Document Body Page Navigation Panel Document Outline

Kaiser Foundation Health Plan of Colorado

Federal Employees Health Benefits Program
2003 Plan Brochure
Accessible Version

Document Outline

Introduction
Plain Language
Stop Health Care Fraud!
Section 1. Facts about this HMO plan
Section 2. How we change for 2003
- Program-wide changes
- Changes to this Plan
Section 3. How you get care
Section 4. Your costs for covered services
Section 5. Benefits
- Overview
Section 6. General exclusions -- things we don't cover
Section 7. Filing a claim for covered services
Section 8. The disputed claims process
Section 9. Coordinating benefits with other coverage
Section 10. Definitions of terms we use in this brochure
Section 11. FEHB facts
Long Term Care Insurance Is Still Available!
Index
Summary of benefits
Rates

Pages 1--72

Page 1


Dear Federal Employees Health Benefits Program Participant: I am pleased to present this Federal Employees Health Benefits (FEHB) Program plan brochure for 2003. The brochure explains all the benefits this health plan offers to its enrollees. Since benefits can vary from year to year, you should review your plan's brochure every Open Season. Fundamentally, I believe that FEHB participants are wise enough to determine the care options best suited for themselves and their families. In keeping with the President's health care agenda, we remain committed to providing FEHB members with affordable, quality health care choices. Our strategy to maintain quality and cost this year rested on four initiatives. First, I met with FEHB carriers and challenged them to contain costs, maintain quality, and keep the FEHB Program a model of consumer choice and on the cutting edge of employer-provided health benefits. I asked the plans for their best ideas to help hold down premiums and promote quality. And, I encouraged them to explore all reasonable options to constrain premium increases while maintaining a benefits program that is highly valued by our employees and retirees, as well as attractive to prospective Federal employees. Second, I met with our own FEHB negotiating team here at OPM and I challenged them to conduct tough negotiations on your behalf. Third, OPM initiated a comprehensive outside audit to review the potential costs of federal and state mandates over the past decade, so that this agency is better prepared to tell you, the Congress and others the true cost of mandated services. Fourth, we have maintained a respectful and full engagement with the OPM Inspector General (IG) and have supported all of his efforts to investigate fraud and waste within the FEHB and other programs. Positive relations with the IG are essential and I am proud of our strong relationship. The FEHB Program is market-driven. The health care marketplace has experienced significant increases in health care cost trends in recent years. Despite its size, the FEHB Program is not immune to such market forces. We have worked with this plan and all the other plans in the Program to provide health plan choices that maintain competitive benefit packages and yet keep health care affordable. Now, it is your turn. We believe if you review this health plan brochure and the FEHB Guide you will have what you need to make an informed decision on health care for you and your family. We suggest you also visit our web site at www.opm.gov/insure.
		Sincerely, Kay Coles James Director

Kaiser Foundation Health Plan of Colorado
http:// www. kaiserpermanente. org
2003 A Health Maintenance Organization

Serving: Metropolitan Denver, Colorado area Colorado Springs, Colorado area
Enrollment in this Plan is limited. You must live in our geographic service area to enroll. See page 8 for requirements.

Enrollment codes for this Plan:
651 Self Only 652 Self and Family

RI 73-019

This Plan has excellent accreditation from the NCQA.
See the 2003 Guide for more information on accreditation.

For changes in benefits
see page 9 1.
1 Page 2 3
2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
By law, the Office of Personnel Management (OPM), which administers the Federal Employees Health Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also required to
give you this notice to tell you how OPM may use and give out (" disclose") your personal medical information held by OPM.

OPM will use and give out your personal medical information:
To you or someone who has the legal right to act for you (your personal representative), To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is
protected, To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and
Where required by law.
OPM has the right to use and give out your personal medical information to administer the FEHB Program. For example:

To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
To review, make a decision, or litigate your disputed claim. For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
For Government healthcare oversight activities (such as fraud and abuse investigations), For research studies that meet all privacy law requirements (such as for medical research or education), and
To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission
at any time, except if OPM has already acted based on your permission.
By law, you have the right to:
See and get a copy of your personal medical information held by OPM. Amend any of your personal medical information created by OPM if you believe that it is wrong or if
information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement added to your personal medical information.
Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any
information that you authorized OPM to release, or that was given out for law enforcement purposes or to pay for your health care or a disputed claim. 3.
3 Page 4 5

Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).
Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You may also call 202/ 606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the following address:
Privacy Complaints Office of Personnel Management
P. O. Box 707 Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the Secretary of the Department of Health and Human Services.
By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail
within 60 days of the change. The privacy practices listed in this notice will be effective April 14, 2003. 4.
4 Page 5 6

2003 Kaiser Foundation Health Plan of Colorado 5 Introduction/ Plain Language/ Advisory
Introduction
This brochure describes the benefits of Kaiser Foundation Health Plan of Colorado under our contract (CS 1268) with the Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. The
address for Kaiser Foundation Health Plan of Colorado's administrative office is:
Kaiser Foundation Health Plan of Colorado 2500 South Havana Street
Aurora, Colorado 80014-1622
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2003, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2003, and changes are summarized on page 9. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the public. For instance,

Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" or "Plan" means Kaiser Foundation Health Plan of Colorado.
We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the Office of Personnel Management. If we use others, we tell you what they mean first.
Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve the structure of this brochure, let us know. Visit OPM's "Rate Us" feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. You may also write
to OPM at the Office of Personnel Management, Office of Insurance Planning and Evaluation, 1900 E Street NW, Washington, DC 20415.

Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB) Program premium.
OPM's Office of the Inspector General investigates all allegations of fraud, waste and abuse in the FEHB Program regardless of the agency that employs you or from which you retired.
Protect Yourself From Fraud Here are some things you can do to prevent fraud:
Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.

Let only the appropriate medical professionals review your medical record or recommend services. 8.
8 Page 9 10
2003 Kaiser Foundation Health Plan of Colorado 6 Introduction/ Plain Language/ Advisory
Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to get it paid.
Carefully review explanations of benefits (EOBs) that you receive from us.
Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.

If you suspect that a provider 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 303/ 338-3800 in Denver/ Boulder or 888/ 681-7878 in Colorado Springs and explain the situation.

If we do not resolve the issue:

CALL THE HEALTH CARE FRAUD HOTLINE
202/ 418-3300
OR WRITE TO:
The United States Office of Personnel Management Office of the Inspector General Fraud Hotline

1900 E Street, NW, Room 6400 Washington, DC 20415

Do not maintain as a family member on your policy:
your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise); or

your child over age 22 (unless he/ she is disabled and incapable of self support).
If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed or with OPM if you are retired.

You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer
enrolled in the Plan. 9.
9 Page 10 11

2003 Kaiser Foundation Health Plan of Colorado 7 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely
responsible for the selection of these providers in your area. Contact the Plan for a copy of our most recent provider directory.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments and coinsurance described in this brochure. When you receive emergency services or services

covered under the travel benefit, from non-Plan providers, 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.

How we pay providers
We contract with the Colorado Permanente Medical Group (Plan physicians) in the Denver/ Boulder area to provide care in our Plan Medical Offices and network physicians (Plan physicians) in the Colorado Springs area. These Plan
physicians are paid in a number of ways, including salary, capitation, per diem rates, case rates, fee-for-service, and incentive payments, for services they provide and services that are referred. If you would like further information
about the way we pay Plan physicians to provide or arrange medical and hospital care in your service area, please call the Customer Service Center at 303/ 338-3800, or for Colorado Springs members, 888/ 681-7878.

