Pages 1--28 from 010R-99 KP Fed Open Enrollment

Kaiser Foundation Health Plan 2000 of the Northwest
A Health Maintenance Organization
For changesin 5 benefitssee
page

Serving Portland and Salem Oregon and Vancouver and Longview Washington
Enrollment in this Plan is limited see page 6 for requirements
Enrollment code
571 High Option Self Only
572 High Option Self and Family
574 Standard Option Self Only
575 Standard Option Self and Family

For commercial HMO health plan This Plan has accreditation with
See the 2000 Guide for more commendation from the JCAHO
information on NCQA See the 2000 Guide for more
information on JCAHO

Visit the OPM Web site at http www opm gov insure and
this Plan's National Web site at http www kaiserpermanente org

Authorized for distribution by the
United States Office of Personnel Management
Retirement and Insurance Service RI 73 004

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Kaiser Foundation Health Plan of the Northwest 2000
Table of contents
Introduction 3

Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations 5
Section 2 How we change for 2000 5
Section 3 How to get benefits 6
Section 4 What to do if we deny your claim or request for service 8
Section 5 Benefits 10
Section 6 General exclusions Things we don't cover 21
Section 7 Limitations Rules that affect your benefits 21
Section 8 FEHB Facts 22
Inspector General Advisory Stop Healthcare Fraud 25
Summary of benefits 26 27
Premiums Back cover

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Kaiser Foundation Health Plan of the Northwest 2000
Introduction
Kaiser Foundation Health Plan of the Northwest 500 N E Multnomah St Suite 100

Portland OR 97232
This brochure describes the benefits you can receive from Kaiser Foundation Health Plan of the Northwest under its contract CS1047 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure
is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page 5 Premiums are listed at the end of this brochure

Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the public by requiring agencies to use plain language Health Plan representatives and Office of Personnel Management staff have

worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical terms you and other personal pronouns active voice and short sentences

We refer to Kaiser Foundation Health Plan of the Northwest as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not rewritten the Benefits section of this brochure You will find new benefits language next year

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Kaiser Foundation Health Plan of the Northwest 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make

comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB Facts Read this for information about the Federal Employees Health Benefits FEHB Program

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Kaiser Foundation Health Plan of the Northwest 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you receive includes preventive

care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and coinsurance listed in this brochure When you receive emergency services at a non Plan facility or follow up

or continuing care under this Plan's travel benefit you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available and or

remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

Section 2 How we change for 2000
Program wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office visits

This year you have a right to more information about this Plan care management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and
you are in the second or third trimester of pregnancy you may be able to continue seeing your ob gyn until the end of your postpartum care You have similar rights if this Plan provider leaves
the FEHB program See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records call Membership Services at 800 813 2000 ext 315051 You may ask that a

physician amend a record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you with your
records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to this Plan Your share of the non postal high option premium will increase by 4.9 for Self Only or 4.5 for Self and Family
Your share of the non postal standard option premium will increase by 5.9 for Self Only or 5.9 for Self and Family
The primary care office visit copay will increase from 8 to 10 under the high option and from 10 to 12 under the standard option See page 10
Self referred chiropractic services will be covered for 20 visits per calendar year at a 15 copay per visit for high option and a 20 copay per visit for standard option See page 11
Infertility treatment services will require a copayment of 50 of charges under both options See page 11
Orthognathic surgery for temporomandibular joint dysfunction TMD will be covered if medical criteria are met subject to annual and lifetime benefit maximums See page 11
Immunizations for travel will no longer be covered See page 11
The benefit maximum for residential day care facility treatment for substance abuse will increase from 3,000 every two calendar years to 3,500 for adults and 4,500 for children every two

calendar years See page 15
The copay for prescription drugs will increase from 8 to 10 under the high option and from 10 to 15 under standard option See page 16

DME diabetic supplies external insulin pumps infusion devices glucose monitors and diabetic footcare appliances will be covered under this Plan's Prescription Drug Benefit at a 50 copay
See page 16
Drugs for travel will no longer be covered See page 16
The copay for a dental office visit will increase from 8 to 10 See page 17
Restorative dental services such as routine fillings and simple extractions will require a copayment of 50 of charges instead of 20 of charges See page 17

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Kaiser Foundation Health Plan of the Northwest 2000
Section 3 How to get benefits
What is this Plan's To enroll in this Plan you must live or work in our service area This is where our providers service area practice Our service area is

These Oregon counties Columbia Multnomah Polk Yamhill
And these Oregon zip codes Benton County 97330 97331 97333 97339 97370

Clackamas County 97004 97009 97011 97013 97015 97017 97022 23 97027 97034 36 97038 97042 97045 97055 97067 68 97070 97080 97222 97267 68
Linn County 97321 97335 97355 97358 97374 97389 Marion County 97002 97020 97026 97032 97071 97137 97301 3 97305 14 97325
97352 97359 60 97362 97373 97375 97381 97383 85 97392 Washington County 97005 8 97062 97075 78 97106 97109 97113 97116 17 97119
97123 25 97133 97140 97144 97223 25 97229 97291
These Washington counties Clark County
And these Washington zip codes Cowlitz County 98581 98603 98609 98611 98625 26 98632 98645 98649 98674

Lewis County 98591 98593 98596 Wahkiakum County 98612 98647

Ordinarily you must receive your care from physicians hospitals and other providers who contract with us However we are part of the Kaiser Permanente Medical Care Program and if
you are visiting another Kaiser Permanente service area you can receive most of the benefits of this Plan at any other Kaiser Permanente facility We also pay for certain follow up services or
continuing care services while you are traveling outside the service area as described on page 13 and for emergency care obtained from any non Plan provider as described on page 14 We will not
pay for any other health care services if received from non Plan providers without prior authorization
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents permanently reside outside of the area you should consider enrolling in

another plan If you or a family member move you do not have to wait until Open Enrollment to change plans Contact your employing or retirement office

How much do I pay You must share the cost of some services This is called either a copayment a set dollar amount for services or coinsurance a set percentage of charges Please remember you must pay this amount when
you receive services If you do not pay at the time you receive your service you will be billed for the service We also will bill you an additional 6 This charge will be added to each bill sent for
services not paid
After you pay 600 in copayments or coinsurance for one family member or 1,200 for two or more family members you do not have to make any further payments for certain services for the

rest of the year This is called a catastrophic limit However copayments or coinsurance for your outpatient prescription drugs contraceptive devices dental services outpatient mental health
services beyond the first 20 covered visits corrective appliances and artificial aids durable medical equipment the 25 charges paid for follow up or continuing care and long term physical therapy
and rehabilitation under both the High Option and Standard Option do not count toward these limits and you must continue to pay for these services as described in this brochure

