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

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

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

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

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

Also, your employing or retirement office can answer your questions and 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 obtain a Certificate of Creditable Coverage (COCC).

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

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

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

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

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

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

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

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

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

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2024 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 2023 benefits until the effective date of your coverage with your new plan. Annuitants coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

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

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

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

Any person covered under the 31 day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31 day temporary extension. You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, please call Member Services at 888-901-4636 or write to us at Kaiser Foundation Health Plan of Washington, Member Services, P.O. Box 34590, Seattle WA 98124-1590. You may also request replacement cards through our website, www.kp.org/wa

You get care from "Plan providers" and "Plan facilities." You will only pay copayments, deductibles, and/or coinsurance 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 Washington Permanente Medical Group (Medical Group) to provide or arrange covered services for our members. Medical care is provided through physicians, nurse practitioners, physician assistants, and other skilled medical personnel. Specialists in most major specialties are available as part of the medical teams for consultation and treatment. We credential Plan providers according to national standards.

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

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

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

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

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

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.

You and each family member should choose a primary care provider. This decision is important since your primary care provider provides or arranges for most of your healthcare. There are several ways to select a physician; you may contact Member Services at 888-901-4636 or your chosen Plan facility for assistance.

Your primary care provider (such as family practitioner or pediatrician) will arrange for most of your healthcare, or give you a referral to see a specialist.

If you want to change primary care providers or if your primary care provder leaves the Plan, call Member Services at 888-901-4636 or contact your chosen Plan facility. We will help you select a new one.

Your primary care provider will refer you to a specialist for needed care, but you may also self-refer to many specialists at Kaiser Foundation Health Plan of Washington facilities. When you receive a referral from your primary care provider, you must return to the primary care provider after the consultation, unless your primary care provider authorized a certain number of visits without additional referrals. However, you may see a woman’s healthcare specialist or a mental health provider without a referral, namely a participating General or Family Practitioner, Physician’s Assistant, Gynecologist, Certified Nurse Midwife, Doctor of Osteopathy, Obstetrician or Advanced Registered Nurse Practitioner for medically appropriate maternity care, reproductive health services, preventive care and general examination, gynecological care, and medically appropriate follow-up visits for the above services. If the chosen provider diagnoses a condition that requires a referral to other specialists or hospitalization, you or your chosen provider must obtain preauthorization and care coordination in accordance with applicable Plan requirements.

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 provider will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care provider will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

Your primary care provider will create your treatment plan. The physician may have to get an authorization or approval beforehand. If you are seeing a specialist when you enroll in our Plan, talk to your primary care provider. If they decide to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

• If you are seeing a specialist and your specialist leaves the Plan, call your primary care provider, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause; 
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; 
  • 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 our Member Services Department at 888-901-4636 or, if we drop out of the Program, contact your new plan.

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

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

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Member Services department immediately at 888-901-4636. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

Your primary care provider arranges most referrals to specialists. For certain services, your Plan physician must obtain approval from us. Before we approve a referral, we consider if the item or service 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:

• Specialty care
• Inpatient hospital
• Surgical treatment of morbid obesity
• Certain prescription medications as identified on our formulary
• Non-emergency ambulance
• Durable Medical Equipment
• Gender Affirming surgery
• Infusion therapy

To confirm if a referral has been approved for a service or item that requires prior authorization, please call Member Service at 888-901-4636 (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.

First, your physician, your hospital, you, or your representative, must call us at 888-901-4636 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

For non-urgent 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 possess an average knowledge of health and medicine.

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 888-901-4636. You may also call OPM’s FEHB 3 at (202) 606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. 

We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 888-901-4636. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

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

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

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

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

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

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

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

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; or

2. Ask you or your provider for more information.

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

If we do not receive the information within 60 days, we will decide within 30 days of the date the information 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 $25 copayment when you receive diagnostic and treatment services in a physician’s office.
• Under the Standard Option, you pay a $25 copayment when you receive diagnostic and treatment services from a primary care provider or a $35 copayment when you receive diagnostic and treatment services from a specialty care provider.
• Under Prosper, you pay a $15 copayment when you receive diagnostic and treatment services from a primary care provider and a $40 copayment when you receive these services from a specialty care provider.

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

• We do not have a deductible for the High Option and Standard Option.
• The calendar year deductible for Prosper is $250 per person. Under a Self Plus One or Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $500.

Annual Deductible Carryover: Under Prosper, charges from the last 3 months of the prior year which were applied toward the individual annual deductible will also apply to the current year individual annual deductible. The individual annual deductible carryover will apply only when expenses incurred have been paid in full. The Family deductible does not carry over into the next year.

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

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

After your cost-sharing total is $3,000 per person up to $6,000 per family enrollment (High Option), $5,000 per person or per family enrollment (Standard Option), or $6,000 per person up to $12,000 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 (Affordable Care Act and implementing regulations).

Example: Your plan has a $3,000 per person up to $6,000 per family maximum out-of-pocket limit. If you or one of your eligible family members has out-of-pocket qualified medical expenses of $3,000 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 or $6,000 in a calendar year, 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.

Be sure to keep accurate records of your copayments, coinsurance, and deductibles 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 old option to the catastrophic protection limit of your new option.