Your Rights
OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types
of information that we must make available to you. Some of the required information is listed below.
We are a federally qualified health maintenance organization, and we have provided health care services to the Denver, Colorado area since 1969. Kaiser Foundation Health Plan of Colorado is a Colorado not-for-profit
organization. This Plan is part of the Kaiser Permanente Medical Care Program, a group of not-for-profit organizations and contracting medical groups that serve over 8 million members nationwide. Our Medical Group, the
Colorado Permanente Medical Group, P. C., operates Plan medical offices in the Denver/ Boulder area. For the Colorado Springs area, we offer you services through participating providers.

If you want more information about us, call our Customer Service Center at 303/ 338-3800 for Denver members or 888/ 681-7878 for Colorado Springs members, or write to Kaiser Foundation Health Plan of Colorado, Customer
Service Center, 2500 South Havana Street, Aurora, Colorado 80014-1622. You may also visit our website at www. kaiserpermanente. org. 10.
10 Page 11 12
2003 Kaiser Foundation Health Plan of Colorado 8 Section 1
Service Area
To enroll in this Plan, you must live in our service area. This is where our providers practice. Our service area is:
Denver. These zip codes in Adams, Arapahoe, Boulder, Broomfield, Clear Creek, Denver, Douglas, Elbert, Gilpin, Jefferson, Larimer, Park and Weld counties: 80001-7, 80010-22, 80024-28, 80030-31, 80033-34, 80036-38, 80040-
42, 80044-47, 80102, 80104, 80107-12, 80116-17, 80120-31, 80134-35, 80137-38, 80150-51, 80154-55, 80160-63, 80201-12, 80214-39, 80241, 80243-44, 80246-52, 80254-56, 80259-66, 80270-71, 80273-75, 80279-81, 80290-95,
80299, 80301-10, 80314, 80321-23, 80328-29, 80401-3, 80421-22, 80425, 80427, 80433, 80437, 80439, 80452-55, 80457, 80465-66, 80470-71, 80474, 80481, 80501-4, 80510, 80513-14, 80516, 80520, 80530, 80533-34, 80537-40,
80542-44, 80601-3, 80614, 80621, 80623, 80640, 80642-43, 80651.
Colorado Springs. These zip codes in Douglas, El Paso, Fremont, Park and Teller counties: 80106, 80118, 80132-33, 80808-09, 80813-14, 80816-17, 80819-20, 80827, 80829, 80831-33, 80840-41, 80860, 80863-64, 80866, 80901,
80903-22, 80925-26, 80928-37, 80940-47, 80949-50, 80960, 80962, 80970, 80977, 80995, 80997, 81007-08, 81212, 81240.

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 virtually all of the benefits of this Plan at any other Kaiser Permanente facility, including our mail order prescription program. You must pay the charges or copayments imposed by the
Kaiser Permanente Plan you are visiting, with the exception of mail order prescriptions which are administered by your home Plan. See Section 5( g), Special Features, for more details. We also pay for certain follow-up services or
continuing care services while you are traveling outside the service area, as described on page 42; and for emergency care obtained from any non-Plan provider, as described on page 33. We will not pay for any other health care
services.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office. 11.
11 Page 12 13
2003 Kaiser Foundation Health Plan of Colorado 9 Section 2
Section 2. How we change for 2003
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5 Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.

Program-wide changes
A Notice of the Office of Personnel Management's Privacy Practices is included. A section on the Children's Equity Act describes when an employee is required to maintain Self and Family

coverage. Program information on TRICARE and CHAMPVA explains how annuitants or former spouses may suspend
their FEHB Program enrollment. Program information on Medicare is revised.
By law, the DoD/ FEHB Demonstration project ends on December 31, 2002.

Changes to this Plan
Your share of the non-Postal premium will increase by 15. 1% for Self Only or 37. 5% for Self and Family.
We increased the specialty care office visit copayment to $20.
We increased pharmacy copayments to $10 for generic drugs and $20 for brand name drugs.
We added a $100 per admission copayment for all inpatient hospital services.
We increased the emergency room copayment to $100 per visit.
We reduced the copayment for each group mental health and substance abuse therapy visit from $10 to $5 per visit.

We increased the charge for food supplements from $3 per day to $3 per product per day.
We exclude any packaging other than the dispensing pharmacy's standard packaging. 12.
12 Page 13 14

2003 Kaiser Foundation Health Plan of Colorado 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation
letter.
If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call our Customer
Service Center. The Customer Service Center's numbers for ID issues are: Denver/ Boulder: 303/ 338-3800, 303/ 338-3820 (TTY/ TDD), and
800/ 632-9700 (toll free). In Colorado Springs, the number is: 888/ 681-7878. Customer Service Center hours are Monday Friday, 8: 00 a. m.
5: 00 p. m. (MST). Members with ID card issues can write to: Kaiser Foundation Health Plan of Colorado, Customer Service Center, 2500
South Havana Street, Aurora, Colorado 80014-1622.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments or coinsurance, and you will not have to file claims.

Plan providers Denver/ Boulder area: We contract with the Colorado Permanente Medical Group, P. C., to provide or arrange all necessary health care
services. Physicians, including specialists, and other health care professionals such as nurse practitioners, physician assistants, and other
skilled medical personnel working as medical teams at our Plan facilities provide your medical care. You also receive other necessary medical
services, such as physical therapy, laboratory and x-ray services at our Plan facilities.

We list Plan physicians in our provider directory, which we update periodically. The list is also on our website, www. kaiserpermanente. org.

Colorado Springs area: We contract, through the Colorado Permanente Medical Group, P. C., with a panel of affiliated primary care physicians,
specialists, and other health care professionals to provide medical services. You can identify these physicians, along with a listing of
affiliated specialists and ancillary providers in the Affiliated Practitioner Directory. You may obtain a copy by calling Customer Service at
888/ 681-7878 or going to our website, www. kaiserpermanente. org/ coloradosprings and clicking on "Affiliated
Practitioner Directory."
Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members.

Denver/ Boulder area: Our contracted hospitals include Exempla St. Joseph's Hospital, Swedish Medical Center and Boulder Community
Hospital.
We offer health care at 16 Plan medical offices conveniently located throughout the Denver/ Boulder metropolitan area. We list these in the
provider directory, which we update periodically. The list is also on our website. 13.
13 Page 14 15

2003 Kaiser Foundation Health Plan of Colorado 11 Section 3
Colorado Springs area: You may access hospital care at affiliated Plan facilities.
When you select your primary care physician, you will receive your services at that physician's office.

You must receive your health services at affiliated Plan facilities, except if you have an emergency. If you are visiting another Kaiser Permanente
service area, you may receive health care services at those Kaiser Permanente facilities. Under the circumstances specified in this
brochure, you may receive follow-up or continuing care while you travel anywhere.

What you must do to get It depends on the type of care you need. First, you and each family covered care member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for most of your health care.

Denver/ Boulder area: Choose your primary care physician from our provider directory. If you want to receive care from a specific physician
who is listed in the directory, call the physician to verify that he or she still participates with the Plan and is accepting new patients.

Colorado Springs area: Choose your primary care physician from our panel of affiliated primary care physicians. Our affiliated physicians,
both primary care and specialists, are listed in the Affiliated Practitioner Directory. You may obtain a copy by calling the Customer Service
Center at 888/ 681-7878 or by going to our website, www. kaiserpermanete. org/ coloradosprings and clicking on "Affiliated
Practitioner Directory".

Primary care Your primary care physician can be a family practitioner, internist or pediatrician. Your primary care physician will provide most of your
health care, or give you a referral to see a specialist. We cover specialists' services only when your primary care physician refers you.

