CALL � THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

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), your Employee Express confirmation letter, or write to us at Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., ATTN: Member Services Correspondence, 2101 E. Jefferson St., Rockville, MD 20852. Members may submit inquiries, requests and complaints through our website my.kaiserpermanente.org/federalemployees. A Member Services representative will work with you to answer questions and resolve issues, including ID card issues.

If you do not receive your ID card within 30 days after we have received your enrollment from your payroll office, or if you need replacement cards, call us at 301/468-6000 inside the Washington, DC metropolitan area or at 800/777-7902 outside the Washington, DC metropolitan area. Our TTY telephone number is 301/879-6380. You may also request replacement cards through our website at my.kaiserpermanente.org/federalemployees.

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, except for emergency, urgent care services outside our service area, and for covered services while you travel.

� Plan providers

Our Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We contract with the Mid-Atlantic Permanente Medical Group, P.C., to provide or arrange for primary care services and specialty care services for our members.

Our Provider Directory lists the Plan providers, with locations and phone numbers. Directories are updated annually and are available at the time of enrollment. However, our online Provider Directory is updated biweekly. Our website address is my.kaiserpermanente.org/federalemployees.

� Plan facilities

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members.

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.

Our Provider Directory lists the Plan facilities. Directories are updated annually and are available at the time of enrollment. However, our online Provider Directory is updated biweekly. Our website address is my.kaiserpermanente.org/federalemployees.

What you must do to get covered care

It depends on the type of care you need. First, you and each family 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.

To choose a primary care physician you can either select one from our Provider Directory, on our website is my.kaiserpermanente.org/federalemployees or you can call us at 301/468-6000 inside the Washington, DC metropolitan area or at 800/777-7902 outside the Washington, DC metropolitan area. Our TTY telephone number is 301/879-6380. We are happy to assist you in selecting a primary care physician.

� Primary care

We require you to choose a primary care physician when you enroll. Your primary care physician can be an internal medicine physician, a pediatrician, or a family practice physician. Your primary care physician will provide most of your health care, or give you a referral to see a specialist.

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.

� Specialty care

� Your primary care physician will refer you to a specialist for needed care. When you receive an approved 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 obtain authorization for all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you an approved referral. You may see Plan gynecologists, optometrists, or mental health and substance abuse providers without a referral. Members may obtain mental health and substance abuse services without a primary care referral by directly calling our Behavioral Health Access Unit at 866/530-8778 to arrange for services.

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

� If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will work with the specialist, in consultation with you, to 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 Plan specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive approved services from your current specialist temporarily until we can make arrangements for you to see a participating specialist.

� If you have a chronic and disabling condition and lose access to your Plan specialist because we:

� Terminate our contract with your Plan 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, 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, call our Member Service department immediately at 301/468-6000 inside the Washington, DC metropolitan area or at 800/777-7902 outside the Washington, DC metropolitan area. Our TTY telephone number is 301/879-6380. 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

� The 92^nd day after you become a member of this Plan, whichever happens first.

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

Circumstances beyond our control

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

Services requiring our prior approval

Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered, is medically necessary, and follows generally accepted medical practice.

We call this review and approval process precertification. Your physician must obtain precertification for the following services:

� Acupuncture

� All inpatient services, except maternity

� Adenoids or tonsil removal

� Ambulance transport (non-emergency)

� Antenatal diagnostic tests outside of the doctor�s office

� Breast surgery not associated with cancer

� Cardiac rehabilitation

� Carpal tunnel surgery

� Chiropractic services

� Clinical trials

� Durable medical equipment

� Gastric bypass surgery

� Genetic testing

� Home health care

� Hospice care

� Hyperbaric oxygen therapy

� Hysterectomy

� Infertility treatment

� Infusion therapy

� Injectable medications

� Nasal surgery

� Occupational therapy

� Oral surgery and dental services covered under the medical plan

� Organ transplants

� Pain management services

� Physical therapy

� Pulmonary rehabilitation

� Prosthetics

� Radiation therapy

� Reconstructive surgery

� Sclerotherapy for varicose veins

� Sleep studies

� Specialty imaging

� Speech therapy

� Spinal surgery and other invasive spinal procedures not associated with cancer

� Surgical procedures

� Temporomandibular Joint treatment

� Tubes in the ears

� Uterine artery embolization

� Video capsule endoscopy

Requests for these services are made to your primary care physician just like any other referral. Your primary care physician submits the request, with supporting documentation. It takes an average of 2 working days to process the request. You should call your primary care physician�s office if you have not been notified of the outcome of the review within 5 working days. If your request is not approved, you have a right to appeal by calling inside the Washington, DC Metropolitan area at 301/468-6000 or toll free at 800/777-7902. Our TTY is 301/879-6380. After business hours, for urgent situations, you may call Appointments/Advice to request an appeal at 703/359-7878, 800/777-7904, TTY is 703/359-7616 or 800/700-4901. If you wish additional services, you must make the request to your primary care physician.