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

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

A surprise bill is an unexpected bill you receive for:

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

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

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

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

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.kp.org/feds or contact the health plan at 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 provider’s office
• In an urgent care center
• Office medical consultation
• Second surgical opinion

$25 per office visit

$25 per primary care office visit (nothing for children through age 17)

$35 per specialty care office visit

$15 per primary care office visit

$40 per specialty care office visit

Procedures received during an office visit

Nothing after you pay the office visit copayment

Nothing after you pay the office visit copayment

Nothing after the deductible

Professional services of physicians

• During a hospital stay
• In a skilled nursing facility
• Advanced care planning  
• At home

Nothing

Nothing

Nothing

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

• Interactive videos
• Phone visits
• Email

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

Nothing 

Nothing

Nothing

Tests, such as:

• Blood test
• Urinalysis
• Non-routine pap test
• Pathology
• Breast imaging

Nothing

Nothing

Nothing

• X-ray
• Ultrasound
• Electrocardiogram, EEG and echocardiogram

Nothing

Nothing

$50 per visit

• CT/CAT scan
• MRI
• PET scan

Nothing

$100 per visit 

$150 per visit

Routine physical according to the Plan's adult well-care schedule

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

Including:

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, 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 
  https://shorturl.at/hovHM.
• 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/preventive-care-women
• Services such as routine prostate specific antigen (PSA) test and retinal photography screening
• We cover other preventive services required by federal healthcare reform legislation (the Affordable Care Act and implementing regulations) and additional services that we include in our preventive services benefit. For a complete list of Kaiser Permanente preventive services visit our website at 
  www.kp.org/prevention
• To build your personalized list of preventive services go to
  www.health.gov/myhealthfinder

Nothing

Nothing

Nothing

• Routine mammogram

Nothing

Nothing

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.
• Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations.

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 and immunizations required for:
• obtaining or continuing employment or insurance
• attending schools or camp
• athletic exams

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 www.brightfutures.aap.org
• Immunizations such as DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations visit the Centers for Disease Control (CDC) website at 
  www.cdc.gov/vaccines/schedules/index.html
• You 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 
  https://shorturl.at/hovHM.
• We cover other preventive services required by federal healthcare reform legislation (the Affordable Care Act and implementing regulations) and additional services that we include in our preventive services benefit. For a complete list of Kaiser Permanente preventive services visit our website at 
  www.kp.org/prevention
• To build your personalized list of preventive services go to 
  www.health.gov/myhealthfinder

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

Nothing

Nothing

Routine maternity (obstetrical) care, such as:

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

Nothing for routine prenatal and postpartum care

Non-routine care: $25 per office visit

Nothing for inpatient professional delivery services

Nothing for routine prenatal and postpartum care

Non-routine care: $25 per primary care office visit (nothing for children through age 17)

$35 per specialty care office visit

Nothing for inpatient professional delivery services

Nothing for routine prenatal and postnatal care

Non-routine care:$15 per primary care office visit

$40 per specialty care office visit

Nothing for inpatient professional delivery services

• Breastfeeding support, supplies, and counseling for each birth

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

Nothing

Notes: Here are some things to keep in mind:

• Your Plan provider does not have to obtain prior approval from us for your vaginal delivery. See Section 3, You need prior Plan approval for certain services, for prior approval guidelines.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to medically necessary circumcision. We cover routine circumcision under Preventive care, children.
• When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.
• We pay hospitalization and surgeon services (delivery) and non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgery benefits Section 5(b).
• See Section 5(a), Diagnostic and treatment services, Procedures received during an office visit.

Applies to this benefit

Applies to this benefit

Applies to this benefit

A range of voluntary family planning services, limited to:

• Contraceptive counseling
• Voluntary sterilization - tubal ligation and vasectomy
• Intrauterine devices (IUDs) - insertion
• Diaphragms - fittings
• Oral contraceptives
• Implantable contraceptives
• Injectable contraceptives (such as Depo Provera)

Note:

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   

Nothing

Nothing

All charges

Diagnosis and treatment of infertility, such as:

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

Notes:

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

50% of our allowance

50% of our allowance

50% of our allowance after the deductible

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

50% of our allowance

50% of our allowance

50% of our allowance after the deductible

Not covered:  These exclusions apply to fertile as well as infertile individuals or couples:

• Assisted reproductive technology (ART) procedures, such as:
  • In vitro fertilization (IVF)
  • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
• Services and supplies related to excluded ART procedures
• Any charges associated with donor eggs or donor sperm
• Any charges associated with cryopreservation, unless listed as covered above for iatrogenic infertility
• Any charges associated with thawing and storage of frozen sperm and eggs, unless listed as covered above for iatrogenic infertility

All charges

• Testing and treatment

Note: See Section 5(a), Diagnostic and treatment services, Procedures received during an office visit.

$25 per office visit

$25 per primary care office visit (nothing for children through age 17)

$35 per specialty care office visit 

$15 per primary care office visit

$40 per specialty care office visit

• Allergy injections
• Allergy Serum

Nothing

Not covered: any testing or treatment that does not meet Plan protocols

All charges

• Chemotherapy and radiation therapy

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

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition
• Dialysis – hemodialysis and peritoneal dialysis
• Infusion therapy in a medical office or outpatient hospital facility
• Ultraviolet light treatments

Notes: 

• See Section 5(a), Diagnostic and treatment services, Procedures received during an office visit.
• See Section 5(f), Prescription drugs for coverage of growth hormone therapy drugs. 
• See Section 5(e), Professional services, for coverage of Applied Behavior Analysis (ABA).