Note that your primary care copayment may apply to other providers, such as obstetricians and gynecologists.
If you want to change primary care physicians or if your primary care physician leaves the Plan, call us. We will help you select a new one.
In Colorado Springs, you may change your primary care physician at any time. Call the Customer Service Center at 888/ 681-7878. Notify us of
your new primary care physician choice by the 15 th day of the month. Your selection will be effective on the first day of the following month.

Specialty care Your primary care physician will refer you to a specialist for needed care. You pay a different copayment for your specialty care. When you
receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary
care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all
follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, you may see a
gynecologist, an optometrist, or our mental health and substance abuse Plan providers without a referral. 14.
14 Page 15 16
2003 Kaiser Foundation Health Plan of Colorado 12 Section 3
Here are other things you should know about specialty care:
If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician
will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary
care physician will use our criteria when creating your treatment plan.
If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide
what treatment you need. If he or she 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.
If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:
terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB plan; or

reduce our service area and you enroll in another FEHB plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out
of the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, for Denver/ Boulder members, call our Customer Service Center immediately
at 303/ 338-3800, or for Colorado Springs members, 888/ 681-7878. If you are new to the FEHB Program, we will arrange for you to receive
care.
If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:

you are discharged, not merely moved to an alternative care center; or
the day your benefits from your former plan run out; or 15.
15 Page 16 17
2003 Kaiser Foundation Health Plan of Colorado 13 Section 3
the 92 nd day after you become a member of this Plan,
whichever happens first.
These provisions apply only to the benefits of the hospitalized person.

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

Services requiring our Your primary care physician has authority to refer you for most services. prior approval However, for certain services, such as oral and maxillofacial surgery,
reconstructive surgery, DME, and pulmonary rehabilitation, your physician must obtain approval from us.

We call this review and approval process "preauthorization." Preauthorization is the process of collecting information so we can
determine coverage, eligibility, medical appropriateness, and benefit limitations.

Preauthorization determinations are made based on the information available at the time the service or procedure is requested.
Registered nurses perform the first level of review using nationally recognized guidelines and resources, as well as our own internal
guidelines and policies. The nurse coordinates with the requesting physician in evaluating the medical appropriateness of the service or
procedure. The Utilization Management nurse will approve cases that meet our criteria. If the nurse is unable to approve the services based on
the application of our criteria, the Medical Director will review the matter. If the Medical Director approves, you will receive the service. If
the Medical Director denies the service we send a denial letter to your physician and you. 16.
16 Page 17 18
2003 Kaiser Foundation Health Plan of Colorado 14 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services. Example: When you see your
primary care physician, you pay a copayment of $10 per office visit.
Deductible We do not have a deductible.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for certain services you receive. Example: In our Plan, you pay 50% of our
allowance for infertility services.
Fees when you fail to If you do not pay your copayment at the time you receive services, we make your copayment will bill you. You will be required to pay a $10 charge for each bill sent
for unpaid services. In Colorado Springs, affiliated physician offices may bill you an additional charge along with any unpaid copayments.

Your catastrophic protection After your copayments and coinsurance total $2,000 per person or $4,500 out-of-pocket maximum for per family enrollment in any calendar year, you do not have to pay any
copayments and coinsurance more for covered services. However, copayments for the following services do not count toward your catastrophic protection out-of-pocket
maximum, and you must continue to pay copayments for these services.
Prescription drugs Dental services
Chiropractic services Extended care services
Durable medical equipment External prostheses and braces
The $25 charges paid for follow-up or continuing care outside the service area

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the maximum. 17.
17 Page 18 19

2003 Kaiser Foundation Health Plan of Colorado 15 Section 5
Section 5. Benefits --OVERVIEW
(See page 9 for how our benefits changed this year and page 67 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claim forms, claims filing advice, or more information about our benefits, contact us at 303/ 338-3800 or at our website at www. kaiserpermanente. org.

(a) Medical services and supplies provided by physicians and other health care professionals........................... 16-25
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Physical and occupational therapies
Speech therapy

Hearing services (testing, treatment, and supplies)
Vision services (testing, treatment, and supplies)
Foot care Orthopedic and prosthetic devices
Durable medical equipment (DME) Home health services
Chiropractic Alternative treatments
Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ....................... 26-29
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services ..................................................... 30-32
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents..................................................................................................... 33-34
Emergency within our service area Emergency outside our service area Ambulance

(e) Mental health and substance abuse benefits.................................................................................................... 35-36
(f) Prescription drug benefits ............................................................................................................................... 37-40
(g) Special features ............................................................................................................................................... 41-43

Flexible benefits option Travel benefit
Services from other Kaiser Permanente Plans
(h) Dental benefits ................................................................................................................................................ 44-48
(i) Non-FEHB benefits available to Plan members .................................................................................................. 49

Summary of benefits ................................................................................................................................................... 67 18.
18 Page 19 20
2003 Kaiser Foundation Health Plan of Colorado 16 Section 5( a)
Section 5 (a). Medical services and supplies provided by physicians and other health care professionals
I
M
P
O
R
T
A
N
T

Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they are medically necessary.

Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.
Different copayments apply for primary care visits and specialty care visits. Please refer to Section 10, Definitions, to learn more about when your primary and specialty care

copayments will apply.
Note: We waive or lower the $10 charge if you enroll in our Medicare+ Choice Plan and assign your Medicare benefits to the Plan.

I
M
P
O
R
T
A
N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians and other health care professionals
In a physician's office
Office medical and clinical pharmacist consultations
Initial examination of a newborn child covered under a family enrollment

Second surgical option

$10 per visit to your primary care provider
$20 per visit to a specialist

Professional services of physicians and other health care professionals
In a Plan urgent care center after office hours
$25 per office visit

Professional services of physicians and other health care professionals
During a hospital stay

In a skilled nursing facility

Nothing

At home Nothing 19.
19 Page 20 21
2003 Kaiser Foundation Health Plan of Colorado 17 Section 5( a)
Lab, X-ray, and other diagnostic tests You pay
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine mammograms
CAT scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing

Preventive care, adult
Routine screenings, such as:
Blood lead level
Total blood cholesterol
Colorectal cancer screening, including
Fecal occult blood test
Sigmoidoscopy -every five years starting at age 50
Routine Prostate Specific Antigen (PSA) test -one annually for men age 40 and older

Routine pap test
Note: You should consult with your physician to determine what is appropriate for you.

Note: You will pay only one copayment if you receive your routine screening on the same day as your office visit.

$10 per visit to your primary care provider
$20 per visit to a specialist

Routine mammogram covered for women age 35 and older, as follows:
From age 35 through 39, one during this five year period
From age 40 through 64, one every calendar year
At age 65 and older, one every two consecutive calendar years
Note: In addition to routine screening, we cover mammograms when medically necessary to diagnose or treat your illness.

Nothing

Routine immunizations and boosters Nothing
Preventive Care -Adult --continued on next page 20.
20 Page 21 22
2003 Kaiser Foundation Health Plan of Colorado 18 Section 5( a)
Preventive care, adult (continued) You pay
Not covered:
Physical exams required for:
Obtaining or continuing employment
Insurance
Attending schools

Travel immunizations

All charges

Preventive care, children
Childhood immunizations recommended by the American Academy of Pediatrics

Examinations, such as:
Eye exams through age 17 to determine the need for vision correction

Ear exams through age 17 to determine the need for hearing correction
Well-child care including routine examinations and immunizations

$10 per visit to your primary care provider
$20 per visit to a specialist

Not covered:
Physical exams required for:
Obtaining or continuing employment

Insurance
Attending schools or camp
Travel immunizations

All charges

Maternity care
Complete maternity (obstetrical) care, such as:
Prenatal care
Delivery
Postnatal care
Note: Here are some things to keep in mind:
You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. Your physician will

extend your inpatient stay if medically necessary.
We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

care of an infant who requires non-routine treatment only if we cover the infant under a Self and Family enrollment.