Emergency services do not require precertification. However, you or your family member must notify the Plan within 48 hours, or as soon as reasonably possible.

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: Under the High Option Plan, you pay a copayment of $10 when your visit takes place in a primary care department, and a copayment of $20 when your visit takes place in a specialty care department. Under the Standard Option Plan, you pay a copayment of $30 in both primary care and specialty care departments

Deductible

Under the Standard Option Plan, we have a $100 deductible for prescription drugs. There is no prescription drug deductible for the High Option Plan. We do not have any other deductibles.

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, ovulation stimulants, weight management drugs, smoke cessation drugs, and oxygen and equipment for home use.

Fees when you fail to make your copayment or coinsurance

If you do not pay your copayment or coinsurance at the time you receive services, we will bill you. You will be required to pay a $10 charge for each bill sent for unpaid services.

Note: Affiliated physician office and other providers and facilities may bill you an additional charge along with any unpaid copayments, coinsurance or for missed appointments that you fail to cancel.

Your catastrophic protection out-of-pocket maximum

Under the High Option Plan, after your copayments and coinsurance total $1,750 per person or $3,500 per family enrollment in any calendar year, you do not have to pay any more for covered services.

Under the Standard Option Plan, after your copayments and coinsurance total $3,000 per person or $6,000 per family enrollment in any calendar year, you do not have to pay any 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 and coinsurance for these services:

� Prescription drugs

� Chiropractic and acupuncture services

� Dental services

� Follow-up continuing care outside the service area

� Infertility services

� Any non-FEHB benefit

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

I

M

P

O

R

T

A

N

T

Here are some important things you should 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 for Medical services and supplies.

� 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.

I

M

P

O

R

T

A

N

T

Diagnostic and treatment services

Professional services of physicians and other health care professionals

� In a physician�s office

� In an urgent care department

� Second surgical opinion

$10 per visit in a primary care department (nothing for children from infancy through age 4)

$20 per visit in specialty care and urgent care departments

$30 per visit in a primary care department (nothing for children from infancy through age 4)

$30 per visit in specialty care and urgent care departments

� During a hospital stay

� In a skilled nursing facility

Note: See Section 5(c) for facility charges

Nothing

Nothing

At home (in the service area)

Nothing

Nothing

Lab, X-ray and other diagnostic tests

Tests, such as:

� Blood tests

� Urinalysis

� Non-routine Pap smears

� Pathology

� X-rays

� Non-routine mammograms

� Ultrasound

� Electrocardiogram and EEG

Nothing

Nothing

Lab, X-ray and other diagnostic tests (continued)

You pay

Standard Option

Specialty imaging such as:

� CAT scans

� MRI

� Pet scans

� Nuclear medicine studies

� Sleep studies

$50 per visit

$100 per visit

Preventive care, adult

Routine screenings, such as:

� Total blood cholesterol

� Colorectal cancer screening, including

� Fecal occult blood test

� Sigmoidoscopy, screening � every five years starting at age 50

� Double contrast barium enema � every five years starting at age 50

� Colonoscopy screening � every ten years starting at age 50

� Bone mass measurement for prevention, diagnosis and treatment of osteoporosis

� Routine Prostate Specific Antigen (PSA) test � one annually for men age 40 and older

� Chlamydia screenings � women under age 20 who are sexually active and women over age 20 with multiple risk factors

� Routine Pap smear

� Travel consultations

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

$10 per visit in a primary care department

$20 per visit in a specialty care department

$30 per visit in a primary care department

$30 per visit in a specialty care department

Preventive care, adult (continued)

You pay

Standard Option

Routine immunizations, limited to:

� Tetanus-diphtheria (Td) booster � once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