$25 per office visit

$25 per primary care for individual office visit (nothing for children through age 17)

$35 per specialty care office visit 

$15 per primary care office visit

$40 per specialty care office visit

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

Nothing

Nothing

Nothing 

• Infusion therapy at home: Medication

Nothing

Nothing

Nothing after the deductible

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

Nothing

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

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

20% of our allowance

20% of our allowance

20% of our allowance

• Parenteral supplements and formula when it is the sole source or essential source of nutrition

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

Nothing

Nothing

Nothing

Not covered: over-the-counter formulas

All charges

All charges

All charges

Up to 60 combined visits for rehabilitative or habilitative care per condition per calendar year for physical, occupational, massage, pulmonary, and speech therapy. Services must be provided by qualified physical, occupational, speech, pulmonary or massage therapists.

This visit limit does not apply to rehabilitative or habilitative care for the treatment of mental health conditions, including neurodevelopmental therapy.

$25 per individual office visit 

$12 per group office visit 

See Section 5(c) for Hospital charges

$25 per primary care individual and $12 per primary care group office visit (nothing for children through age 17)

$35 per specialty care individual and $17 per specialty care group office visit 

See Section 5(c) for Hospital charges

$15 per primary care individual and $7 per primary care group office visit

$40 per specialty care individual and $20 per specialty care group office visit

See Section 5(a), Diagnostic and treatment services, Procedures received during an office visit.

See Section 5(c) for Hospital charges

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

All charges

Up to 60 combined visits for rehabilitative or habilitative care per condition per calendar year for physical, occupational and speech therapy. Services must be provided by qualified physical, occupational, speech or massage therapists.

This visit limit does not apply to rehabilitative or habilitative care for the treatment of mental health conditions, including neurodevelopmental therapy.

$25 per individual office visit

$12 per group office visit  

See Section 5(c) for Hospital charges

$25 per primary care individual and $12 per primary care group office visit (nothing for children through age 17)

$35 per specialty care individual and $17 per specialty care group office visit 

See Section 5(c) for Hospital charges

$15 per primary care individual and $7 per primary care group office visit

$40 per specialty care individual and $20 per specialty care group office visit

See Section 5(a), Diagnostic and treatment services, Procedures received during an office visit.

See Section 5(c) for hospital 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.
• Testing and examinations for hearing aids

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

$25 per office visit

$25 per primary care office visit (nothing for children through age 17)

$35 per specialty care office visit 

$15 per primary care office visit

$40 per specialty care office visit

Hearing aids

Notes:

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

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

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

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

Not covered: Over-the-counter hearing aids

All charges

When dispensed through a Plan facility, contact lenses or eyeglasses are covered when medically necessary for eye pathology, including following cataract surgery.  

Note: Replacement lenses for eye pathology, including following cataract surgery will be provided only when needed due to change in your medical condition and will be replaced only one time within any 12 month period.

• Eye exam to determine the need for vision correction
• Annual eye exams or refractions

Notes:

• See Section 5(a), Preventive care, children for eye exams for children.
• See Section 5(a), Diagnostic and treatment services, Procedures received during an office visit.

$25 per office visit

$25 per primary care office visit (nothing for children through age 17)

$35 per specialty care office visit 

$15 per primary care office visit

$40 per specialty care office visit

Not covered:

• Eyeglasses except as provided above
• Contacts lenses and related supplies including examinations and fittings for them, except as provided above
• Eye exercises and orthoptics
• Evaluations and surgical procedures to correct refractions which are not related to eye pathology including complications

All charges

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

Notes:

• See Orthopedic and prosthetic devices for information on podiatric shoe inserts
• See Section 5(a), Diagnostic and treatment services, Procedures received during an office visit.

$25 per office visit

$25 per primary care office visit (nothing for children through age 17)

$35 per specialty care office visit

$15 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

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy
• Ostomy supplies necessary for the removal of bodily secretions or waste through an artificial opening
• Auditory osseointegrated implants/bone anchored health assistance (BAHA) and cochlear implants
• Intraocular lenses
• Occlusal splints (including fittings) for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
• Therapeutic shoe inserts for severe diabetic foot disease
• Braces, such as back, knee, and leg braces, but not dental braces
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.

Note: We pay internal prosthetic devices as hospital benefits; see Section 5(c) for payment information. See Section 5(b) for coverage of the surgery to insert the device.

20% of our allowance

20% of our allowance

20% of our allowance after the deductible

Not covered:

• orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• lumbosacral supports
• corsets, trusses, elastic stockings, support hose, and other supportive devices
• cost of artificial or mechanical hearts
• orthopedic and prosthetic replacements provided except when medically necessary
• replacement of devices, equipment and supplies due to loss, theft, breakage or damage

All charges

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

• Hospital beds
• Standard wheelchairs
• Crutches
• Walkers
• Speech generating devices
• Canes
• Oxygen and oxygen equipment for home use
• Nasal CPAP device
• Blood glucose monitors
• External insulin pumps
• Medically necessary replacement of supplies

20% of our allowance

20% of our allowance after the deductible

• Peak flow meter
• Glucometer

20% our allowance

20% our allowance

20% our allowance

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

Note: Equipment and supplies to support dyads with breastfeeding difficulties are also covered.