We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Section 5( c) for hospital benefits and
Section 5( b) for surgery benefits.

$10 per office visit

Not covered:
Routine sonograms to determine fetal age, size, or sex
All charges 21.
21 Page 22 23
2003 Kaiser Foundation Health Plan of Colorado 19 Section 5( a)
Family planning You pay
A broad range of voluntary family planning services, limited to:
Family planning services including counseling
Voluntary sterilization (See Surgical procedures Section 5( b))
Note: We cover surgically implanted time-release contraceptive drugs, injectable contraceptive drugs, intrauterine devices (IUDs), and

diaphragms under the prescription drug benefit.

$10 per visit to your primary care provider
$20 per visit to a specialist

Not covered:
Reversal of voluntary surgical sterilization
Genetic counseling

All charges

Infertility services
Medical services for diagnosis of involuntary infertility.

Treatment of involuntary infertility including artificial insemination limited to intrauterine insemination (IUI).
50% of our allowance

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

Intravaginal insemination (IVI)
Intra-cervical insemination (ICI)
Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
gamete and zygote intrafallopian transfer (GIFT and ZIFT)
Services and supplies related to excluded ART procedures
Cost of donor sperm and donor eggs and services related to their procurement and storage

Drugs related to infertility treatment

All charges

Allergy care
Testing and treatment
Allergy injections
$10 per visit to your primary care provider

$20 per visit to a specialist
Allergy serum Nothing 22.
22 Page 23 24
2003 Kaiser Foundation Health Plan of Colorado 20 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: We limit high dose chemotherapy in association with autologous bone marrow transplants to those transplants listed under Organ/ tissue

transplants.
Respiratory and inhalation therapy
Dialysis hemodialysis and peritoneal dialysis
Note: We waive office visit charges if you enroll in Medicare Part B and assign your Medicare benefits to us.

Note: Intravenous (IV)/ Infusion Therapy we cover home IV and antibiotic therapy and growth hormone therapy (GHT) under the
Prescription Drug benefit.

$10 per visit to your primary care provider
$20 per visit to a specialist

Not covered:
Chemotherapy supported by a bone marrow transplant or with stem cell support, for any diagnosis not listed as covered
All charges

Physical and occupational therapies
Two consecutive months of therapy per condition:
Physical therapy by qualified physical therapists to restore bodily function when you have a total or partial loss of bodily function due

to illness or injury
Occupational therapy by occupational therapists to assist you in achieving and maintaining self-care and improved functioning in

other activities of daily life
Note: If you have not received 20 or more outpatient visits within the two-month period that started with your first visit to a therapist, we may

continue your therapy for up to 20 outpatient visits per therapy per condition.

Cardiac rehabilitation in a Multifit Intervention Program that provides exercise stress testing, exercise prescriptions, home self-monitored
exercise and case management by registered nurses.
Four educational sessions in "Cardiac College" to learn about diet, exercise, lipids, smoking cessation, and on-site monitored programs.

$10 per visit to your primary care provider
$20 per visit to a specialist
Nothing for inpatient

Pulmonary rehabilitation. The program consists of:
Initial evaluation
6 education sessions
12 exercise sessions
A final evaluation
Note: You must complete the course within a two to three-month period.

$50 for the program

Physical and occupational therapies --continued on next page 23.
23 Page 24 25
2003 Kaiser Foundation Health Plan of Colorado 21 Section 5( a)
Physical and occupational therapies (continued) You pay
Not covered:
Long-term rehabilitative therapy
Exercise programs

All charges

Speech therapy
Two consecutive months of therapy per condition:
Speech therapy by speech therapists when medically necessary
Note: If you have not received 20 or more outpatient visits within the two-month period that started with your first visit to a therapist, we may

continue your therapy for up to 20 outpatient visits per therapy per condition.

$10 per visit to your primary care provider
$20 per visit to a specialist
Nothing for inpatient

Not covered:
Speech therapy that is not medically necessary such as:
Therapy for educational placement or other educational purposes
Training or therapy to improve articulation in the absence of injury, illness, or medical condition affecting articulation

Therapy for tongue thrust in the absence of swallowing problems

All charges

Hearing services (testing, treatment, and supplies)
Exam to determine the need for hearing correction
Hearing testing for children through age 17 (see Preventive care, children)
$10 per visit to your primary care provider

$20 per visit to a specialist
Not covered:
All other hearing testing
Hearing aids and supplies

All charges

Vision services (testing, treatment, and supplies)
Diagnosis and treatment of diseases of the eye
Eye exam to determine the need for vision correction for children through age 17 (see Preventive care, children)

Eye refractions to provide a written lens prescription for eyeglasses only

$10 per visit to your primary care provider
$20 per visit to a specialist

Not covered:
Corrective eyeglass lenses or frames
Examinations for contact lenses or the fitting of contact lenses
Eye exercises
Radial keratotomy and other refractive surgery

All charges 24.
24 Page 25 26
2003 Kaiser Foundation Health Plan of Colorado 22 Section 5( a)
Foot care You pay
Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes. $10 per visit to your primary care provider

$20 per visit to a specialist
Not covered:
Cutting, trimming or removal of corns, calluses, or the free edge of toenails and similar routine treatment of conditions of the foot

Treatment of weak, strained or flat feet or bunions or spurs of any instability, imbalance or subluxation of the foot

All charges

Orthopedic and prosthetic devices
When prescribed by a Plan physician, we cover internal prosthetic devices, such as:

Artificial joints
Pacemakers
Cochlear implants
Surgically implanted breast implant following mastectomy.
Note: See Section 5( b) for coverage of the surgery to insert the device.

Nothing

When prescribed by a Plan physician, we cover:
Artificial legs, arms, and eyes; stump hose
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

20% of our allowance

Note: We will pay no more than $2000 per year for all DME, including orthopedic and prosthetic devices. The $2000 limit does not apply to
artificial arms and legs.
Note: We cover only those standard items that are adequate to meet the medical needs of the member.

Orthopedic and prosthetic devices --continued on next page 25.
25 Page 26 27
2003 Kaiser Foundation Health Plan of Colorado 23 Section 5( a)
Orthopedic and prosthetic devices (continued) You pay
Not covered:
Comfort, convenience, or luxury equipment or features
Orthopedic and corrective shoes
Podiatric use devices and arch supports
Foot orthotics
Dental prostheses, devices, and appliances
Note: We will provide medically necessary orthodontic and prostho-dontic treatment for cleft lip or cleft palate for newborn members,

unless these services are covered under a dental insurance policy.
Spare or alternate use devices
Replacement of lost prosthetic and orthotic devices
Repairs, adjustments, or replacements because of misuse
Devices, equipment, and prosthetics related to treatment of sexual dysfunction

All charges

Durable medical equipment (DME)
When prescribed by a Plan physician, we cover rental or purchase, at our option, of durable medical equipment intended to be used

repeatedly and in the home. Covered items include:
Oxygen and oxygen equipment
Dialysis equipment
Infant apnea monitors
Insulin pumps for Type 1 diabetes
Hospital beds
Wheelchairs, including motorized wheelchairs when medically necessary

Crutches
Walkers
Commodes
Respirators
Blood glucose monitors
Repair and adjustment

Note: We will pay no more than $2000 per year for all DME, including orthopedic and prosthetic devices. Oxygen and insulin pumps are not

subject to the $2000 limit. When outside the service area, you must obtain your oxygen supplies and services from Apria.

