are also getting covered home healthcare from a licensed provider that only a licensed provider can provide.
• See Section 3 How you get care for services that need prior Plan approval.

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
• Personal care and hygiene items
• Care of a type that an unlicensed family member or other layperson could provide safely and effectively in the home setting after receiving appropriate training. This care is excluded even if we would cover the care if it were provided by a qualified medical professional in a hospital or a skilled nursing facility.

All charges

Up to 20 combined visits for accupuncture and chiropractic services per calendar year, limited to:

• Diagnosis and treatment of neuromusculoskeletal disorders
• Laboratory tests and plain film X-rays associated with diagnosis and treatment

Notes:

• You may only self-refer to a participating American Specialty Health (ASH) network chiropractor. The participating chiropractor must provide, arrange or prescribe your care and appliances.
• Participating chiropractors are listed in the ASH Participating Provider Directory. For a list of ASH Participating Providers, call 800-678-9133.

$15 per visit

$15 per visit

All charges

• Chiropractic appliances

All charges

• Acupuncture services, primarily for the treatment of chronic pain and nausea

$15 per visit

$30 per visit

$30 per 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, including adjunctive therapy
• Massage therapy

All charges

Health education classes including:

• Tobacco cessation programs, including individual, group and phone counseling, prescribed over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco cessation.
• Stress reduction
• Chronic conditions, such as diabetes and asthma
• Individual health education visits
• Childhood obesity screening programs and treatment interventions

Notes:

• Please call your local Health Education department or Member Services at 800-464-4000 for information on classes near you.
• See Section 5(f), Prescription drug benefits, for important information about coverage of tobacco cessation and other drugs.

Nothing

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and postoperative 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)
• Male voluntary sterilization (e.g., vasectomy)
• Treatment of burns
• Insertion of other implanted time-release drugs

Notes:

• We cover the cost of these drugs and devices under the prescription drug benefit (see Section 5(f)).
• See Section 3, How you get care for services that need prior Plan approval

Nothing

Nothing

Nothing

• Surgical treatment of morbid obesity (bariatric surgery). You must:
  • have a Body Mass Index (BMI) of 40 or greater. If your BMI is 35 to 39.9, bariatric surgery may be covered if the Medical Group authorizes the services in accord with the Medical Group’s bariatric surgery referral guidelines. The guidelines may require that another or a combination of medical condition(s) be present, such as: coronary artery disease, diabetes or sleep apnea; and
  • meet all other bariatric surgery referral guidelines, including but not limited to: nutritional, psychological, medical, and social readiness for surgery, and complete a Medical Group approved pre-surgical educational preparatory program regarding lifestyle changes necessary for long-term bariatric surgery success

Notes:

• You should consult with your physician to determine what is appropriate for you.
• A Plan physician, who is a specialist in bariatric care, must determine that the surgery is medically necessary.
• If you live 50 miles or more from the facility to which you are referred for a covered bariatric surgery, we will reimburse you for certain authorized and documented travel and lodging expenses as follows if:
  • The Medical Group gives you prior written authorization for travel and lodging reimbursement and
  • You send us adequate documentation including receipts.
• Reimbursement benefits are subject to certain limits. Please call our Member Services Call Center at 800-464-4000 for more information.

Nothing

Nothing

Nothing

• Female voluntary sterilization, including anesthesia and confirmation testing following tubal occlusion
• Insertion of surgically implanted time-release contraceptive drugs and intrauterine devices (IUDs)

Nothing

• Surgical and any other procedures requiring licensed staff to monitor your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort.

Nothing

Nothing

Nothing

• Insertion of internal prosthetic devices. See Section 5(a) Orthopedic and prosthetic devices, for device coverage information.

Note: The following contraceptive devices and drugs are provided at no charge: intrauterine devices (IUDs), implanted time-release contraceptive drugs and injectable contraceptive drugs. We cover oral contraceptives, cervical caps, and diaphragms under the prescription drug benefit.

Nothing

Nothing

Nothing

Not covered:

• Reversal of voluntary surgical 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; webbed fingers and toes

Note: We cover dental extractions, dental procedures necessary to prepare the mouth for an extraction and orthodontic services that are an integral part of reconstructive surgery for cleft palate, cleft lip, or other craniofacial anomalies associated with cleft palate.