• Ultraviolet light treatment equipment

Nothing

Nothing

Nothing

Not covered:

• Motorized wheelchairs except when approved by the medical director as medically necessary
• Replacement of devices, equipment and supplies due to loss, theft, breakage or damage
• Wigs/hair prosthesis

All charges

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), physical therapist, occupational therapist or speech therapist.  Home health services require the skill of one of the listed providers based on the complexity of the service and the condition of the patient.

• Services may include oxygen therapy, intravenous therapy or services provided by a Social Worker,  licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide, when provided in connection with the skilled services described above

Nothing

20% for oxygen therapy

Nothing

20% for oxygen therapy

Nothing

20% for oxygen therapy after the deductible

Not covered:

• Nursing care requested by, or for the convenience of the patient or the patient’s family
• Home care primarily for personal assistance, custodial care or maintenance care that is not diagnostic, therapeutic, or rehabilitative

All charges

Up to 20 treatments per calendar year for manipulation of spine and extremities 

Note: See Section 5(a), Diagnostic and treatment services, Procedures received during an office visit.

$25 per office visit

$25 per office visit (nothing for children through age 17)

$15 per primary care office visit

$40 per specialty care office visit

Not covered:

• Maintenance therapy
• Care given on a non-acute asymptomatic basis
• Services provided for the convenience of the member

All charges

Acupuncture services – Self referral to a licensed or certified acupuncture practitioner for up to 8 visits per medical diagnosis per calendar year. Additional visits must meet Plan protocols and be authorized in advance by your Plan.

• anesthesia
• pain relief
• substance use disorder - unlimited
• dry needling

Naturopathic services – Self referral to a Plan provider for up to 3 visits per medical diagnosis per calendar year. Additional visits must meet Plan protocols and be authorized in advance by your Plan.

Note: See Section 5(a), Diagnostic and treatment services, Procedures received during an office visit.

$25 per office visit

$25 per primary care office visit (nothing for children through age 17)

$35 per specialty care office visit

$15 per primary care office visit

$40 per specialty care office visit

Not covered:

All charges

• 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.

See Section 5(f), Prescription Drug Benefits, for important information about coverage of tobacco cessation and other drugs.

Nothing

Nothing

Nothing

• Diabetes self-management
• Routine nutritional counseling

Note: See Section 5(a), Diagnostic and treatment services, Procedures received during an office visit.

$25 per office visit

$25 per primary care office visit (nothing for children through age 17)

$35 per specialty care office visit 

$15 per primary care office visit

$40 per specialty care office visit

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Insertion of internal prosthetic devices. See Section 5(a) – “Orthopedic and prosthetic devices” for device coverage information
• Voluntary sterilization (e.g., tubal ligation, vasectomy)
• Treatment of burns
• Non-routine Circumcision

Note: Generally, we pay for internal prostheses (devices) according to where the procedure is done. For example, we pay Hospital benefits for a pacemaker and Surgery benefits for insertion of the pacemaker.

Surgical treatment of severe obesity (bariatric surgery). 

Note: Visit www.kp.org/feds to get a list of criteria you must meet to qualify for bariatric surgery. You must meet these qualifications before your Plan provider will refer you to our bariatric surgery program.  This program may refer you to other Plan providers to determine if you meet the additional criteria necessary for bariatric surgery, including nutritional, psychological, medical and social readiness for surgery. Final approval for surgical treatment will be required from the Kaiser Permanente clinical review physician.

Nothing

Nothing

Nothing after the deductible

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot; see Foot care
• Devices related to sexual dysfunction
• Services for the promotion, prevention or other treatment of hair loss or hair growth
• Cosmetic surgery, any surgery procedure (or any portion of the procedure) performed primarily to improve physical appearance through change in bodily form
• Cost of an artificial or mechanical heart
• Weight loss programs
• Adjustable gastric banding, Laparoscopic or Open
• Bilio-pancreatic bypass
• Distal gastric bypass
• Duodenal Switch
• Mini-gastric bypass

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and webbed toes.
• All stages of breast reconstruction surgery following a mastectomy, such as: 
• Surgery to produce a symmetrical appearance of breasts
• Treatment of any physical complications, such as lymphedemas
• Compression garments to treat lymphedemas (see Durable Medical Equipment)
• 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

Nothing

Nothing

Nothing after the deductible

Not covered: Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

All charges

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion
• Removal of stones from salivary ducts
• Excision of malignancies
• Excision of non-dental cysts and incision of non-dental 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 after the deductible

Not covered:

• Oral implants including preparation for 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

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 after the deductible

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

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

Nothing

Nothing

Nothing after the deductible

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

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

Nothing

Nothing

Nothing after the deductible

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 after the deductible

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

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

Nothing

Nothing

Nothing after the deductible

Notes:

• We cover related medical and hospital expenses of the donor when we cover the recipient.  We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members. 
• We cover medically necessary routine dental services in preparation for chemotherapy, radiation therapy, and transplants. Covered services may include a routine oral examination, cleaning (prophylaxis), extractions, and X-rays. You pay cost-sharing listed in Section 5(a) for services performed during an office visit.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

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

All charges

All charges

All charges

Professional services provided in –

• Hospital (inpatient)
• Skilled nursing facility 
• Hospital outpatient department
• Ambulatory surgical center
• Provider's office

Nothing

Nothing after the deductible

Room and board, such as:

• Semiprivate room accommodations
• Special care units such as intensive care or cardiac units
• 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.