� Influenza vaccines, annually

� Pneumococcal vaccine, age 65 and older and for members at increased risk

� Travel immunizations and vaccines

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

$10 per visit in a primary care department

$20 per visit in a specialty care department

$30 per visit in a primary care department

$30 per visit in a specialty care department

Routine mammogram � covered for women age 35 and older, as follows:

� From age 35 to 39, one during this five year period

� From age 40 to 64, one every calendar year

� At age 65 and older, one every two consecutive calendar years

Nothing

Nothing

� Not covered:

� Physical exams required for:

� Obtaining or continuing employment

� Participating in employee programs

� Insurance or licensing

� Court ordered for parole or probation

� Attending schools

All charges

All charges

Preventive care, children

� Childhood immunizations recommended by the American Academy of Pediatrics

� Examinations, such as:

� Eye exams to determine the need for vision correction

� Ear exams to determine the need for hearing correction

� Travel consultations

� Travel immunizations and vaccines

$10 per visit in a primary care department (nothing for children from infancy through age 4)

$20 per visit in a specialty care department

$30 per visit in a primary care department (nothing for children from infancy through age 4)

$30 per visit in a specialty care department

Preventive care, children (continued)

You pay

Standard Option

� Not covered:

� Physical exams required for:

� Obtaining or continuing employment

� Participating in employee programs

� Insurance or licensing

� Court ordered for parole or probation

� Attending school

All charges

All charges

Maternity care

Complete outpatient maternity (obstetrical) care, such as:

� Prenatal care

� Postnatal care

$10 for the first office visit to confirm pregnancy

Nothing for outpatient services once pregnancy is confirmed through the post-partum office visit

$30 for the first office visit to confirm pregnancy

Nothing for outpatient services once pregnancy is confirmed through the post-partum office visit

Inpatient � hospitalization during pregnancy and for delivery

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

Note: Here are some things to keep in mind:

� You do not need to precertify your normal delivery.

� You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. Your inpatient stay will be extended if medically necessary.

� We cover routine nursery care of the newborn child during the covered portion of the mother�s maternity stay. We cover other care of an infant who requires non-routine treatment only if the infant is covered under a Self and Family enrollment

$100 per inpatient admission for hospital charges

$250 per day up to $750 maximum per inpatient admission for hospital charges

Not covered:

� Sonograms that are not medically necessary.

All charges

All charges

Family planning

You pay

Standard Option

� Family planning services, including counseling

� Voluntary sterilization (See Surgical procedures Section 5 (b))

� Information on birth control

� Genetic counseling

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 in a primary care department

$20 per visit in a specialty care department

$30 per visit in a primary care department

$30 per visit in a specialty care department

Not covered:

1) Reversal of voluntary surgical sterilization

All charges

All charges

Infertility services

Diagnosis and treatment of involuntary infertility

� Artificial insemination:

� intravaginal insemination (IVI)

� intracervical insemination (ICI)

� intrauterine insemination (IUI)

� Fertility drugs

Note: We cover injectable fertility drugs under the prescription drug benefit.

50% of our allowance

50% of our allowance

In vitro fertilization, (limited to three (3) attempts per live birth) if:

� your oocytes are fertilized with your spouse�s sperm; and

� you have been unable to become pregnant through a less costly infertility treatment for which coverage is available under the Plan; and

� you and your spouse have a history of infertility of at least 2 years duration; or

� the infertility is associated with endometriosis, exposure in utero to diethylstilbestrol, commonly known as DES, blockage of, or surgical removal of, one or both fallopian tubes (lateral or bilateral salpingectomy), or abnormal male factors, including oligospermia, contributing to the infertility.

50% of our allowance; Plan pays up to $100,000 in a member�s lifetime

50% of our allowance; Plan pays up to $100,000 in a member�s lifetime

Infertility services (continued)

You pay

Standard Option

Not covered:

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

� Assisted reproductive technology (ART) procedures, such as:

� embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)

� Donor sperm and donor eggs, including the retrieval of eggs

� Cryopreservation including storage, freezing, and thawing of eggs, sperm, or embryo

� Intracytoplasmic sperm injection (ICSI)

� Surrogacy (host uterus/gestational carrier)

� Preimplantation Genetic Diagnosis (PGI)

� Medical and surgical retrieval of sperm

Note: Infertility services are not available when either member of the family has been voluntarily surgically sterilized.