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the limits

Do I have to You normally won't have to submit claims to us unless you receive emergency services from submit claims a provider who doesn't contract with us or you receive follow up or continuing care under the
travel benefit If you file a claim please send us all of the documents we need to respond to your claim as soon as possible You must submit claims by December 31 of the year after the year you
received the service Either OPM or we can extend this deadline if you show that circumstances beyond your control prevented you from filing on time

Who provides Kaiser Permanente offers comprehensive health care at Plan medical centers medical offices my health care and dental care at dental offices conveniently located throughout the Portland Vancouver Salem
and Longview Kelso areas

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Kaiser Foundation Health Plan of the Northwest 2000
The Plan contracts with Northwest Permanente P C Physicians and Surgeons an independent multi specialty group of physicians to provide or arrange all necessary physician care for Plan

members Permanente Dental Associates an independent group of dentists provides or arranges dental care for members of the High Option plan

Plan physicians nurse practitioners physician assistants and other skilled medical personnel working as medical teams provide your health care services Specialists consult with these
medical teams in determining your treatment Plan physicians refer patients to community specialists when necessary Other services such as physical therapy and laboratory and X ray
are available at Plan facilities Inpatient care is available at Kaiser Sunnyside Medical Center Providence St Vincent Medical Center Providence Portland Medical Center Southwest
Washington Medical Center Salem Hospital St John Medical Center Doernbecher Children's Hospital for children only and Legacy Emanuel Hospital and Health Center for low risk
childbirth services Check this Plan's Medical Directory for additional information on the location and services provided at each hospital

You must receive your health care services at Plan facilities except if you have an emergency If you are visiting another Kaiser Permanente service area you may receive health care services
from those Kaiser Permanente facilities This Plan also offers a benefit that will allow you to receive follow up or continuing care while you travel anywhere

Your primary care physician PCP either a family practitioner pediatrician or internist will coordinate most aspects of your health care including arranging for you to receive services from
a specialist This Plan will cover specialists services only when your primary care physician refers you If you are referred to a community provider the Plan must approve the referral However
a woman may see her obstetrician gynecologist without having to obtain a referral You may also receive outpatient alcohol and drug treatment cancer counseling eye examination outpatient
mental health occupational health and social work services without a referral
Choose your primary care physician from this Plan's provider directory The directory which is updated on a regular basis lists primary care physicians generally family practitioners

pediatricians and internists with their locations and phone numbers A Medical Directory will be sent to you after you enroll or you may obtain one by calling the Membership Services
department at 503 813 2000 or 800 813 2000

What do I do if my primary Call us We will help you select a new one care physician leaves the Plan
What do I do if I need Your primary care physician or specialist will make the necessary arrangements and continue to go into the hospital to supervise your care

What do I do if I'm in the First call our Membership Services department at 503 813 2000 or 800 813 2000 If you are new hospital when I join this Plan to the FEHB Program we will arrange for you to receive care If you are currently in the FEHB
Program and are switching to us your former plan will pay for the hospital stay until You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or The 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized

How do I get specialty care Call the appointment desk of your medical office during office hours to schedule routine appointments in the following specialty departments outpatient alcohol and drug treatment
cancer counseling contact lenses eye examinations outpatient mental health obstetrical gynecology occupational health and social work

Your primary care physician will determine if you need care from other Plan specialists Most specialty care is provided by physicians within the Plan If your primary care physician refers
you to a specialist in the community he or she will obtain necessary authorizations from the Plan The referral will describe the services you will receive You should return to your primary care
physician after your consultation with the specialist If your specialist recommends additional visits or services your primary care physician must review the recommendation and authorize
the visits or services if appropriate You may go to a community specialist only when your primary care physician and your Plan have authorized the referral

If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that allows you to see your
specialist for a specified number of visits You will not need to obtain additional referrals until you have received the specified number of visits Contact your primary care physician if you
need additional care Your primary care physician will obtain Plan authorization for these visits
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Kaiser Foundation Health Plan of the Northwest 2000
What do I do if I am seeing Your primary care physician will decide what treatment you need If your primary care physician a specialist when I enroll decides 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

What do I do if my Call your primary care physician who will arrange for you to see another specialist You may specialist leaves the Plan receive services from your current specialist until we can make arrangements for you to see
someone else

But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue serious illness and my seeing your physician for up to 90 days after we notify you that we are terminating our contract
provider leaves the with the provider unless the termination is for cause If you are in the second or third trimester of Plan or this Plan leaves pregnancy you may continue to see your ob gyn provider until the end of your postpartum care
the Program You may also be able to continue seeing your physician if this Plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your second or third trimester Your new plan will pay for

or provide your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the ob gyn
care you receive from your current provider until the end of your postpartum care

How do you authorize Your physician must get our approval before referring you to a community specialist Before medical services giving approval we consider if the service is medically necessary to prevent diagnose or treat
an illness or condition We follow generally accepted medical practice in providing services to you

How do you decide if When the service or supply including a drug 1 has not been approved by the FDA or 2 it is a service is experimental the subject of a new drug or new device application on file with the FDA or 3 is part of a Phase I
or investigational 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 then this Plan considers that service supply or drug to be experimental and not covered by the Plan This Plan and its Medical Group
or Dental Group 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

Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must

1 Be in writing 2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond
your control
We have 30 days from the date we receive your reconsideration request to 1 Maintain our denial in writing

2 Pay the claim 3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do

not receive the requested information within 60 days we will make our decision based on the information we already have

When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal to review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim
or request for service

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Kaiser Foundation Health Plan of the Northwest 2000
What if I have a serious Call us at 503 813 2000 or 800 813 2000 and we will expedite our review or life threatening condition

and you haven't responded to my request for service

What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will my request for care and inform OPM so that they can give your claim expedited treatment too Alternatively you can
my condition is serious call OPM's health benefits Contract Division 3 at 202 606 0755 between 8 a m and 5 p m or life threatening Serious or life threatening conditions are ones that may cause permanent loss of bodily functions
or death if they are not treated as soon as possible

Are there other time limits You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial or refusal of service You may also ask OPM to review your claim if
1 We did not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you
for additional information

What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information 1 A statement about why you believe our decision is wrong based on specific benefit
provisions in this brochure 2 Copies of documents that support your claim such as physicians letters operative reports
bills medical records and explanation of benefits EOB forms 3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and 5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents apply to which claim