$350 per admission

$750 per admission

$350 per day up to $1,050 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
• Administration of blood and blood products
• Blood and blood derivatives
• Donor human milk provided through a milk bank
• Dressing, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services

Nothing

Nothing

Nothing after the deductible

• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

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

Not covered:

• Custodial care, rest cures, domiciliary or convalescent care
• Non-covered facilities, such as nursing home, schools
• Personal comfort items, such as phone, television, barber services, guest meals and beds
• Private nursing care, except when medically necessary

All charges

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications administered at the facility 
• Diagnostic laboratory tests, X-rays, and pathology services
• Administration of blood, blood plasma, and other biologicals
• Blood and blood derivatives
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service

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

$75 per day

$150 per day

$250 per day after the deductible

Up to 2 months of physical therapy, occupational therapy, and speech therapy – per condition per calendar year

$350 per inpatient hospitalization per person

$750 per inpatient hospitalization per person 

$350 per inpatient hospitalization per person per day up to $1,050 after the deductible

All charges

Skilled nursing facility (SNF) benefit: When full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and authorized by the Plan, you will receive up to 100 days per calendar year.

Nothing 

Nothing after the deductible

Not covered:

• Custodial care
• Rest cures
• Domiciliary or convalescent care
• Personal comfort items such as phone or television

All charges

Supportive and palliative care for a terminally ill member is covered in the home or a hospice facility. Services could include:

• Inpatient and outpatient care
• Drugs
• Biologicals
• Medical appliances and supplies that are used primarily for the relief of pain and symptom management
• Family counseling

These services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately 6 months or less.

Nothing 

Nothing after the deductible

All charges

Local licensed ambulance services when medically necessary.

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

20% of our allowance

$100 per trip

20% of our allowance

Not covered: Transportation by car, taxi, bus, gurney van, wheelchair van, and any other type of transportation (other than a licensed
ambulance), even if it is the only way to travel to a Plan provider

All charges

All charges

All charges

• Emergency or urgent care at a Plan doctor's office
• Emergency or urgent care at a Plan urgent care center

Note: See Section 5(a), Diagnostic and treatment services for procedures received during an office visit

$25 per office visit

$25 per primary care office visit (nothing for children through age 17)

$35 per specialty care office visit 

$15 per primary care office visit

$40 per specialty care office visit

• Emergency care at a Plan or Plan designated emergency department
• Emergency care at a non-Plan facility, including doctors' services

Notes:

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

$100 per member per visit

$150 per member per visit 

$200 per member per visit after the deductible

All charges 

All charges 

All charges

• Emergency or urgent care at a doctor's office
• Emergency or urgent care at an urgent care center

Note: See Section 5(a), Diagnostic and treatment services for procedures received during an office visit

$25 per member per visit

$25 per primary care services office visit (nothing for children through age 17)

$35 per specialty care services office visit 

$15 per primary care office visit

$40 per specialty care office visit

• Emergency care at a hospital, including doctors' services

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

$100 per member per visit

$150 per member per visit

$200 per member per visit after the deductible

Not covered:

• Elective care or non-emergency care
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges

Licensed ambulance service when medically necessary

Notes:

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

$100 per trip

20% of charges

Not covered: 

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

All charges

We cover all diagnostic and treatment services for the treatment of mental health and substance use conditions that are clinically necessary and recommended by the member’s primary physician and approved by the Plan Medical Director or designee.

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

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

• Diagnostic evaluation
• Consultation services
• Psychiatric treatment (individual, family and group therapy) by providers such as psychiatrists, psychologists, or clinical social workers
• Diagnosis, treatment and counseling for substance use disorders
• Medication evaluation and management (pharmacotherapy)
• Professional charges for intensive outpatient treatment in a provider's office or other professional setting
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Alcohol and drug education
• Applied Behavioral Analysis (ABA) therapy for the treatment of autism spectrum disorder or a developmental disability
• Electroconvulsive therapy
• Crisis intervention and stabilization for acute episodes

$25 per individual therapy office visit

Nothing per group therapy office visit

See Section 5(f) for mental health prescription drug coverage

$25 per individual therapy office visit (nothing for children through age 17)

Nothing per group therapy office visit 

Nothing for diagnostic tests 

See Section 5(f) for mental health prescription drug coverage.

$15 per individual therapy office visit

Nothing per group therapy office visit

See Section 5(a), Diagnostic and treatment services for procedures received during an office visit

See Section 5(f) for mental health prescription drug coverage

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

Nothing 

Nothing for lab

$50 per visit for X-ray and imaging

$150 per visit for MRI/CT/PET Scan

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
• Hospitalization (including inpatient professional services)
• Detoxification
• Diagnostic tests
• Diagnostic evaluation
• Consultation services
• Residential treatment

$350 per person per hospitalization

$750 per person per hospitalization 

$350 per day up to $1,050 after the deductible

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

• Services in approved treatment programs, such as partial hospitalization

$25 per office visit.