Note: We cover only those standard items that are adequate to meet the medical needs of the member.
Note: We use a DME formulary to determine which items will be provided to members.

20% of our allowance

Durable medical equipment --continued on next page 26.
26 Page 27 28
2003 Kaiser Foundation Health Plan of Colorado 24 Section 5( a)
Durable medical equipment (DME) (continued) You pay
Not covered:
Comfort, convenience, or luxury equipment or features
Devices, equipment, supplies, and prosthetics related to the treatment of sexual dysfunction

Electric monitors of bodily functions
Devices to perform medical testing of bodily fluids, excretions, or substances

Devices not medical in nature such as whirlpools, saunas, elevators, convenience, or comfort items
Disposable supplies
Replacement of lost equipment
Repair, adjustments, or replacements because of misuse
More than one piece of durable medical equipment serving essentially the same function, except for replacements

Spare or alternate use equipment

All charges

Home health services
If you are homebound and reside in the service area:
You may receive home health services of nurses and health aides, physical or occupational therapists, and speech and language

pathologists
Services include oxygen therapy, intravenous therapy, and medications

Nothing

Not covered:
Custodial care
Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or

rehabilitative
Homemaker services
Care that a Plan physician determines may appropriately be provided at a Plan Medical Office, hospital, or skilled nursing

facility
Services outside our service area

All charges 27.
27 Page 28 29
2003 Kaiser Foundation Health Plan of Colorado 25 Section 5( a)
Chiropractic You pay
Chiropractic services, limited to 20 visits per calendar year, including:
Evaluation
Associated laboratory
X-ray services
Treatment of musculoskeletal disorders
Note: You may self-refer to one of our participating chiropractors. For a list of participating chiropractors contact Columbine Health Plan at

303/ 825-7526 or toll free at 800/ 915-7526.

$15 per office visit

Not covered:
Treatment for non-neuroskeletal disorders
Vocational rehabilitation services
Thermography
Transportation costs, including ambulance
Prescription drugs, vitamins, minerals, nutritional supplements, or other similar type products

MRI or other types of diagnostic radiology
Durable medical equipment or supplies for use in the home

All charges

Alternative treatments
No benefit All charges

Educational classes and programs
Health education services and education in the appropriate use of Health Plan services $10 per visit to your primary care provider

$20 per visit to a specialist
Health education classes, such as smoking cessation, stress reduction, or weight control The specific charge we set for the class you select 28.
28 Page 29 30
2003 Kaiser Foundation Health Plan of Colorado 26 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

medically necessary.
Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.
The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the

facility (i. e. hospital, surgical center, etc.).
YOUR PHYSICIAN MUST GET PREAUTHORIZATION OF SOME SURGICAL PROCEDURES. Please refer to the pre-authorization information shown in Section 3 to

be sure which services require pre-authorization and identify which surgeries require pre-authorization.

I M
P O
R T
A N
T

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
Operative procedures
Treatment of fractures, including casting
Normal pre-and post-operative care by the surgeon
Pre-surgical testing
Correction of amblyopia and strabismus
Endoscopy procedures
Biopsy procedures

Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)

Surgical treatment of morbid obesity
Insertion of internal prosthetic devices. See Section 5( a) Orthopedic
and prosthetic devices for coverage information.

Voluntary sterilization (e. g., Tubal ligation, Vasectomy)

Surgically implanted time-release contraceptive drugs and intrauterine devices (IUDs). Note: Drugs and devices are covered

under Section 5( f).
Other implanted time-release drugs. Note: Drugs are covered under Section 5( f).

Treatment of burns

$50 for outpatient surgery
$100 per inpatient admission

Surgical procedures --continued on next page 29.
29 Page 30 31
2003 Kaiser Foundation Health Plan of Colorado 27 Section 5( b)
Surgical procedures (continued) You pay
Not covered:
Reversal of voluntary sterilization

Implants or devices related to the treatment of sexual dysfunction

All charges

Reconstructive surgery
Surgery to correct a functional defect
Surgery to correct a condition caused by injury or illness if:
the condition produced a major effect on the member's appearance; and

the condition can reasonably be expected to be corrected by such surgery.
Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are protruding ear deformities, cleft lip, cleft palate, birthmarks, webbed fingers, and webbed toes.

Surgery for treatment of a form of congenital hemangioma known as port wine stains on the face or neck of members 18 years or younger
All stages of breast reconstruction surgery following a mastectomy, such as:

surgery to produce a symmetrical appearance on the other breast;
treatment of any physical complications, such as lymphedemas; and

breast prostheses and surgical bras and replacements (see Prosthetic devices).
Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure.

$50 per outpatient surgery
$100 per inpatient admission

Not covered:
Cosmetic surgery any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance

through change in bodily form
Surgeries related to sex transformation

All charges 30.
30 Page 31 32
2003 Kaiser Foundation Health Plan of Colorado 28 Section 5( b)
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
Reduction of fractures of the jaws or facial bones
Surgical correction of cleft lip, cleft palate, or severe functional malocclusion

Removal of stones from salivary ducts
Excision of leukoplakia or malignancies
Excision of cysts and incision of abscesses when done as independent procedures

Other surgical procedures that do not involve the teeth or their
supporting structures

$20 per visit with specialist
$50 for outpatient surgery
$100 per inpatient admission

Not covered:
Shortening of the mandible or maxillae for cosmetic purposes
Correction of malocclusion
Oral implants and transplants
Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

Dental care involved in treatment of the temporomandibular joint (TMJ) pain dysfunction syndrome

All charges

Organ/ tissue transplants
Limited to:
Cornea
Heart
Heart/ Lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single Double
Pancreas
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
Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,

stomach, and pancreas
Note: We cover related medical and hospital expenses of the donor when we cover your transplant.

$50 per outpatient surgery
$100 per inpatient admission

Organ/ tissue transplants --continued on next page 31.
31 Page 32 33
2003 Kaiser Foundation Health Plan of Colorado 29 Section 5( b)
Organ/ tissue transplants (continued) You pay
Not covered:
Donor screening tests and donor search expenses, except those performed for the actual donor

Implants of non-human or artificial organs
Bone marrow transplants associated with high dose chemotherapy for other solid tissue tumors

Transplants not listed as covered

All charges

Anesthesia
Professional services provided in:
Hospital (inpatient)
Hospital outpatient department
Ambulatory surgical center
Office

Nothing 32.
32 Page 33 34
2003 Kaiser Foundation Health Plan of Colorado 30 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T

medically necessary.
Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.
The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs

associated with the professional charge (i. e., physicians, etc.) are covered in Sections 5( a) or (b)

I M
P O
R T
A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as
Semiprivate accommodations, or when a Plan physician determines it is medically necessary, private accommodations or private duty

nursing care
Specialized care units such as intensive or cardiac care units
General nursing care
Meals and special diets
Note: Your physician may prescribe private accommodations or private duty nursing care if it is medically necessary. If you want at private

room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$100 per inpatient admission

Inpatient hospital --continued on next page 33.
33 Page 34 35
2003 Kaiser Foundation Health Plan of Colorado 31 Section 5( c)
Inpatient hospital (continued) You pay
Other hospital services and supplies, such as:
Operating, recovery, maternity, and other treatment rooms
Prescribed drugs and medicines
Diagnostic laboratory tests and X-rays
Administration of blood and blood products
Blood or blood plasma, if not donated or replaced
Dressings, splints, casts, and sterile tray services
Medical supplies and equipment, including oxygen
Anesthetics, including nurse anesthetist services
Take-home items
Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Note: You may receive covered hospital services for certain dental procedures if a Plan physician determines you need to be hospitalized for
reasons unrelated to the dental procedure. The conditions for which we will provide hospitalization include hemophilia and heart disease. The
need for anesthesia, by itself, is not such a condition.
We cover general anesthesia for dental services for a member's child due to physical, mental, or behavior problems.