Where should I mail my Send your request for review to Office of Personnel Management Office of Insurance Programs disputed claim to Contract Division 3 P O Box 436 Washington D C 20044
Who can make the request Those who have a legal right to file a disputed claim with OPM are 1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and 3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with the review request

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our the Plan's denial decision your only recourse is to sue
If you decide to sue 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 or supplies

What laws apply 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 made its decision on your claim You
may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure

described above

Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you the Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during
the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will become part of the court record

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Kaiser Foundation Health Plan of the Northwest 2000
Section 5 Benefits
Medical and Surgical Benefits What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan

physicians and other Plan providers This includes all necessary office and outpatient surgery visits
High Option Standard Option You pay 10 per visit You pay 12 per visit
for the following services Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two
years for women age 50 through 64 one mammogram every year and for women age 65 and above one mammogram every two years at no charge In addition to routine screening
mammograms are covered when prescribed by the physician as medically necessary to diagnose or treat your illness
Routine immunizations and boosters at no charge Allergy testing and treatment including test and treatment materials such as allergy serum
Visits to receive injections Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays at no charge Complete obstetrical maternity care for all covered females prenatal delivery and postnatal
care by a Plan physician The mother at her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will
be extended if medically necessary If enrollment in the Plan is terminated during pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary nursery care
of the newborn child during the covered portion of the mother's confinement for maternity will be covered under either a Self Only or Self and Family enrollment other care of an
infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family enrollment
Voluntary sterilization and family planning services Diagnosis and treatment of diseases of the eye
The insertion of internal prosthetic devices such as pacemakers and artificial joints Cornea heart heart lung kidney simultaneous pancreas kidney liver and lung single and
double transplants allogeneic donor bone marrow transplants autologous bone marrow transplants autologous stem cell and peripheral stem cell support for the following
conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer
multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors Related medical and hospital expenses of the donor are covered
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis office visit charges will be waived if you enroll in Medicare Part B and assign your Medicare benefits to the Plan
Chemotherapy respiratory therapy and radiation therapy Cardiac rehabilitation following a heart transplant bypass surgery or myocardial infarction
Surgical treatment of morbid obesity For homebound members residing in the service area home health services of nurses and
health aides physical or occupational therapists and speech and language pathologists when prescribed by your Plan physician who will periodically review the program for continuing
appropriateness and need at no charge Medical management of mental health conditions including drug therapy evaluation and
maintenance Services of physicians and other health professional in the hospital or extended care facility

If you do not pay any of the charges required for the services at the time you receive the services you will be billed You will also be required to pay a 6 charge for each bill sent for unpaid services

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Kaiser Foundation Health Plan of the Northwest 2000
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures

occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or
intra oral areas surrounding the teeth are not covered including any dental care involved in treatment of temporomandibular joint TMJ pain dysfunction syndrome

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from injury or surgery that has produced a major effect on the member's appearance
and if the condition can reasonably be expected to be corrected by such surgery A patient and their attending physician may decide whether to have breast reconstruction surgery following a
mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two months per condition if significant improvement can be expected

within two months you pay 10 per outpatient session under the High Option and 12 per outpatient session under the Standard Option and nothing for an inpatient session Speech and language
services are limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist the member to achieve and maintain self care and improved
functioning in other activities of daily living You may receive outpatient or inpatient therapy as part of a specialized therapy program in a specialized rehabilitation facility for up to two months
per condition per lifetime you pay nothing
Diagnosis and treatment of infertility is covered for diagnosis you pay 10 per outpatient session High Option and 12 per outpatient session Standard Option for treatment you pay

50 of charges Standard and High Option Artificial intrauterine insemination IUI is covered you pay 50 of charges Standard and High Option Intravaginal insemination IVI and
intracervical insemination ICI are not covered Cost of donor sperm and donor eggs and services related to their procurement and storage are not covered Other assisted reproductive
technology ART procedures that enable a woman with otherwise untreatable infertility to become pregnant through other artificial conception procedures such as in vitro fertilization
gamete and zygote intrafallopian transfers are not covered Infertility services are not available when either member of the family has been voluntarily surgically sterilized Drugs used in the
treatment of infertility are not covered
Prosthetic devices to restore or manage head and facial structures that are defective will be provided you pay 20 of charges Breast prostheses surgical bras and their replacements are

covered at no charge Devices used primarily for cosmetic purposes that are not necessary to control or eliminate infection pain or restore functions such as speech swallowing or chewing
are not covered Artificial larynxes voice machines artificial hearts internally implanted insulin pumps penile prosthetic devices dentures and devices to treat temporomandibular joint conditions
are not covered
Orthognathic surgery for temporomandibular joint dysfunction TMD will be covered if medical criteria are met subject to an annual benefit maximum of 1,000 and a lifetime benefit

maximum of 5,000 You pay 100 of charges after benefit maximum is reached
Self Referred Chiropractic services Up to 20 visits per calendar year of self referred chiropractic services provided by Participating Chiropractors Covered services include evaluation and

management musculoskeletal treatments physical therapy modalities such as hot and cold packs and X rays You pay 15 per visit for the High Option 20 per visit for the Standard Option The
following are not covered non neuroskeletal disorders vocational rehabilitation services laboratory services MRI or other type of advanced diagnostic radiology and durable medical
equipment or supplies for use in the home

What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending camp or travel
Reversal of voluntary surgically induced sterility Surgery primarily for cosmetic purposes
External and internally implanted hearing aids Homemaker services
Long term rehabilitative and cognitive therapy Transplants not listed as covered
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as nearsightedness myopia farsightedness hyperopia and astigmatism
Orthopedic devices including foot orthotics Durable medical equipment such as wheelchairs and hospital beds
Devices equipment supplies and prosthetics related to the treatment of sexual dysfunction Travel immunizations
Medications related to foreign travel 11
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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Kaiser Foundation Health Plan of the Northwest 2000
Hospital Extended Care Benefits

What is covered
Hospital Care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan physician You pay nothing All necessary services are

covered including Semiprivate room accommodations when a Plan physician determines it is medically
necessary the physician may prescribe private accommodations or private duty nursing care Specialized care units such as intensive care or cardiac care units
Prescribed drugs and their administration blood and blood products and the administration of blood biologicals supplies and equipment ordinarily provided or arranged as part of
inpatient services If determined to be medically necessary by the attending Plan physician members hospitalized
for medical non psychiatric conditions will be provided all necessary inpatient psychiatric consultations This inpatient consultation benefit is in addition to the mental conditions
benefits shown on page 15