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

Nothing

Nothing

Nothing

• Reconstructive surgical and any other procedures requiring licensed staff to monitor your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort.

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
• Gender Affirming Surgery not listed above

All charges

Oral surgical procedures, limited to:

• Reduction of fractures of the jaw 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

Nothing

Nothing

Nothing

• Oral surgical procedures requiring licensed staff to monitor your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort.

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)
• 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 authorization procedures. Solid organ tissue transplants are limited to:

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

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 in Section 3 for prior authorization procedures.

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

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)
  • 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
  • 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)
  • Chronic myelogenous leukemia
  • 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

Transplant services requiring licensed staff to monitor your vital signs as you regain sensation after receiving drugs to reduce sensation or to minimize discomfort.

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.
• We cover medically necessary routine dental services required in preparation for a transplant. You pay cost-sharing listed in Section 5(a) for services performed during an office visit. Covered services may include a routine oral examination, cleaning (prophylaxis), extractions, and X-rays.
• Please refer to Section 5(h), Special features, for information on our Centers of Excellence.
• See Section 3 How you get care for services that need prior Plan approval.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

• Donor screening tests and donor search expenses, except those listed above
• Implants of non-human artificial organs
• Transplants not listed as covered

All charges

Professional services provided in:

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

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.

$250 per admission

$500 per admission

Nothing for maternity care

$750 per admission after the 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 after the deductible

Not covered:

• Custodial care and care in an intermediate care facility
• Non-covered facilities, such as nursing homes
• Personal comfort items, such as barber services, and guest meals and beds
• Private nursing care, except when medically necessary
• Inpatient dental procedures

All charges

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Lab, X-rays, and other diagnostic tests
• Blood and blood products
• Pre-surgical testing
• Dressing, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

$300 per admission after the deductible

Up to 100 days per benefit period when you need full-time skilled nursing care. A benefit period begins when you enter a hospital or skilled nursing facility and ends when you have not been a patient in either a hospital or skilled nursing facility for 60 consecutive days.

All necessary services are covered, including:

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

Nothing 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:

• The Services are provided inside our Service Area or inside California but within 15 miles or 30 minutes from our Service Area (including a friend's or relative's home even if you live there temporarily)
• 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 twelve months or less.

Nothing

Nothing

Nothing

Not covered:

• Independent nursing (private duty nursing)

All charges

• Local licensed ambulance service when medically necessary

Note: See Section 5(d) for emergency services.

$50 per trip

$200 per trip after the deductible

Not covered:

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

All charges

• Urgent care at a Plan urgent care center

$30 per visit (nothing for children through age 17)

$30 per visit

• Emergency room visits at a Plan hospital, including physicians’ services
• Emergency care as an outpatient at a non-Plan hospital, including physicians’ services
• Urgent care at a Plan emergency room 

Notes:

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

$150 per visit after the deductible

• Elective care or non-emergency care (unless you receive prior authorization)
• Urgent care at a non-Plan urgent care center

All charges

• Urgent care at an urgent care center

$30 per visit (nothing for children through age 17)

$30 per visit

• Emergency care at an urgent care center
• Emergency care as an outpatient at a hospital, including physicians’ services
• Urgent care at an emergency room 

Note: See Section 5(h) for travel benefit coverage of continuing or follow-up care.

$150 per visit after the deductible

Not covered:

• Elective care or non-emergency care at non-Plan facilities (unless you receive prior authorization)

All charges

Licensed ambulance services are covered when:

• Your treating physician determines that you must be transported to another facility because your emergency medical condition is not stabilized and the care you need is not available at the treating facility.
• You are not already being treated, and you reasonably believed that the medical condition was an emergency medical condition which required ambulance services.