$25 per day for partial hospitalization; no day limit.

$25 per primary care office visit (nothing for children through age 17) 

$35 per specialty care office visit.

$25 per day for partial hospitalization; no day limit. (nothing for children through age 17)

$15 per primary care office visit

$40 per specialty care office visit

$15 per day for partial hospitalization

Not covered:

Mental health inpatient and outpatient treatment that the Plan excludes are:

• Psychiatric evaluation or therapy that is court ordered as a condition of parole or probation unless determined by a Plan provider to be necessary and appropriate
• Psychological testing that is not medically necessary
• Services that are custodial in nature
• Assessment and treatment services that are primarily vocational and academic in nature (i.e., educational testing)
• Services provided under a Federal, state, or local government
• Services rendered or billed by a school or a member of its staff
• Treatment not authorized by a Plan provider, provided by the Plan, or specifically contracted for by the Plan

All charge

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy:

• Drugs (including injectables) for which a prescription is required by Federal law
• Insulin
• Diabetic supplies limited to: 
  • Disposable needles, syringes, lancets, urine and blood glucose testing reagents; a copayment charge applies per item per each 30-day supply
• Compound dermatological preparations
• Disposable needles and syringes for the administration of covered prescribed medications
• Drugs to treat gender dysphoria, including hormones and androgen blockers

Notes:

• Intravenous fluids and medication for home use are covered under Section 5(a), Treatment therapies
• Allergy serums are covered under Section 5(a), Allergy care

$20 for generic formulary drugs or $40 for brand name formulary drugs (including insulin and diabetic supplies), per prescription unit or refill for up to a 30-day supply or 100-unit supply, whichever is less; or one commercially prepared unit (i.e., one inhaler, one vial ophthalmic medication or insulin).

$60 for non-formulary drugs when prescribed by a Plan doctor.

25% coinsurance up to $200 per 30-day supply for preferred specialty drugs when prescribed by a Plan doctor.

50% coinsurance up to $500 per 30-day supply for non-preferred specialty drugs when prescribed by a Plan doctor.

Note: You pay no more than $35 for up to a 30-day supply of insulin.

$5 for preventive generic formulary drugs, $20 for all other generic formulary drugs, or $40 for brand name formulary drugs (including insulin and diabetic supplies), per prescription unit or refill for up to a 30-day supply or 100-unit supply, whichever is less; or one commercially prepared unit (i.e., one inhaler, one vial ophthalmic medication or insulin).

$60 for non-formulary drugs when prescribed by a Plan doctor. 

25% coinsurance up to $200 per 30-day supply for preferred specialty drugs when prescribed by a Plan doctor.

50% coinsurance up to $500 per 30-day supply for non-preferred specialty drugs when prescribed by a Plan doctor.

Note: You pay no more than $35 for up to a 30-day supply of insulin.

$5 for preventive generic formulary drugs, $20 for all other generic formulary drugs or $60 for brand name formulary drugs (including insulin and diabetic supplies), per prescription unit or refill for up to a 30-day supply or 100-unit supply, whichever is less; or one commercially prepared unit (i.e., one inhaler, one vial ophthalmic medication or insulin).

$100 for non-formulary drugs when prescribed by a Plan doctor.

35% coinsurance up to $300 per 30-day supply for preferred specialty drugs when prescribed by a Plan doctor.

50% coinsurance up to $500 per 30-day supply for non-preferred specialty drugs when prescribed by a Plan doctor.

Note: You pay no more than $35 for up to a 30-day supply of insulin.

Mail Order Drug Program

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

2 times the applicable prescription drug copayment for a supply of 90 days or less of each prescription or refill.

Mail order not available for specialty drugs.

2 times the applicable prescription drug copayment for a supply of 90 days or less of each prescription or refill.

Mail order not available for specialty drugs.

2 times the applicable prescription drug copayment for a supply of 90 days or less of each prescription or refill.

Mail order not available for specialty drugs.

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

• Drugs to aid in tobacco cessation when prescribed and dispensed as part of our designated tobacco cessation program.

Nothing

• Sexual dysfunction drugs

50% coinsurance

50% coinsurance

50% coinsurance

• Fertility drugs, including drugs for in vitro fertilization

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

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

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

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

Not covered:

• Drugs available without a prescription or for which there is an over-the-counter (nonprescription) equivalent available
• Drugs obtained at a non-Plan pharmacy except when due to an out-of-area emergency
• Vitamins and nutritional substances not listed as a covered benefit even if a physician prescribes or administers them, including dietary formulas and special diets, except for the treatment of inborn errors of metabolism; total parenteral; and enteral nutrition therapy
• Oral nutritional supplements
• Medical supplies such as dressings, antiseptics, etc.
• Experimental drugs, devices, and biological products
• Drugs for cosmetic purposes
• Drugs to enhance athletic performance
• Replacement of lost or stolen drugs, medications, or devices
• Drugs related to non-covered services, except as stated above

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco cessation benefit. (See Section 5(a))

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

• Medications 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, herbal supplements that can be purchased without a prescriptions, unless they are included in our drug formulary or listed as covered above or below
• Over-the-counter, unless they are included in our drug formulary or listed as covered above
• Prescription drugs not on our drug formulary, unless approved through an exception process 
• Any requested packaging of drugs other than the dispensing pharmacy's standard packaging 
• Replacement of lost, stolen, damaged prescription, drugs, and accessories
• Drugs related to non-covered services 

All charges

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 claim process (see Section 8). 