Extended Care The Plan provides a comprehensive range of benefits for up to 100 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is in lieu
of hospitalization You pay nothing All necessary services are covered including Bed board and general nursing care
Prescribed drugs and their administration biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan physician

Hospice Care Supportive and palliative care for a terminally ill member is covered in the home or a Plan approved hospice facility You pay nothing Services include inpatient and outpatient care
and family counseling these services are provided under the direction of a Plan physician who certifies that the patient is in the terminal stages of illness with a life expectancy of
approximately six months or less

Ambulance Service Benefits are provided for ambulance transportation ordered or authorized by a Plan physician You pay 25 per transport

Limited benefits
Inpatient Dental Hospitalization for certain dental procedures is covered when a Plan physician determines there Procedures is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will

cover the hospitalization but not the cost of the professional dental services Conditions for which hospitalization may be covered include hemophilia and heart disease the need for anesthesia
by itself is not such a condition

Acute Inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis Detoxification treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan physician determines that outpatient management is not medically appropriate See page 15 for nonmedical substance abuse benefits

What is not covered Personal comfort items such as telephone and television Custodial care or care in an intermediate care facility
Collection processing and storage of blood donated by donors designated by you or a family member Costs associated with blood donated by you for a scheduled covered surgery are covered

Benefits available When you are outside the service area of this Plan you may still receive covered health care away from home services There are two types of coverage provided under your enrollment in this Plan

12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
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Kaiser Foundation Health Plan of the Northwest 2000
Services from other When you are visiting in the service area of another Kaiser Permanente plan you are entitled Kaiser Permanente Plans to receive virtually all the benefits described in this brochure at any Kaiser Permanente medical

office or medical center and from any Kaiser Permanente provider If the Plan you are visiting has a charge that is different from the charges listed in this brochure you will have to pay the
charges imposed by the Plan you are visiting If the Kaiser Permanente plan in the area you are visiting has a benefit that is different from the benefits of this Plan you are not entitled to receive
that benefit Some services covered by this Plan such as artificial reproductive services and the services of specialized rehabilitation facilities will not be available in other Kaiser Permanente
service areas If a benefit is limited to a specific number of visits or days you are entitled to receive only the number of visits or days covered by the Plan in which you are enrolled

If you are seeking routine non emergent or non urgent services you should call the Kaiser Permanente Membership Services department in that service area and request an appointment
You may obtain routine follow up or continuing care from these Plans even when you have obtained the original services in the service area of this Plan If you require emergency services
as the result of an unexpected or unforeseen illness that requires immediate attention you should go directly to the nearest Kaiser Permanente facility to receive care

At the time you register for services you will be asked to pay the charges required by the local plan
If you plan to travel to an area with another Kaiser Permanente plan and wish to obtain more information about the benefits available to you from that Kaiser Permanente Plan please call

Membership Services at 503 813 2000 or 800 813 2000

Benefits available If you are outside the service area of this Plan by more than 100 miles or outside the service area while you travel of any other Kaiser Permanente Plan the following health care services will be covered
Follow up care care necessary to complete a course of treatment following receipt of covered out of plan emergency care or emergency care received from Plan facilities if the care would
otherwise be covered and is performed on an outpatient basis Examples of covered follow up care include the removal of stitches a catheter or a cast

Continuing care care necessary to continue covered medical services normally obtained at Plan facilities as long as care for the condition has been received at Plan facilities within the
previous 90 days and the services would otherwise be covered Services must be performed on an outpatient basis Services include scheduled well baby care prenatal visits medication
monitoring blood pressure monitoring and dialysis treatments The following services are not covered hospitalization infertility treatments childbirth services and transplants Prescription
drugs are not covered However you may have prescriptions filled by mail through this Plan's Prescription Drug Benefit

If you have any questions about how to use these benefits call the Travel Benefits Information Line at 800 390 3509 You may obtain the Travel Benefits for Federal Employees brochure by
calling this number You should pay the provider at the time you receive the service Submit a claim to the Plan for the services on the Plan's Claim for Follow up Continuing Care Medical
Services Form with necessary supporting documentation Submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your
ID card as you would an emergency claim Claims should be submitted to Claims Department Kaiser Foundation Health Plan of the Northwest 500 N E Multnomah Street Suite 100
Portland Oregon 97232 If the services are covered under this Travel Benefit you will be reimbursed the usual and customary charges for the care up to a maximum of 1,200 per calendar year
You pay 25 for each follow up or continuing care visit This amount will be deducted from the payment the Plan makes to you

Emergency Benefits What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you
emergency believe endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they
might become more serious examples include deep cuts and broken bones Others are emergencies because they are potentially life threatening such as heart attacks strokes poisonings gunshot
wounds or the sudden inability to breathe There are many other acute conditions that the Plan may determine are medical emergencies what they all have in common is the need for quick action

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Kaiser Foundation Health Plan of the Northwest 2000
Emergencies within In a life threatening emergency call the local emergency system e g the local 911 telephone the service area system When the operator answers stay on the phone and answer all questions If an ambulance

comes tell the paramedics that the person who needs help is a Kaiser Permanente member You or a family member must notify the Plan within 48 hours It is your responsibility to ensure that
the Plan has been notified
For other serious conditions go to the emergency department at a Plan facility a Kaiser Permanente hospital or a designated plan hospital or a participating Group Health facility

unless the time it would take to do so would result in serious medical consequences If that is the case go to the nearest hospital

If you are admitted to a non Plan facility call the Patient Transfer Coordinator at 503 813 4540 or 800 813 2000 and ask for the Patient Transfer Coordinator You must call within 48 hours or
on the first working day following your admission unless it was not reasonably possible to notify the Plan within that time If you are hospitalized in non Plan facilities and Plan physicians believe
your care can be better provided in a Plan facility you will be transferred when medically feasible
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan facility would result in death disability or significant jeopardy to your condition

At Plan facilities Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per visit plus any charges which would have been required if the care had been rendered by the Plan If the visit results in an inpatient admission you pay only the office visit charge

At non Plan Plan pays Reasonable charges for emergency services to the extent the services would have hospitals been covered if received from Plan providers
You pay 50 of the first 100 plus any charges which would have been required if care had been rendered by the Plan

Emergencies outside You may obtain emergency and urgent care services from Kaiser Permanente medical facilities the service area and providers when you are in the service area of another Kaiser Permanente plan The facilities
will be listed in the local telephone book under Kaiser Permanente These numbers are available 24 hours a day seven days a week You may also obtain information about the location of
facilities by calling the Membership Services department at 503 813 2000 or 800 813 2000
Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that
time If a Plan physician believes care can be better provided in a Plan hospital you will be transferred when medically feasible