Notes:

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

$200 per trip after the deductible

Not covered:  

• Transportation by car, taxi, bus, gurney van, wheelchair van, and any other type of transportation (other than a licensed ambulance or psychiatric transport van), 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 that 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:

• Diagnostic evaluation
• Treatment and counseling (including individual and group therapy visits)
• Crisis intervention and stabilization for acute episodes
• Psychological and neuropsychological testing that is medically necessary to determine the appropriate psychiatric treatment
• Medication evaluation and management (pharmacotherapy)
• Electroconvulsive therapy

$15 per individual office visit

$7 per group office visit

$30 per individual office visit (nothing for children through age 17)

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

$30 per individual office visit

$15 per group office visit

• Applied Behavior Analysis (ABA) program for the treatment of autism spectrum disorder

$15 per day

$30 per day

$30 per day

Diagnosis and treatment of substance use disorders. Services include:

• Treatment and counseling (including individual, family, and group therapy visits)
• Outpatient detoxification (medical management of withdrawal from the substance)

$15 per individual office visit

$5 per group office visit

$30 per individual office visit (nothing for children through age 17)

$5 per group office visit (nothing for children through age 17)

$30 per individual office visit

$5 per group office visit

Notes:

• You may see a Plan mental health or substance use provider for outpatient services without a referral from your primary care physician. 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.

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. 

See Section 5c, Other Hospital Services and Supplies.

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

See Section 5c, Other Hospital Services and Supplies.

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

See Section 5c, Other Hospital Services and Supplies.

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
• Inpatient psychiatric care
• Inpatient substance use care

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

$750 per admission after the deductible

• Psychiatric and substance use care in a residential treatment center

Note: Residential treatment programs require approval by a Plan mental health or substance use disorder treatment physician.

$100 per stay after the deductible

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

• Hospital alternative services, such as partial hospitalization and intensive outpatient psychiatric treatment programs  

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

Nothing 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:

• Certain self-administered IV drugs and fluids requiring specific types of parenteral infusion, and the supplies required for their administration
• Hematopoietic agents for dialysis
• Amino acid-modified products used to treat congenital errors of amino acid metabolism
• Diabetes urine-testing supplies limited to ketone test strips, test tape and acetone test tablets, up to a 100-day supply
• Elemental dietary enteral formula when used as a primary therapy for regional enteritis

Note: See Section 5(a), Durable medical equipment, for diabetes blood-testing equipment and supplies.

Nothing

• Drugs and medications that, by federal law, require a prescription for their purchase, except those listed as Not covered. We also cover certain drugs that do not require a prescription by law if they are listed on our drug formulary.
• Insulin
• Disposable needles and syringes for the administration of covered medications
• Growth hormone
• Drugs to treat gender dysphoria, including hormones and androgen blockers
• Vaccines and immunizations approved for use by the Food and Drug Administration

Notes:

• For information about mail order discounts, see "These are the dispensing limitations" in the introduction in Section 5(f).
• The preferred or non-preferred brand name or specialty drug cost share will apply to compound drugs.
• 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 and when one of the ingredients requires a prescription by law.

$10 for generic drugs, $40 for preferred and non-preferred brand name drugs, and $100 for specialty drugs per prescription or refill for up to a 30-day supply at a Plan pharmacy

All charges if you request a brand name drug in place of a generic drug

$15 for generic drugs, $50 for preferred and non-preferred brand name drugs, and $150 for specialty drugs per prescription or refill for up to a 30-day supply at a Plan pharmacy

All charges if you request a brand name drug in place of a generic drug

$15 for generic drugs, $60 for preferred and non-preferred brand name drugs, and $200 for specialty drugs per prescription or refill for up to a 30-day supply at a Plan pharmacy

All charges if you request a brand name drug in place of a generic drug

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

Nothing

• Insulin administration devices, such as:
  • Disposable needles and syringes 
  • Pen delivery devices 
  • Visual aids required to ensure proper dosage (except eyewear)

Up to a 100-day supply at $15

Contraceptive drugs and devices as listed in the ACA/HRSA site. Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in all methods 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.  

• We cover contraceptive drugs and devices, including implanted contraceptive devices, diaphragms, hormonal contraceptive methods, and prescribed FDA approved over-the-counter women's contraceptives and devices 
• We cover non-preferred contraceptives if they would otherwise be covered, and a Plan provider receives an approved drug formulary exception. 
• 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

All charges if you request a brand name drug in place of a generic drug

Nothing

All charges if you request a brand name drug in place of a generic drug

Nothing

All charges if you request a brand name drug in place of a generic drug

• Fertility drugs

50% of our allowance

• Sexual dysfunction drugs

Note: If a drug for which a prescription is required by law is excluded and we had been covering and providing it to you for a use approved by the FDA, we will continue to provide the drug upon payment of 50% of our allowance if a Plan physician continues to prescribe the drug for the same condition.