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

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. Visiting member services are described in our visiting member brochure. For more information about receiving visiting member services, including provider and facility locations in other Kaiser Permanente services areas, please call our Washington Visiting Member Services at 800-466-4296 or visit wa.kaiserpermanente.org/html/public/services/traveling.  

Kaiser Permanente’s travel benefits for Federal employees provide you with outpatient follow-up and/or continuing medical and mental health and substance use disorder 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 the applicable copayment 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 $2,000 each calendar year. For more information about this benefit, call our Member Services Call Center at 888-901-4636 (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

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, contact us at 888-901-4636 or at our website at
www.kp.org/wa.

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

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

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

Submit your claims to: Kaiser Foundation Health Plan of Washington, Claims Administration, P.O. Box 30766, Salt Lake City, UT 84130-0766

Phone: 888-901-4636

Outpatient drugs and medicines obtained at non-Plan pharmacies are not covered; except when due to an out of area emergency.

Submit your claims to: Kaiser Foundation Health Plan of Washington, Claims Administration, P.O. Box 30766, Salt Lake City, UT 84130-0766

Phone: 888-901-4636

Submit your claims to: Kaiser Foundation Health Plan of Washington, Claims Administration, P.O. Box 30766, Salt Lake City, UT 84130-0766

Phone: 888-901-4636

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

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

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

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

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

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

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

b) Send your request to us at: Kaiser Foundation Health Plan of Washington, Member Appeal Department, P.O. Box 34593, Seattle, WA 98124-1593, 866-458-5479; 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.

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

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

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

a) Pay the claim or  

b) Write to you and maintain our denial or

c) Ask you or your provider for more information

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

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

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal 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; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM’s decision via email.  Please note that by providing your email address, you may receive OPM’s decision more quickly.

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

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

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

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

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

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 you must pay cost sharing described in this FEHB brochure (See Sections 4 and 5. Members with Medicare should also see Section 9). We will not pay more than our allowance.

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

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

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

We do not cover services that:

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

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

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

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

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

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

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

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

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

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

If you need more information, contact Member Services toll-free at 888-901-4636 for our subrogation procedures.

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

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

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

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

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

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 888-901-4636.

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 two programs designed to help members with their Medicare Part B premium.

The first program is called, "Medicare Advantage 2." For each month you are enrolled in Medicare Advantage 2, have Medicare Parts A and B and are enrolled in Medicare Advantage for Federal Members, you will be reimbursed up to $150 (up to $1,800 per year) of your Medicare Part B monthly premium. Kaiser Permanente Medicare Advantage for Federal Members is a Medicare Advantage HMO plan approved by Medicare.

In addition to reimbursing you for the Part B monthly premium we will cover additional benefits, including lower copays for office visits and inpatient hospitalization.

You may enroll in the Medicare Advantage 2 program if:

• You enroll in the Plan’s High Option or Standard Option
• You live in our Medicare Advantage service area
• You have Medicare Parts A and B and you enroll in Medicare Advantage for Federal Members
• The FEHB subscriber completes an additional application for enrollment in Medicare Advantage 2

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

The second program is called, “Medicare Choice for High Option.” This program is for High Option members who reside outside Kaiser Permanente's Medicare Advantage service area. You will be reimbursed $50 of your Medicare Part B monthly premium (up to $600 per year). We will automatically enroll you in the Medicare Choice for High Option program if:

• You enroll in the Plan’s High Option
• We can verify that you have Medicare Parts A and B and you are not enrolled in Medicare Advantage

We encourage you to contact us if you are a High Option member who is retired and have Medicare Parts A and B.

To start your monthly reimbursement, you must provide proof of the amount you pay for your Part B premium to our Health Reimbursement Arrangement (HRA) vendor. The Part B reimbursement will begin the month after you provide proof. If we can independently verify your Medicare Part B enrollment, we may send you an annual reimbursement automatically after the plan year ends.

To learn more about our Medicare programs 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/wa-core. For TTY for the deaf, hard of hearing, or speech impaired, call 711.

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 Federal Employees Health Benefits Medicare Advantage plan. The Federal Employees Medicare Advantage and Medicare Choice plans enhance your FEHB coverage by lowering cost shares for certain services and/or adding benefits. High and Standard Option members can choose between 2 Medicare Advantage plans: "Medicare Advantage 1" (richest benefits) and "Medicare Advantage 2" (some rich benefits and Part B premium reimbursement). If you live in our Medicare Advantage service area, are a Medicare-eligible retiree, and have Medicare Parts A and B, you can enroll in our Federal Employees Medicare Advantage plan. Enrolling in Medicare Advantage for Federal Members does not change your FEHB premium. Your enrollment in our Federal Employee Medicare Advantage plan is in addition to your FEHB High Option, Standard Option, or Prosper enrollment. If you are considering enrolling in the Federal Employees Medicare Advantage plan, please call us at 800-446-8882 (TTY: 711), 8 a.m. to 8 p.m., Monday through Friday. Note: you must complete an election form to enroll in the Federal Employee Medicare Advantage plan.