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 of the first 100 plus any charges which would have been required if the care had been rendered by the Plan

What is covered Emergency care at a physician's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including physician services
Ambulance service approved by the Plan

What is not covered 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

Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency non Plan providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim
form You should submit claim forms to Claims Department Kaiser Foundation Health Plan of the Northwest 500 N E Multnomah Street Suite 100 Portland Oregon 97232 If you are
required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card

14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14
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Kaiser Foundation Health Plan of the Northwest 2000
Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the denial

and the provisions of the contract on which denial was based If you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure
described on page 8

Mental Conditions Substance Abuse Benefits
Mental Conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders

Diagnostic evaluation Psychological testing
Psychiatric treatment including individual and group therapy Medical management visits including drug evaluation and treatment
Hospitalization including inpatient professional services

Outpatient Up to 40 outpatient visits to Plan physicians consultants or other psychiatric personnel every Care two calendar years

High Option Standard Option You pay 5 per visit for visits 1 40 You pay 10 per visit for visits 1 40
Under both options you pay 50 of charges for all visits following the 40th visit
If you do not pay any of the charges required for the services at the time you receive the services you will be billed You will also be required to pay a reasonable administrative charge for each

service for which a bill is sent

Inpatient Both Options Up to 60 days of hospitalization every two calendar years You pay nothing Care for the first 60 days 50 of charges thereafter

Residental Both Options All necessary treatment up to 29 days every two calendar years You pay 50 Day Care per day up to a maximum of 250 per admission
Facility
What is not covered Care for psychiatric conditions that in the professional judgment of Plan physicians are
not subject to significant improvement through relatively short term treatment Psychiatric evaluation or therapy on court order or as a condition of parole or probation

unless determined by a Plan physician to be necessary and appropriate Psychological testing that is not medically necessary to determine the appropriate treatment
of a short term psychiatric condition
Substance Abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction

the same as for any other illness or condition In addition the Plan provides

Outpatient Dependency counseling Care
High Option Standard Option You pay 5 per visit You pay 8 per visit
If you do not pay any of the charges required for the services at the time you receive the services you will be billed You will also be required to pay a reasonable administrative charge for each
service for which a bill is sent

Residential All necessary treatment up to a maximum benefit paid by the Plan of 3,500 for adults and 4,500 Day Care for children every two calendar years You pay 20 of charges for covered services both options
Facility
What is not covered Treatment which is not authorized by a Plan physician

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Kaiser Foundation Health Plan of the Northwest 2000
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor or any licensed dentist and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply or 100 dosage units for oral solids or

one pint for oral liquid medications or if obtained through the mail order pharmacy will be dispensed for up to a 90 day supply for oral solids or one point for oral liquid medications You pay 10
High Option or 15 Standard Option per prescription or refill
You may receive refills by mail at no extra charge and there is no additional charge for delivery Ask for details at a Plan pharmacy

This Plan uses a formulary to determine which prescribed drugs will be provided to members If the physician specifically prescribes a nonformulary drug because it is medically necessary
the nonformulary drug will be covered If you request the nonformulary drug when your physician has prescribed a substitution the nonformulary drug is not covered However you
may purchase the nonformulary drug from a Plan pharmacy at prices charged to members for non covered drugs

The following drugs are drugs provided at the 10 High Option or 15 Standard Option charge unless another charge is specifically identified
Drugs for which a prescription is required by law Oral contraceptive drugs dispensed in 90 days supply you pay 10 High Option or
15 Standard Option per prescription per 30 day supply contraceptive devices such as diaphragms intrauterine devices and cervical caps you pay 10 High Option or 15
Standard Option times the number of months the device is expected to be effective Implanted time release drugs You pay 10 High Option or 15 Standard Option times
the expected number of months the medication will be effective There will be no refund if the implanted drug is removed before the end of its expected life
Injectable contraceptives You pay 10 High Option or 15 Standard Option per prescription times the expected number of months the medication will be effective
Insulin Glucose test strips
Smoking cessation drugs and medication including prescribed nicotine gum and patches when used in conjunction with smoking cessation programs
Chemotherapy Certain over the counter medications which are prescribed by a Plan physician and listed
on the Plan's formulary as the most appropriate treatment for a particular condition Prescription drugs for a dental condition as listed in the Plan's dental drug formulary
Disposable needles and syringes needed to inject covered prescribed medication DME diabetic supplies such as external insulin pumps infusion devices glucose monitors
and diabetic footcare appliances You pay 50 of charges
The following are provided at no charge Amino acid modified products used in the treatment of inborn errors of amino acid

metabolism PKU Immunosuppressive drugs required after a transplant
Intravenous fluids and medication for home

Limited benefits Drugs to treat sexual dysfunction have dispensing limitations You pay 50 of charges Contact the Plan for details

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available except those listed on the Plan's formulary and prescribed by a Plan physician
Drugs obtained at a non Plan pharmacy except for out of area emergencies Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics Drugs for cosmetic purposes
Drugs to enhance athletic performance Drugs for the treatment of infertility
Drugs related to non covered services Drugs used in weight management
Drugs for foreign travel

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Kaiser Foundation Health Plan of the Northwest 2000
Other benefits
Dental Care High Option only

What is covered For members who have elected the High Option Plan a comprehensive range of dental services as described below are covered when prescribed by Plan dentists and provided at Plan dental offices
Office Visits You pay 10 for each office visit
Diagnostic Services and Preventive Care You pay 10 per visit for routine oral examinations and X rays oral prophylaxis routine teeth cleaning including topical application of fluoride

when prescribed by a Plan dentist but not more than two visits in any twelve consecutive months prescribed space maintainers and habit appliances

Restorative Services You pay 10 per visit plus 50 of charges for restorative services including routine fillings local anesthesia stainless steel or plastic crowns and simple extractions
Oral Surgery You pay 10 per visit plus 50 of the charges for diagnosis evaluation consultation and treatment for removal of teeth including local anesthesia minor surgical
preparation of mouth for insertion of dentures and surgical treatment normally performed by a dentist for minor pathological conditions

Periodontics You pay 10 per visit plus 50 of the charges for diagnosis evaluation consultation and treatment for periodontics diseases of tissues supporting the teeth including
all follow up cleaning visits
Endodontics You pay 10 per visit plus 50 of the charges for diagnosis evaluation consultation and treatment for endodontics root canal therapy