$100 per inpatient admission

Not covered:
Custodial care

Non-covered facilities, such as nursing homes, extended care facilities, and schools

Personal comfort items, such as telephone, television, barber services, guest meals, and beds
Any inpatient dental procedures

All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms
Prescribed drugs and medicines
Dressings, casts and sterile trays
Diagnostic laboratory tests, X-rays, and pathology services
Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced
Pre-surgical testing
Medical supplies, including oxygen
Anesthetics and anesthesia service

$50 per surgery 34.
34 Page 35 36
2003 Kaiser Foundation Health Plan of Colorado 32 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You pay
Up to 100 days per calendar year
When full-time skilled nursing care is necessary
Confinement in a skilled nursing facility is medically appropriate

Nothing

Not covered:
Custodial care
Care in an intermediate care facility

All charges

Hospice care
Supportive and palliative care for a terminally ill member:
You must reside in the service area
Services are provided in the home, or
In a Plan approved hospice facility.
Services include inpatient care, outpatient care, and family counseling. A Plan physician must certify that you have a terminal illness, with a

life expectancy of approximately six months or less.
Special Services Program

Hospice-eligible members who have not yet elected hospice care are eligible to receive 15 home visits by Plan special service hospice

providers
Note: Hospice is a program for caring for the terminally ill that emphasizes supportive services, such as home care and pain control,

rather than curative care of the terminal illness. A person who is terminally ill may elect to receive hospice benefits. These palliative
and supportive services include nursing care, medical social services, physician services, and short-term inpatient care for pain control and
acute and chronic symptom management. We also provide counseling and bereavement services for the individual and family members, and
therapy for purposes of symptom control to enable the person to continue life with as little disruption as possible. If you make a hospice
election, you are not entitled to receive other health care services that are related to the terminal illness. If you have made a hospice election,
you may revoke that election at any time, and your standard health benefits will be covered.

Nothing for home-based hospice services
$100 per inpatient admission

Ambulance
Local professional ambulance service when ordered or authorized by a Plan physician $50 per transport

Not covered:
Transports that we determine are not medically necessary
All charges 35.
35 Page 36 37

2003 Kaiser Foundation Health Plan of Colorado 33 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you 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 sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies what they all have in common is the need for quick action.

What to do in case of emergency:
In a life-threatening emergency, call 911. When the operator answers, stay on the phone and answer all questions.

Emergencies within our service area:
Denver/ Boulder area: If you are in an emergency situation, call 911, go to the closest emergency room or a Plan hospital. If you are not sure whether your situation is an emergency, call our Emergency Care Telephone Line at

303/ 861-3434, 24 hours a day, seven days a week. If an ambulance is necessary, we will authorize it.
For urgently needed services, such as an earache or sore throat with fever that cannot wait for a routine visit, you may call your PCP's Medical Office to schedule a same-day appointment during regular office hours. You may obtain

urgent care services after regular office hours at various facilities in the Denver/ Boulder area. Please call 303/ 338-3800 for information on locations and hours of accessibility for after-hours/ urgent care.

Colorado Springs area: If you are in an emergency situation, call 911, or go to the closest emergency room. If you are not sure your situation is an emergency, call your PCP.
For urgent care that cannot wait for a routine office visit, call your PCP to schedule a same-day or urgent care appointment during regular office hours. Urgent/ after hours care is available by calling your PCP. You can also check
our website, www. kaiserpermanente. org/ coloradosprings, for a listing of urgent care/ after hours clinics.
Emergencies outside our service area:
We cover emergency situations, such as myocardial infarction, appendicitis or premature delivery, outside the service area. If you are hospitalized for emergency services while outside our service area, you or a family member

should notify us within 48 hours or as soon as possible after you have been admitted. We will make arrangements for any necessary continued hospitalization or to transfer you to a hospital within our Plan. By notifying us as soon
as possible, you will protect yourself from potential liability for payment of services you receive after a transfer would have been possible.

Note: Emergency services are limited to those services required before your medical condition permits your travel or transfer to care in our Plan. Continuing or follow-up care from out-of-plan providers is not covered.
You may obtain emergency and urgent care services from Kaiser Permanente medical facilities and providers when you are in the service area of another Kaiser Permanente plan. The facilities are 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 Customer Service at 303/ 338-3800. 36.
36 Page 37 38
2003 Kaiser Foundation Health Plan of Colorado 34 Section 5( d)
Benefit Description You pay
Emergency within our service area
Emergency care as an outpatient or inpatient at a hospital, including physicians' services

At a Plan medical office
After hours/ urgent care services
In a hospital emergency room
Note: Your copayment is waived if you are admitted to a Plan hospital.

$10 per visit
$25 per visit
$100 per visit

Not covered:
Elective care or non-emergency care
All charges

Emergency outside our service area
Emergency care as an outpatient or inpatient at a hospital, including physicians' services

Urgent care services
In a hospital emergency room
In a Kaiser Foundation hospital in another Kaiser Foundation Health Plan service area

Note: See the Travel Benefit for coverage of continuing or follow-up care.

$25 per visit
$100 per visit
The amount you would be charged if you were a member in
that service area

Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges

Ambulance
Professional ambulance services to the nearest hospital equipped to handle your medical condition where authorized by a Plan physician.

We will authorize air ambulance if ground transportation is not
medically appropriate

$50 per transport

Not covered:
Transports that we determine are not medically necessary
All charges 37.
37 Page 38 39
2003 Kaiser Foundation Health Plan of Colorado 35 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

When you get our approval for services and follow a treatment plan we approve, cost-sharing and limitations for Plan mental health and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.
Here are some important things to keep in mind about these benefits:
Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they are clinically

appropriate to treat your condition.
Plan physicians must provide or arrange your care.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Mental health and substance abuse benefits
We cover all diagnostic and treatment services recommended by a Plan provider and contained in a treatment plan. The treatment plan may

include services, drugs, and supplies described elsewhere in this brochure.

Note: We cover the services only when we determine that the care is clinically appropriate to treat your condition, and only when you receive
the care as part of a treatment plan developed by a Plan provider.
Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order

us to pay or provide one clinically appropriate treatment in favor of another.

Your cost sharing responsibilities are not greater than for other
illnesses or conditions

Mental health and substance abuse benefits --continued on next page 38.
38 Page 39 40
2003 Kaiser Foundation Health Plan of Colorado 36 Section 5( e)
Mental health and substance abuse benefits (continued) You pay
Diagnosis and treatment of psychiatric conditions for children, adolescents, and adults. Services include:

Diagnostic evaluation
Psychiatric treatment, including group and individual therapy
Medication evaluation and management

Diagnosis and treatment of alcoholism and drug abuse. Services include:

Detoxification (medical management of withdrawal from the substance)
Treatment and counseling (including individual and group therapy visits)
Rehabilitative care
Note: Your mental health or substance abuse provider will develop a treatment plan to assist you in improving or maintaining your condition

and functional level, or to prevent relapse and will determine which diagnostic and treatment services are appropriate for you.

Note: You may see a mental health provider for these services without a referral from your primary care physician.