With Kaiser Permanente Federal Employees Medicare Advantage and Medicare Choice for High Option, you’ll get more coverage, such as lower cost-sharing and additional benefits. This 2024 benefit summary allows you to make a comparison of your choices:

This is a summary of the features of the Kaiser Permanente Medicare Advantage for Federal Members. As a Medicare 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 Medicare Advantage for Federal Members Evidence of Coverage.

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

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

When we are the primary payor, we process the claim first. If you enroll in Medicare Part D and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB Plan.

• You have FEHB coverage on your own or through your spouse who is also an active employee

• You have FEHB coverage through your spouse who is an annuitant

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD

• This Plan was the primary payor before eligibility due to ESRD (for 30-month coordination period)

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

• Medicare based on ESRD (for the 30-month coordination period)

• Medicare based on ESRD (after the 30-month coordination period)

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

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

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

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

See Section 4, page 22.

See Section 4, page 22.

See Section 4, page 22.

(1) Assistance with activities of daily living, for example, walking, getting in and out of bed, dressing, feeding, toileting, and taking medicine. (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 longer is sometimes known as long-term care.

See Section 4, page 22.

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.

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

a) Rendered for the treatment or diagnosis of an injury or illness; and

b) Appropriate for the symptoms, consistent with diagnosis, and otherwise in accordance with sufficient scientific evidence and professionally recognized standards; and

c) Not furnished primarily for the convenience of the Member, the attending physician, or other provider of service.

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

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

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance as follows: the charges are consistent with those normally charged to others by the provider or organization for the same services or supplies; and the charges are within the general range of charges made by other providers in the same geographical area for the same services or supplies.

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

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

An unexpected bill you receive for:

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

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

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

Urgent care claims usually involve Pre-serve 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 Customer Service Department, 888-901-4636. 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.

Us and we refer to Kaiser Foundation Health Plan of Washington.

$25 per primary care or specialist office visit

(Applies to printed brochure only)

Nothing

(Applies to printed brochure only)

$350 per person per hospitalization

(Applies to printed brochure only)

$75 per procedure or visit

(Applies to printed brochure only)

$100 per visit

(Applies to printed brochure only)

Regular cost-sharing

(Applies to printed brochure only)

$20 for generic prescription; $40 for brand name prescription; $60 for non-formulary prescription; 25% up to $200 per 30-day supply for preferred specialty drugs; 50% up to $500 per 30-day supply for non-preferred specialty drugs

(Applies to printed brochure only)

2 times the applicable prescription drug copayment; Mail order not available for specialty drugs

(Applies to printed brochure only)

Not covered

(Applies to printed brochure only)

$25 per office visit.

(Applies to printed brochure only)

See Section 5(h) for more information. 

(Applies to printed brochure only)

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

(Applies to printed brochure only)

$25 per primary care services (nothing for children through age 17) 
$35 per specialty care services office visit

(Applies to printed brochure only)

Nothing 

(Applies to printed brochure only)

$750 per person per hospitalization

(Applies to printed brochure only)

$150 per procedure or visit.

(Applies to printed brochure only)

$150 copayment per visit

(Applies to printed brochure only)

Regular cost-sharing

(Applies to printed brochure only)

$5 for preventive generic drugs, $20 for all other generic prescriptions; $40 for brand name prescriptions; $60 for non-formulary prescription; 25% up to $200 per 30-day supply for preferred specialty drugs; 50% up to $500 per 30-day supply for non-preferred specialty drugs

(Applies to printed brochure only)

2 times the applicable prescription drug copayment; Mail order not available for specialty drugs

(Applies to printed brochure only)

Not covered

(Applies to printed brochure only)

$25 for primary care services (nothing for children through age 17)
$35 for specialty care services per office visit

(Applies to printed brochure only)

See Section 5(h) for more information. 

(Applies to printed brochure only)

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

(Applies to printed brochure only)

$250 per person
$500 per family

(Applies to printed brochure only)

$15 per primary care services
$40 per specialty care services office visit

(Applies to printed brochure only)

Nothing for lab services. $50 per visit for X-ray services. 

(Applies to printed brochure only)

$350 per day up to $1,500*

(Applies to printed brochure only)

$250 per procedure or visit*

(Applies to printed brochure only)

$200 per member per visit*

(Applies to printed brochure only)

Regular cost-sharing

(Applies to printed brochure only)

$5 for preventive generic drugs, $20 for all other generic prescriptions; $60 for brand name prescriptions; $100 for non-formulary prescription; 35% up to $300 per 30-day supply for preferred specialty drugs; 50% up to $500 per 30-day supply for non-preferred specialty drugs

(Applies to printed brochure only)

2 times the applicable prescription drugs copayment; Mail order not available for specialty drugs

(Applies to printed brochure only)

Not Covered

(Applies to printed brochure only)

$15 for primary care services
$40 for specialty care services per office visit

(Applies to printed brochure only)

See Section 5(h) for more information. 

(Applies to printed brochure only)

Nothing after $6,000 for Self Only or $12,000 for Self and Family enrollment per year. Some costs do not count toward this protection.

(Applies to printed brochure only)