Prosthetics You pay 10 per visit plus 50 of the charges for diagnosis evaluation consultation and treatment for prosthetics including full or partial dentures gold or porcelain crowns inlays
or bridge pontics There will be an additional charge for the use of precious metals if a clinically acceptable non precious metal alternative material is available and prescribed by a Plan dentist

After Hours Care You pay an additional 25 per visit for any dental care received from a Plan dentist after Plan dental hours or on weekends except for prescheduled appointments
Out of Area Emergency Care The Plan pays up to 100 for emergency care for relief of pain acute infection or hemorrhage or necessary treatment including local anesthesia and
premedication due to injury You pay all charges exceeding 100
Prescription Drugs Covered under Prescription Drug Benefits See page 16
Nitrous Oxide You pay 15 per occurrence except children 12 years of age and under pay nothing for the service

Accidental Injury Benefit You pay 10 per visit for restorative services and supplies necessary to promptly repair but not replace sound natural teeth The need for these services must result
from accidental injury

What is not covered Orthodontics Treatment for problems of the jaw joint including temporomandibular joint syndrome
craniomandibular disorders or other conditions of the joint linking the jaw bone and skull and of the complex of muscles nerves and other tissues related to that joint See Medical
and Surgical Benefits page 10 for coverage Dental implants including bone augmentation and the fixed or removable prosthetic devices
attached to or covering the implants and all services and materials relating to the placement or removal of implants including but not limited to diagnostic consultations impressions
oral surgery and removal of implants for cleaning and services related to post operative conditions or complications arising from implants
Restorative or reconstructive services for congenital or developmental malformations Full mouth reconstructions This includes appliances restoration and procedures needed to
alter vertical dimension or occlusion or in conjunction with alteration of vertical dimension or occlusion or for the purpose of splinting teeth or correcting attrition or abrasion
Cosmetic dental services Restoration replacement Clinically acceptable restorations or material will not be removed
or replaced with alternative materials unless a pathological condition of the teeth exists Missed appointments you pay 10 for each appointment missed unless the Plan dental
office is notified in advance IV sedation
Genetic testing

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Kaiser Foundation Health Plan of the Northwest 2000
Vision Care In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye this Plan provides vision care benefits to members when prescribed by Plan physicians

or optometrists and provided at Plan facilities and optical departments

What is covered Refractions You pay 10 per visit High Option and 12 per visit Standard Option for eye exams for eyeglasses and contact lenses
Eyeglasses and contact lenses when prescribed by a Plan physician or optometrist
High Option One pair of eyeglasses regular lenses and designated frames medically indicated contact lenses or designated industrial safety glasses from the Plan's Optical

department is provided at no charge once every two years since last provided by the Plan If a significant change in correction occurs in one or both eyes before the two years has elapsed
lenses with the new correction are provided at no charge If you select non medically indicated contact lenses or eyeglasses which cost more than regular lenses and designated frames you pay
charges less a credit equal to the cost of the regular designated eyeglasses
Standard Option You receive a credit of 25 toward the purchase of eyeglasses contact lenses or industrial safety glasses from the Plan's Optical department once every two years since

last provided by the Plan The 25 credit will apply also toward post cataract surgery benefits described below If a significant change in correction in one or both eyes occurs before the two
year period has elapsed an additional 25 credit will apply toward the purchase of lenses with the new correction

Medically Indicated Medically indicated contact lenses as described under the High Standard Options above will be Contact lenses provided at no charge under the High Option and at a credit of 25 under the Standard Option for
Post cataract surgery Extremely high degrees of near or far sightedness
Distorted corneas which limit the best visual acuity with glasses Visual errors of the two eyes which are greatly different in power

Post Cataract Post cataract surgery patients will be provided the following items at no charge under the High Surgery Option and included as part of the 25 credit under the Standard Option
One pair of regular lenses and designated frames or One pair of contact lenses and one pair of designated frames and reading lenses if both must
be worn at the same time to provide a significant improvement in visual acuity Medically necessary intraocular lenses at no charge for both Options

What is not covered Sunglasses prescription or plain Athletic safety glasses
Photogrey photosun and tinted lenses Two pairs of lenses and frames in lieu of bifocals in the same frames
Repair or replacement of broken lost or stolen lenses or frames Contact lenses having no refractive value
Fitting and routine follow up services for non medically indicated contact lenses Visual training
Refractions for non medically indicated contact lenses Vision therapy orthoptics or eye exercises

18 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 18
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Kaiser Foundation Health Plan of the Northwest 2000
Special Benefits for Medicare Eligible Enrollees If you are enrolled in this Plan through the FEHBP have Medicare Part A coverage and have

purchased Part B coverage you also may enroll in the Kaiser Permanente Senior Advantage program
The Senior Advantage Program Plan provides all Medicare covered Part A and Part B benefits to the Medicare beneficiary as well as some benefits not covered by Medicare It is an arrangement

between Medicare and this Plan in which Medicare pays a specific amount to this plan for each Medicare beneficiary who enrollees in the Plan

Like your FEHBP enrollment in this Plan you are required to obtain your services from this Plan's physicians and providers except for emergencies and out of area urgent care The rules
regarding enrollment in Kaiser Permanente Senior Advantage are fully explained in A Guide to Your Kaiser Permanente Senior Advantage Benefits For a copy of these rules please contact
Membership Services at 503 813 2000 or 800 813 2000
Following your enrollment in Kaiser Permanente Senior Advantage you will be entitled to receive an enhanced benefits package that combines your FEHBP coverage with your Kaiser

Permanente Senior Advantage benefits
If you choose to enroll in Senior Advantage you will be responsible for paying the Part B premium You must make an affirmative enrollment in Senior Advantage You will also continue to pay the

employee share of the FEHBP premium

19 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 19
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Kaiser Foundation Health Plan of the Northwest 2000
Non FEHB benefits available to Plan members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members who are members of this Plan The cost of the benefits described on this page is not
included in the FEHB premium any charges for these services do not count toward any FEHB deductibles out of pocket maximum
copay charges etc These benefits are not subject to the FEHB disputed claims procedure

Classes to change your lifestyle and keep you healthy At Kaiser Permanente we actively encourage you to share responsibility for your health care

Choices you make every day about what you eat and drink whether you exercise or smoke how you handle stress or whether
you wear a seat belt are tied directly to your health They affect your chances of having a stroke or a heart attack getting cancer
or being at risk for handicapping injuries

We have developed a wide range of health education and health promotion classes to help you stay healthy You can learn how to kick the
smoking habit for good effectively manage your weight improve personal and family relationships deal more effectively with a chronic
health problem have a safe and healthy pregnancy and much more Descriptions of the Freedom From Cigarettes and Freedom
From Fat classes are shown below Over 40 other classes are also offered Class fees begin as low as 3 per member for some classes