50% of our allowance up to a maximum of $50 for generic drugs;

50% of our allowance up to a maximum of $100 for preferred brand-name drugs

50% of our allowance up to a maximum of $50 for generic drugs;

50% of our allowance up to a maximum of $100 for preferred brand-name drugs

50% of our allowance up to a maximum of $50 for generic drugs;

50% of our allowance up to a maximum of $100 for preferred brand-name drugs

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• 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 or below
• Over-the-counter (nonprescription) drugs, including prescription drugs for which there is an over-the-counter 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
• Drugs for the promotion, prevention, or other treatment of hair loss or growth

All charges      

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

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

Nothing

Not covered:

• Prescriptions filled at a non-Plan pharmacy, except for emergencies as described in Section 5(d), Emergency services/accidents
• Vitamins, nutritional 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 they are included in our drug formulary or listed as covered above
• Prescription drugs not on our drug formulary, unless approved through an exception process
• Any requested packaging of drugs other than the dispensing pharmacy’s standard packaging
• Replacement of lost, stolen or damaged prescription drugs and accessories
• Drugs related to non-covered services

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.

• 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.

Note: Services will be covered only when provided within 72 hours following the accidental injury.

Nothing up to the benefit maximum of $500 of covered charges per accidental injury

Nothing up to the benefit maximum of $500 of covered charges per accidental injury

Nothing up to the benefit maximum of $500 of covered charges per accidental injury

All charges after reaching the benefit maximum of $500 per accidental injury

Not covered:

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

All charges

All charges

We have no other dental benefits.

All charges

All charges

All charges

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).

The Centers of Excellence program began in Fall 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.

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 www.kp.org/travel.

Kaiser Permanente travel benefits for Federal employees provide 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 benefits 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 and/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 Service Call Center at 800-464-4000 (TTY: 711). File claims as shown in Section 7.

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

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

Take steps to improve your well-being by completing the Kaiser Permanente Total Health Assessment and a healthy lifestyle program. FEHB subscribers and their enrolled spouses (age 18 and over) are eligible for the following rewards:

• $50 for completing a confidential, online, Total Health Assessment (available in English or Spanish). You will get a picture of your overall health and a customized action plan with tips and resources to improve your well-being.
• $25 for completing an online healthy lifestyle program of your choice. Personalized and self-paced, they can help you reduce stress, quit smoking, lose weight and more. You can complete as many of these online programs as you would like, but you will only earn a reward for one program completion.

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/or a healthy lifestyle program during the plan year. We will issue you a Kaiser Permanente Health Payment Card 4-6 weeks after you complete either activity. 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.

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Facilities will file on the UB-04 form. For claims questions and assistance, call our Member Service Call Center at 800-464-4000 (TTY: 711). 

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

• Covered member’s name, date of birth, address, phone number and ID number
• Name and address of the provider or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• 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:

Southern California service area:
Kaiser Foundation Health Plan, Inc.
Claims Department
P.O. Box 7004
Downey, CA 90242-7004

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

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

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

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

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

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

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

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

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

b) Send your request to us at: Kaiser Permanente, Special Services Unit, P.O. Box 7136, Pasadena, CA 91109; 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 you do not agree with our decision, you may ask OPM to review it.

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 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 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 our 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 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. Our right to receive payment is not subject to reduction based on attorney fees or costs under the “common fund” doctrine and is fully enforceable regardless of whether you are “made whole” or fully compensated for the full amount of damages claimed.

We are entitled to full recovery regardless of whether any liability for payment is admitted by any person, entity or insurer. We are entitled to full recovery regardless of whether the settlement or judgment received by you identifies the medical benefits provided or purports to allocate any portion of such settlement or judgment to payment of 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:

The Rawlings Group
Surrogacy Mailbox
P.O. Box 2000
LaGrange, KY  40031

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 711), 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 800-443-0815 (TTY: 800-777-1370), 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.