$10 per individual therapy office visit
$5 per group therapy office visit

Inpatient psychiatric care
Hospital alternative services, such as partial hospitalization, day and night care, and intensive outpatient psychiatric treatment programs

Inpatient care
Note: All inpatient admissions and hospital alternative services treatment programs require approval by a Plan physician.

$100 per inpatient admission

Not covered:
Care that is not clinically appropriate for the treatment of your condition

Services we have not approved
Intelligence, IQ, aptitude ability, learning disorders, or interest testing not necessary to determine the appropriate treatment of a

psychiatric condition
Evaluation or therapy on court order or as a condition of parole or probation, or otherwise required by the criminal justice system,

unless determined by a Plan physician to be medically necessary and appropriate

Services that are custodial in nature
Services rendered or billed by a school or a member of its staff
Services provided under a federal, state, or local government program

Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or
symptoms

All charges

Limitation: We may limit your benefits if you do not obtain a treatment plan. 39.
39 Page 40 41

2003 Kaiser Foundation Health Plan of Colorado 37 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
We cover prescribed drugs and medications, as described in the chart beginning on the next page.

Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and we cover them only when we determine they
are medically necessary.
We have no calendar year deductible.
Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.

I M
P O
R T
A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A Plan or referral physician or licensed dentist (for acute conditions only) must write the prescription.

Where you can obtain them.
Denver/ Boulder area: You must fill the prescription at a Plan pharmacy. You may refill prescriptions at Plan pharmacies, through Direct Rx, our mail order service or online. We provide refills in the same

quantities as the original prescription, at the applicable brand or generic copayment, for up to a 60-day supply as prescribed. You can obtain reorder envelopes at Plan pharmacies. Envelopes are included in
every order mailed by Direct Rx. Direct Rx mails refills by First Class U. S. Mail at no charge to you for postage and handling. You should receive your prescription within 7-10 days. To place an order by
telephone, call Direct Rx at 303/ 344-5077. This refill line can be used 24 hours a day.
You may order prescription refills online, using our Members Only website www. kponline. org. This site requires online registration. You can choose to have your prescriptions mailed to your home or to a

Plan medical office pharmacy for you to pick up. Online prescription orders must be paid for in advance, by a credit card.

Colorado Springs area: You must fill the prescription at a pharmacy designated by the Plan. A list of affiliated pharmacies can be obtained by calling our Customer Service Center at 888/ 681- 7878 or by
accessing our Colorado Springs website at www. kaiserpermanente. org/ coloradosprings. You may have prescriptions for maintenance medications filled by our convenient mail-order prescription service,
ScripPharmacy, available 24 hours a day. Refills will be mailed by First Class U. S. Mail at no charge to you for postage and handling. You should receive your prescription within 7-10 days. Contact
ScripPharmacy customer services representatives at 800/ 677-4323 (TTY for deaf and hearing impaired: 877/ 517-9301) for more information, or check our Colorado Springs website. You may also access
ScripPharmacy's online pharmacy to order your refills. You can access it through the "Our Services" section of our website at www. kaiserpermanente. org/ coloradosprings.

We use a formulary. A formulary is a listing of preferred pharmaceutical substances and formulas. A team of Kaiser Permanente physicians and pharmacists independently and objectively evaluates the
scientific literature to identify the FDA-approved drugs best suited to treat specific medical conditions. When your physician believes a non-formulary drug is necessary, he may request a formulary exception.
The physician, pharmacist, and our medical director will determine the best medication to treat your condition. If you request the non-formulary drug when your Plan physician has prescribed a generic
substitution, the non-formulary drug will not be covered. However, you may purchase the non-formulary drug from a Plan pharmacy or designated pharmacies in the Colorado Springs area at our
allowance.
Note: Some prescription drugs, such as (but not limited to) Zyban or Interferon, require preauthorization in Colorado Springs. Your Plan physician should contact MedImpact, our pharmacy benefit manager, to

obtain approval.
These are the dispensing limitations. You may purchase covered drugs in prescribed quantities for up to a 60-day supply for maintenance drugs or part of a 60-day supply for non-maintenance drugs, except

certain drugs that have a significant potential for waste will be provided for up to a 30-day supply. 40.
40 Page 41 42
2003 Kaiser Foundation Health Plan of Colorado 38 Section 5( f)
Please contact our Pharmacy Call Center at 303/ 338-4503 for the current list of these drugs. Refills of prescriptions will be provided subject to the same conditions as the original prescription. Plan
pharmacies may substitute a generic equivalent for a name-brand drug unless prohibited by the Plan physician. If a generic equivalent is not available, you pay the brand-name copayment. If you request a
brand-name drug not on the formulary when your Plan physician has prescribed an approved generic drug, you pay the applicable copayment plus the difference in price between the generic drug and your
requested brand-name drug.
Why use generic drugs? Generic drugs contain the same active ingredients and are equivalent in
strength and dosage to the original name-brand product. Generic drugs cost you and your plan less money than a name-brand drug.

When you have to file a claim. When you receive drugs from a Plan pharmacy, you do not have to
file a claim. For a covered out-of-area emergency, you will need to file a claim when you receive drugs from a non-Plan pharmacy.

Prescription drug benefits begin on the next page. 41.
41 Page 42 43
2003 Kaiser Foundation Health Plan of Colorado 39 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program:
Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except as excluded

below
Oral and injectable contraceptive drugs, contraceptive devices, and intrauterine devices

Insulin
Growth hormone
Niacin
Chemotherapy drugs
Note: If we do not have a generic equivalent for a brand name drug, you will pay the $20 copayment.

$10 per prescription for generic drugs
$20 per prescription for brand-name drugs

Disposable needles and syringes for the administration of covered medications
Glucose test strips
Injectable hormone therapyi (in place of surgery for prostate cancer)

20% of our allowance

Implanted time-release contraceptive drugs
Other implanted time-release drugs
Note: We do not refund any portion of the copayment if you request removal of the implanted time-release medication before the end of its

expected life.

A one-time payment equal to $10 times the expected number of
months the medication will be effective, not to exceed $200

Food supplements and supplies, for use in the home
For individuals unable to absorb or digest food
Includes enteral and parenteral elemental dietary formulas and amino acid modified product for treatment of inborn errors of

metabolism

$3 per product per day

Drugs to treat sexual dysfunction
Note: There are dispensing limitations for drugs to treat sexual dysfunction. Please contact us for details.
50% of our allowance

Immunosuppressant drugs after a covered transplant $20 per prescription or refill
Intravenous fluids and medications for home use Nothing
Covered medications and supplies --continued on next page 42.
42 Page 43 44
2003 Kaiser Foundation Health Plan of Colorado 40 Section 5( f)
Covered medications and supplies (continued) You pay
Not covered:
Drugs available without a prescription or for which there is a nonprescription equivalent available

Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
Vitamins and nutritional supplements that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs related to infertility services
Condoms
Any packaging other than the dispensing pharmacy's standard packaging

Replacement of lost, stolen, or damaged drugs and accessories

All charges 43.
43 Page 44 45
2003 Kaiser Foundation Health Plan of Colorado 41 Section 5( g)
Section 5 (g). Special features
Feature Description

Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative

benefit
We review alternative benefits on an ongoing basis
By approving an alternative benefit, we cannot guarantee you will get it in the future

The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits
Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process
Special features --continued on next page 44.
44 Page 45 46
2003 Kaiser Foundation Health Plan of Colorado 42 Section 5( g)
Section 5 (g). Special features, continued
Feature Description