Our classes are open to everyone but we offer them at special reduced rates to our members If you would like to enroll you must
fill out a registration form For the latest class catalog call

Health Education Membership Services Portland 503 286 6816 Portland 503 813 2000

8 a m 5 p m Monday Friday 8 a m 7 p m Monday Friday Salem 503 316 2344 All other areas 800 813 2000
Washington 360 604 2070 8 a m 7 p m Monday Friday
Freedom from Fat A 16 week program divided into two 8 week series Getting Started and Moving On plus the optional follow up program called
On going Progress
Are you tired of losing weight just to gain it back Do you want to learn to eat low fat foods to keep your cholesterol level safe
The Freedom From Fat program can help you manage your low fat lifestyle for good That's because Freedom From Fat is more
than a diet program It is a new approach to eating developed by researchers at Kaiser Permanente The classes are conducted by
professional nutrition and behavior change specialists Each meeting provides a format for problem solving discussion

Series I Getting Started Eight 2 hour sessions
Series II Moving On Eight 2 hour sessions
Ongoing program follow up Twelve 1.5 hour sessions

Freedom From Cigarettes The cold turkey approach to stop smoking or chewing tobacco

Learn the latest and most effective techniques for kicking the smoking habit for good Sessions include
Relaxation techniques
Understanding cigarette addiction
Practicing effective ways to remain a non smoker

Six 1 1 2 hour classes

Freedom from Cigarettes with Temporary Drug Therapy Ten 1 hour sessions

These classes are designed to provide you with techniques and support that will increase your chances for lifelong freedom from tobacco
To be eligible for Freedom from Cigarettes with Drug Therapy the participants must
Have made repeated attempts to quit tobacco use on his her own and
Be medically appropriate

Drug therapy has been proven to be most successful when used in conjunction with a behavior change program The medication
treatment is a short term aid for people committed to learning how to stop smoking or chewing and who have been unsuccessful
with other methods

Your present pharmacy benefit provides coverage for smoking cessation drugs nicotine gum and patches when used in conjunction
with this program

Sessions from both Freedom From Cigarettes and Freedom from Fat provide a free no obligation 1 hour Explanatory Session
no registration needed Call 503 286 6880 message recorder and leave your name address and phone number We will send
you class dates times and locations

20 Benefits on this page are not part of the FEHB contract 20
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Kaiser Foundation Health Plan of the Northwest 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan physician determines it is medically necessary to

prevent diagnose or treat your illness or condition
We do not cover the following Services drugs or supplies that are not medically necessary

Services not required according to accepted standards of medical dental or psychiatric practice Care by non Plan doctors or hospitals except for authorized referrals or emergencies and
services received under the travel benefit see Emergency Benefits and Benefits available away from home
Experimental or investigational procedures treatments drugs or devices Procedures services drugs and supplies related to abortions except when the life of the
mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On

occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on suspending
your FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next
Open Enrollment
If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 800 638 6833 For information on the Medicare Choice
plan offered by this Plan see page 19

Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance coverage You must tell us if you or a family member has double coverage You must also send us documents
about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is primary according to the

National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or our regular benefit

whichever is less We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must still tell us that you have double coverage

Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to our control provide them In that case we will make all reasonable efforts to provide you with necessary care

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Kaiser Foundation Health Plan of the Northwest 2000
When others are When you receive money to compensate you for medical or hospital care for injuries or illness responsible for injuries that another person caused you must reimburse us for whatever services we paid for We will

cover the cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more
information contact us for our subrogation procedures

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover
you we are the primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage

Workers Compensation We do not cover services that You need because of a workplace related disease or injury that the Office of Workers Compensation
Programs OWCP or a similar Federal or State agency determine they must provide 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
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other government agencies We do not cover services and supplies that a local State or Federal Government agency directly or indirectly pays for

Section 8 FEHB Facts
You have a right OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the to information right to information about your health plan its networks providers and facilities You can also

about your HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's Web site
http www opm gov insure lists the specific types of information that we must make available to you
If you want specific information about us call 503 813 2000 or 800 813 2000 or write to Kaiser Permanente Membership Services 5115 N Greeley Avenue Portland Oregon 97217 You may

also contact us by fax at 503 735 2706 or visit our Web site at http www kaiserpermanente org or by e mail at Membership Services at www kaiserpermanente org locations northwest

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to
enrolling in the make an informed decision about FEHB Program 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 When your enrollment ends and
The next Open Enrollment for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office

When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your and premiums effective coverage and premiums begin on the first day of your first pay period that starts on or after
January 1 Annuitants premiums begin January 1

What happens when I retire 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 which is described later in this section

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Kaiser Foundation Health Plan of the Northwest 2000
What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your are available for my unmarried dependent children under age 22 including any foster or step children your employing

family and me or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a 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 you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or

remove family members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan

Are my medical and We will keep your medical and claims information confidential Only the following will have claims records confidential access to it
OPM this Plan and subcontractors when they administer this contract This plan and appropriate third parties such as other insurance plans and the Office of
Workers Compensation Programs OWCP when coordinating benefit payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits Individuals involved in bona fide medical research or education that does not disclose your
identity or OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members
Identification cards We will send you an identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can

also use an Employee Express confirmation letter

What if I paid a Your old plan's deductible continues until our coverage begins deductible under
my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before conditions you enrolled in this Plan solely because you had the condition before you enrolled

When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when my enrollment in Your enrollment ends unless you cancel your enrollment or

this Plan ends You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage

What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage
under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information about your coverage choices

23 23
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Kaiser Foundation Health Plan of the Northwest 2000
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For

example you can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about TCC You can pick a new plan

If you leave Federal service you can receive TCC for up to 18 months after you separate If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends If you or your employing office delay processing your request you still have to pay premiums
from the 32nd day after your regular coverage ends even if several months have passed You pay the total premium and generally a 2 percent administrative charge The government
does not share your costs You receive another 31 day extension of coverage when your TCC enrollment ends unless
you cancel your TCC or stop paying the premium You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I If you leave Federal service your employing office will notify you of your right to enroll under enroll in TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling
in TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline

How can I convert to You may convert to an individual policy if individual coverage 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 service your employing office will notify you if individual coverage is available You must apply in writing to us 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 apply in writing to us 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 and we will not impose a waiting period or limit
your coverage due to pre existing conditions