You must tell us if you or a covered family member has Medicare coverage, and let us obtain information about services denied or paid under Medicare if we ask. You must also tell us about other coverage you or your covered family members may have, as this coverage may affect the primary/secondary status of this Plan and Medicare.

We offer a plan designed to help High and Standard Option 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 Part B and are enrolled in Senior Advantage for Federal Members, you will be reimbursed up to $250 of the Medicare Part B monthly premium you pay, including any amount added to your Part B premium for the Part B late enrollment penalty (LEP) or Income Related Monthly Adjustment Amount (IRMAA). In addition to reimbursing you for the Part B monthly premium, we will cover additional benefits, including lower office visit copayments, urgent care and emergency care, plus additional coverage for benefits, such as the Silver&Fit fitness program.

You may enroll in this program if:

• You enroll in the plan's High or Standard Option
• You live in our Medicare Advantage Service Area
• You have Medicare Parts A and B, or Medicare Part B only, and you enroll in Senior Advantage for Federal Members
• The FEHB subscriber completes an additional application for enrollment in Senior Advantage 2

Reimbursements will begin on the first of the month following receipt of your additional application for enrollment in Senior Advantage 2 and when we receive proof from you for the Part B premium amount you pay.  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 or Standard Option benefits will resume.  You may be required to repay any reimbursements paid to you in error.

To learn more about Senior Advantage 2 and how to enroll, call us at 855-366-9013, 8 a.m. to 8 p.m., 7 days a week , or visit our website at www.kp.org/feds.  For TTY for the deaf, hard of hearing, or speech impaired, call 711. We will send you additional information and an additional application for enrollment in Senior Advantage 2.

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 2 Kaiser Permanente Senior Advantage plans: "Senior Advantage 1" (best benefits) and "Senior Advantage 2" (some better benefits and Part B premium reimbursement) and Senior Advantage for Prosper. If you live in our Senior Advantage service area and you have Medicare Parts A and B, or Medicare Part B only, 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 Medicare rules. If you are already a member of Senior Advantage for Federal Members and would like to understand your additional benefits in more detail, please refer to your Senior Advantage for Federal Members Evidence of Coverage. If you are considering enrolling in Senior Advantage for Federal Members, please call us at 800-443-0815 (TTY: 800-777-1370), 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 2023 benefit summary allows you to make a comparison of your choices:

Benefit Description: Deductible
High Option without Medicare you pay: None
High Option with Senior Advantage 1 you pay: None
High Option with Senior Advantage 2 you pay: None
Standard Option without Medicare you pay: None
Standard Option with Senior Advantage 1 you pay: None
Standard Option with Senior Advantage 2 you pay: None
Prosper without Medicare you pay: $100
Prosper with Senior Advantage you pay: None

Benefit Description: Primary Care
High Option without Medicare you pay: $15
High Option with Senior Advantage 1 you pay: $5
High Option with Senior Advantage 2 you pay: $10
Standard Option without Medicare you pay: $30
Standard Option with Senior Advantage 1 you pay: $15
Standard Option with Senior Advantage 2 you pay: $20
Prosper without Medicare you pay: $30
Prosper with Senior Advantage you pay: $25

Benefit Description: Specialty Care
High Option without Medicare you pay: $25
High Option with Senior Advantage 1 you pay: $5
High Option with Senior Advantage 2 you pay: $10
Standard Option without Medicare you pay: $40
Standard Option with Senior Advantage 1 you pay: $15
Standard Option with Senior Advantage 2 you pay: $30
Prosper without Medicare you pay: $40
Prosper with Senior Advantage you pay: $35

Benefit Description: Outpatient Surgery
High Option without Medicare you pay: $50
High Option with Senior Advantage 1 you pay: $5
High Option with Senior Advantage 2 you pay: $50
Standard Option without Medicare you pay: $200
Standard Option with Senior Advantage 1 you pay: $15
Standard Option with Senior Advantage 2 you pay: $150
Prosper without Medicare you pay: $300*
Prosper with Senior Advantage you pay: $200