Travel benefit Kaiser Permanente's travel benefits for Federal employees provide you with outpatient follow-up or continuing medical care when you are temporarily outside your home service area by more than 100 miles
and outside of any other Kaiser Permanente service area. These benefits are in addition to your emergency and urgent care benefits and
include:
Outpatient follow-up care necessary to complete a course of treatment after a covered emergency. Services include removal of

stitches, a catheter, or a cast
Outpatient continuing care for conditions diagnosed and treated within the previous 90 days by a Kaiser Permanente health care

provider or affiliated Plan provider. Services include dialysis and prescription drug monitoring

You pay $25 for each follow-up or continuing care office visit. We deduct this amount from the payment we make to you
We pay no more than $1200 each calendar year
For more information about this benefit call the Travel Benefit Information Line at 800/ 632-9700

Claims should be submitted to the Claims Department, Kaiser Foundation Health Plan of Colorado, P. O. Box 372970, Denver,
CO 80237-6970 (Denver/ Boulder area) or the Claims Department, Kaiser Foundation Health Plan of Colorado, P. O. Box 378020,
Denver, CO 80237-8020 (Colorado Springs)
The following are not included in your travel benefits coverage:
Non-emergency hospitalization
Infertility treatments
Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

Transplants
DME
Prescription drugs
Home health services

Services from other Kaiser Permanente
Plans

When you visit the service area of another Kaiser Permanente plan, you are entitled to receive virtually all the benefits described in this brochure
(including our mail order prescription program) at any Kaiser Permanente medical office or medical center. You must pay the charges or
copayments imposed by the Kaiser Permanente Plan you are visiting, with the exception of mail order prescriptions which are administered by your
home Plan. You will have to pay the copayments or other charges imposed by the Plan you are visiting. If the Plan you are visiting has a
benefit that differs from the benefits of this Plan, you are not entitled to receive that benefit.

Services from other Kaiser Permanente Plans --continued on next page 45.
45 Page 46 47
2003 Kaiser Foundation Health Plan of Colorado 43 Section 5( g)
Services from other Kaiser Permanente
Plans (continued)

Some services covered by this Plan, such as artificial reproductive services and the services of specialized rehabilitation facilities, will not be covered
if you receive them 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 this Plan.
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 our service area. If you require emergency services as the result of 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 wish to obtain more information about the benefits available to you from a Kaiser Permanente Plan in an area you visit, please call the
Customer Service Center at 303/ 338-3800 in Denver/ Boulder and 888/ 681-7878 in Colorado Springs. 46.
46 Page 47 48
2003 Kaiser Foundation Health Plan of Colorado 44 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

necessary.
Plan dentists must provide or arrange your care.
We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the

patient. See Section 5( c) for inpatient hospital benefits. We do not cover the dental procedure unless it is described below.

Your calendar year benefit maximum is limited to $1,000 per member.
Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.
For a list of participating providers, please contact Delta Dental Plan of Colorado at 303/ 741-9305 or 800/ 610-0201 and identify your EPO -Exclusive Provider Option Plan.

Emergency services and supplies to repair sound natural teeth, due to accidental injury, are covered under and administered by Health Plan. Emergency dental procedures
needed to alleviate severe pain, as described in the dental benefits listed below, are covered under your EPO Plan and administered by Delta Dental Plan of Colorado.

I M
P O
R T
A N
T

Accidental injury benefit You pay
We cover emergency services and supplies necessary to promptly repair (but not replace) sound natural teeth. The
need for these services must result from an accidental injury. Any other services are provided as described
below.

$100 per inpatient admission
$10 for outpatient services

Dental benefits begin on the next page 47.
47 Page 48 49
2003 Kaiser Foundation Health Plan of Colorado 45 Section 5( h)
Dental Benefits
Service You pay
Diagnostic
Initial Exam
Periodic Exam
Emergency Exam
Full Mouth X-Rays
1 Intraoral Xray
Additional Intraoral Xray
Occlusal Xray
Bitewing
2 Bitewings
3 Bitewings
4 Bitewings
Panoramic Film
Cephalometric Film
Pulp Tests
Diagnostic Casts

$ 10.00
Nothing
18.00
35.00
6.00
4.00
10.00
5.00
11.00
11.00
15.00
28.00
27.00
11.00
26.00

Service
Preventive
Prophylaxis Adult
Prophylaxis Age 0-14
Topical Fluoride W/ Prophy
Top Fluoride Child No Prophy
Top Fluoride Adult No Prophy
Sealant -Per Tooth
Spacer Fixed Unilateral
Spacer Fixed Bilateral

$ 5. 00
5. 00
16. 00
5. 00
5. 00
9. 00
85. 00
130. 00
Dental benefits --continued on next page 48.
48 Page 49 50
2003 Kaiser Foundation Health Plan of Colorado 46 Section 5( h)
Dental Benefits (continued)
Service You pay
Restorative
Amalgam 1 Surface Primary
Amalgam 2 Surface Primary
Amalgam 3 Surface Primary Amalgam 1
Surface Permanent
Amalgam 2 Surface Permanent
Amalgam 3 Surface Permanent
Amalgam 4 Surf/ Plus Permanent
Anterior Resin 1 Surface
Anterior Resin 2 Surfaces
Anterior Resin 3 Surfaces
Porc/ High Noble Metal Crown
Porc/ Predom Base Metal Crown
Porc/ Noble Metal Crown
Full High Noble Metal Crown
Full Predom Base Metal Crown
Full Noble Metal Crown
3/ 4 Metallic Crown
Recement Crown
Prefab Stainless Steel Crown Primary
Sedative Filling
Crown Buildup Pin Retained
Pin Retention Excl Of Restoration
Cast Post & Core In Add To Crown
Prefab Post & Core No Crown

$ 29. 00
36. 00
45. 00
34. 00
44. 00
55. 00
66. 00
40. 00
52. 00
64. 00
365. 00
312. 00
348. 00
358. 00
298. 00
340. 00
350. 00
26. 00
76. 00
26. 00
75. 00
16. 00
118. 00
95. 00

Service

Endodontics
Therapeutic Pulpotomy
Root Canal Anterior
Root Canal Bicuspid
Root Canal Molar
Apicoectomy Anterior
Apicoectomy Bicuspid
Apicoectomy Molar

$ 45. 00
195. 00
230. 00
310. 00
190. 00
230. 00
235. 00
Dental benefits --continued on next page 49.
49 Page 50 51
2003 Kaiser Foundation Health Plan of Colorado 47 Section 5( h)
Dental Benefits (continued)
Service You pay
Periodontics
Gingivectomy Per Quad
Gingivectomy Per Tooth
Gingival Curettage Per Quad
Gingv Flap W/ Root Pl-Per Quad
Osseous Surgery Per Quad
Perio Root Plan Per Quad
Maintenance Following Therapy

$ 148. 00
58. 00
144. 00
250. 00
640. 00
84. 00
44. 00

Service
Prosthodontics
Complete Upper Denture
Complete Lower Denture
Comp Immediate Upper Denture
Comp Immediate Lower Denture
Partial Upper Denture/ Metal Base
Partial Lower Denture/ Metal Base
Repair Broken Complete Denture
Replace Missing/ Broken Teeth
Repair/ Replace Broken Clasp
Replace Tooth on Denture
Add Tooth to Partial Denture
Add Clasp to Partial Denture
Lab Reline Upper Denture
Lab Reline Lower Denture
Cast High Noble Metal Pontic
Cast Predom Base Metal Pontic
Cast Noble Metal Pontic
Porcelain With High Noble Metal Pontic
Porcelain Predom Base Metal Pontic
Porcelain Noble Metal Pontic
Porcelain High Noble Metal Crown
Porcelain Predom Base Metal Crown
Porcelain Noble Metal Crown
Full High Noble Metal Crown
Full Predom Base Metal Cr