How can I get If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage a Certificate of that indicates how long you have been enrolled with us You can use this certificate when getting
Group Health health insurance or other health care coverage You must arrange for the other coverage within 63 Plan Coverage days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or
exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well

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Kaiser Foundation Health Plan of the Northwest 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error If the provider does not resolve the matter call us at 503 813 2000 or 800 813 2000 and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE 202 418 3300
U S Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400 Washington D C 20415

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may
investigate anyone who uses an ID card if they Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you

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Kaiser Foundation Health Plan of the Northwest 2000
Summary of Benefits for Kaiser Foundation Health Plan of the Northwest 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or

change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE COVERED FOLLOW UP AND CONTINUING CARE SERVICES AND CARE RECEIVED FROM OTHER KAISER PERMANENTE PLANS ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN PHYSICIANS

Benefits High Option pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day Care limit Includes in hospital physician care room and board general nursing care

private room and private nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating room intensive care and complete
maternity care You pay nothing 12
Extended Care All necessary services for up to 100 days per calendar year You pay nothing 12
Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up to 60 days of inpatient care every two calendar years You pay nothing for first 60 days 50

of charges thereafter all necessary residential day care treatment up to 29 days every two calendar years You pay 50 per day up to a maximum of 250 per admission 15

Substance Abuse Treatment services up to 3,500 for adults and 4,500 for children benefit maximum
every two calendar years You pay 20 of charges Mental conditions benefits are

Outpatient also covered as shown 15 Care Comprehensive range of services such as diagnosis and treatment of illness or

injury including specialist's care preventive care including well baby care periodic check ups and routine immunizations laboratory tests and X rays
complete maternity care You pay 10 per office outpatient surgery or physician's home visit 10

Self Referred You pay 15 per visit up to 20 visits per year 11 Chiropractic Services
Home Health Services All necessary visits by nurses and health aides physical or occupational therapists and speech and language pathologists You pay nothing 10
Mental Conditions Up to 40 outpatient visits every two calendar years You pay 5 per outpatient visit 50 of charges thereafter 15
Substance Abuse Short term counseling You pay 5 per office visit Mental conditions benefits are also covered as shown 15
Emergency Care Usual and customary charges for services and supplies required because of a medical emergency You pay 25 per visit for in Plan emergency care plus any
charges which would have been required if the care had been rendered by the Plan If the visit results in an inpatient admission you pay only the office visit charge
You pay 50 of the first 100 in charges for non Plan for emergency care applicable Plan copayments and any charges for services that are not covered by this Plan 13

Prescription Drugs Drugs prescribed by a Plan physician and obtained at a Plan pharmacy You pay 10 per prescription unit or refill 16
Dental Care Preventive dental care comprehensive range of restorative and other services You pay 10 per office visit 50 of charges for restorative services and simple
extractions 50 of charges for certain other services 17
Vision Care Covered refractions You pay 10 per visit One pair of eyeglasses medically necessary contact lenses or industrial safety glasses as shown every two years

You pay nothing 18
Out of Pocket Copayments are required for a few benefits however after your out of pocket Maximum expenses reach a maximum of 600 per Self Only or 1,200 per Self and Family

enrollment per calendar year covered benefits will be provided at 100 6

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26 Page 27 28
Kaiser Foundation Health Plan of the Northwest 2000
Summary of Benefits for Kaiser Foundation Health Plan of the Northwest 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the definitions limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to

enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY
CARE COVERED FOLLOW UP AND CONTINUING CARE SERVICES AND CARE RECEIVED FROM OTHER KAISER PERMANENTE PLANS ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN PHYSICIANS

Benefits Standard Option pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day Care limit Includes in hospital care room and board general nursing care private

room and private nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating room intensive care and complete
maternity care You pay nothing 12
Extended Care All necessary services for up to 100 days per calendar year You pay nothing 12
Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up to 60 days of inpatient care every two calendar years You pay nothing for first 60 days 50

of charges thereafter all necessary residential day care treatment up to 29 days every two calendar years You pay 50 per day up to a maximum of 250
per admission 15
Substance Abuse Treatment services up to a 3,500 for adults and 4,500 for children benefit maximum every two calendar years You pay 20 of charges Mental conditions

benefits are also covered as shown 15
Outpatient Comprehensive range of services such as diagnosis and treatment of illness Care or injury including specialist's care preventive care including well baby care

periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay 12 per office outpatient surgery or physician's
home visit 10
Self Referred You pay 20 per visit up to 20 visits per year 11 Chiropractic Services

Home Health Services All necessary visits by nurses and health aides physical or occupational therapists
and speech and language pathologists You pay nothing 10

Mental Conditions Up to 40 outpatient visits every two calendar years You pay 10 per outpatient visit 50 of charges thereafter 15

Substance Abuse Short term counseling You pay 8 per office visit Mental conditions benefits are also covered as shown 15
Emergency Care Usual and customary charges for services required because of a medical emergency You pay 25 per visit for in Plan emergency care plus any charges which would have
been required if the care had been rendered by the Plan If the visit results in an inpatient admission you pay only the office visit charge You pay 50 of the first 100 in charges
for non Plan for emergency care applicable Plan copayments and any charges for services that are not covered by this Plan 13

Prescription Drugs Drugs prescribed by a Plan physician and obtained at a Plan pharmacy You pay
15 per prescription unit or refill 16

Dental Care No current benefit
Vision Care Covered refractions You pay 12 per visit You receive a 25 credit toward the
purchase of a pair of eyeglasses contact lenses or industrial safety glasses every two years You pay any amount above the credit 18

Out of Pocket Copayments are required for a few benefits however after your out of pocket Maximum
expenses reach a maximum of 600 per Self Only or 1,200 per Self and Family enrollment per calendar year covered benefits will be provided at 100 6

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2000 Rate Information for Kaiser Foundation Health Plan of the Northwest
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees but do not apply to non career Postal employees Postal retirees certain special Postal employment categories or associate members of any Postal employee organization If you are in a special
Postal employment category refer to the FEHB Guide for that category

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Enrollment Code Gov't Your Gov't Your USPS Your USPS Your Share Share Share Share Share Share Share Share

High Option 571 78.83 29.74 170.80 64.44 93.06 15.51 93.26 15.31 Self Only
High Option 572 175.97 73.19 381.27 158.58 207.74 41.42 201.02 48.14 Self and Family

Standard Option 574 66.67 22.22 144.45 48.15 78.89 10.00 78.89 10.00 Self Only
Standard Option 575 153.00 51.00 331.50 110.50 181.05 22.95 181.05 22.95 Self and Family

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