Benefit Description: Inpatient Hospital Care
High Option without Medicare you pay: $250
High Option with Senior Advantage 1 you pay: $0
High Option with Senior Advantage 2 you pay: $250
Standard Option without Medicare you pay: $500
Standard Option with Senior Advantage 1 you pay: $250
Standard Option with Senior Advantage 2 you pay: $350
Prosper without Medicare you pay: $750* per admit
Prosper with Senior Advantage you pay: $500 per admit

Benefit Description: Additional Benefits Offered
High Option without Medicare: Not Applicable
High Option with Senior Advantage 1: Eyeglasses and contact lenses allowance, dental cleaning, home-delivered meals, and transportation
High Option with Senior Advantage 2: Hearing aid allowance and Silver&Fit
Standard Option without Medicare: Not Applicable
Standard Option with Senior Advantage 1: Eyeglasses and contact lenses allowance and dental cleaning
Standard Option with Senior Advantage 2: Silver&Fit
Prosper without Medicare: Not applicable
Prosper with Senior Advantage: Eyeglasses and contact lenses allowance and Silver&Fit

Benefit Description: Out-of-pocket (2x per family)
High Option without Medicare you pay: $2,000 per person
High Option with Senior Advantage 1 you pay: $2,000 per person
High Option with Senior Advantage 2 you pay: $2,000 per person
Standard Option without Medicare you pay: $3,000 per person
Standard Option with Senior Advantage 1 you pay: $2,000 per person
Standard Option with Senior Advantage 2 You pay: $2,500 per person
Prosper without Medicare you pay: $5,000
Prosper with Senior Advantage you pay: $3,000

Benefit Description: Part B Premium reimbursement
High Option without Medicare: $0
High Option with Senior Advantage 1: $0
High Option with Senior Advantage 2: Up to $250 monthly
Standard Option without Medicare: $0
Standard Option with Senior Advantage 1: $0
Standard Option with Senior Advantage 2: Up to $250 monthly
Prosper without Medicare: $0
Prosper with Senior Advantage: $0

*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), but we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

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

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

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

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

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

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

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

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

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.

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 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 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.

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 Service Call Center at 800-464-4000. 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
$25 per specialty care office visit

(Applies to printed brochure only)

$250 per admission

(Applies to printed brochure only)

$50 per admission

(Applies to printed brochure only)

$100 per visit*

(Applies to printed brochure only)

Regular cost-sharing

(Applies to printed brochure only)

$10 Generic; $40 preferred and non-preferred brand; $100 specialty

(Applies to printed brochure only)

No benefit

(Applies to printed brochure only)

Nothing

(Applies to printed brochure only)

See Section 5(h) for more information.

(Applies to printed brochure only)

Nothing after $2,000/Self Only or $4,000/Family enrollment per year. Some costs do not count toward this protection.

(Applies to printed brochure only)

$30 per primary care office visit
$40 per specialty care office visit

(Applies to printed brochure only)

$500 per admission

(Applies to printed brochure only)

$200 per admission

(Applies to printed brochure only)

$150 per visit*

(Applies to printed brochure only)

Regular cost-sharing

(Applies to printed brochure only)

$15 Generic; $50 preferred and non-preferred brand; $150 specialty

(Applies to printed brochure only)

No benefit

(Applies to printed brochure only)

Nothing

(Applies to printed brochure only)

See Section 5(h) for more information.

(Applies to printed brochure only)

Nothing after $3,000/Self Only or $6,000/Family enrollment per year. Some costs do not count toward this protection.

(Applies to printed brochure only)

$100 per person
$200 per family

(Applies to printed brochure only)

$30 per primary care office visit,
$40 per specialty care office visit

(Applies to printed brochure only)

$750 per admission*

(Applies to printed brochure only)

$300 per admission*

(Applies to printed brochure only)

$150 per visit*

(Applies to printed brochure only)

Regular cost-sharing

(Applies to printed brochure only)

$15 generic drugs; $60 preferred and non-preferred brand; $200 specialty

(Applies to printed brochure only)

No benefit

(Applies to printed brochure only)

Nothing

(Applies to printed brochure only)

See Section 5(h) for more information.

(Applies to printed brochure only)

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

(Applies to printed brochure only)