All charges

All charges

Allergy care

� Testing and treatment

$10 per visit in a primary care department (nothing for children from infancy through age 4)

$20 per visit in a specialty care department

$30 per visit in a primary care department (nothing for children from infancy through age 4)

$30 per visit in a specialty care department

� Allergy injection

Note: Allergy serum is covered in full as a part of the office visit copayment.

$10 per visit

$30 per visit

Not covered:

� Provocative food testing

� Sublingual allergy desensitization

All charges

All charges

Treatment therapies

You pay

Standard Option

� Respiratory and inhalation therapy

� Intravenous/Infusion Therapy

Note: We cover growth hormone therapy (GHT) under the prescription drug benefit

� Qualified medical clinical trials that provide treatment for life-threatening conditions or for preventive, early detection, or treatment studies of cancer for Phases I, II, III and IV

� Dialysis � Hemodialysis and peritoneal dialysis

� 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 .

$10 per visit in a primary care department (nothing for children from infancy through age 4)

$20 per visit in a specialty care department

$30 per visit in a primary care department (nothing for children from infancy through age 4)

$30 per visit in a specialty care department

Not covered:

� Long-term rehabilitative therapy

� Cognitive therapy

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

� Sleep therapy

� Thermography and related services

All charges

All charges

Physical and occupational therapies

Inpatient and outpatient rehabilitative physical and occupational therapy as defined below:

� Physical therapy by a qualified Plan therapist in consultation with a Plan physician to restore bodily function when you have a total or partial loss of bodily function due to illness or injury

� Occupational therapy by a Plan therapist in consultation with a Plan physician to assist you in resuming self-care and other activities of daily life when you have a total or partial loss of bodily function due to illness or injury

Inpatient Services � up to 2 consecutive months of therapy per condition

� We provide inpatient multidisciplinary rehabilitation in a prescribed, organized program in a plan facility or skilled nursing facility for up to two consecutive months for all covered rehabilitation services and supplies you may receive at different sites for the same condition.

Note: The inpatient admission charge is waived if your have been admitted directly from a hospital inpatient stay.

$100 per inpatient admission

$250 per day up to $750 maximum per inpatient admission

Physical and occupational therapies (continued)

You pay

Standard Option

Outpatient physical and occupational therapy

� We cover up to 30 office visits or 60 days (whichever is greater) per condition of out-patient physical therapy services

� We cover up to 90 days per condition of out-patient occupational therapy services

Habilitative services for children � from birth to age 19 for the treatment of congenital and genetic birth defects

� We cover services to help a child function age-appropriately within his or her environment and enhance his or her functional ability without an effective cure

Cardiac Rehabilitation provided or coordinated by a hospital or other facility which is approved by a physician and includes exercise stress testing, rehabilitative exercises, education and counseling

� We cover services for up to 12 weeks or 36 sessions following coronary surgery or a myocardial infarction

$20 per visit in a specialty care department

$30 per visit in a specialty care department

Not covered:

� Long-term rehabilitative therapy

� Exercise programs

� Cognitive rehabilitative programs

� Vocational rehabilitative programs

� Therapies done primarily for education purposes, except as may otherwise be covered above

� Services provided by local, state, and Federal Government agencies including schools

All charges

All charges

Speech therapy

Speech therapy by a Plan therapist in consultation with a Plan physician when medically necessary

� Inpatient Services -- up to 2 consecutive months of therapy per condition

Note: The admission charge is waived if you have been admitted directly from a hospital inpatient stay

$100 per inpatient admission

$250 per day up to a $750 maximum per inpatient admission

Speech therapy (continued)

You pay

Standard Option

� Outpatient Services --up to 90 days per condition per year of outpatient speech therapy

Habilitative services for children � from birth to age 19 for the treatment of congenital and genetic birth defects

� We cover services to help a child function age-appropriately within his or her environment and enhance his or her functional ability without an effective cure

$20 per visit in a specialty care department

$30 per visit in a specialty care department

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

� Voice therapy for occupation or performing arts

� Services provided by local, state, and Federal Government agencies including schools

All charges

All charges

Hearing services (testing, treatment, and supplies)

� Hearing tests to determine the need for hearing correction

$10 per visit in a primary care department (nothing for children from infancy through age 4)

$20 per visit in a specialty care department

$30 per visit in a primary care department (nothing for children from infancy through age 4)

$30 per visit in a specialty care department

� Hearing aids for children under age 18

All charges in excess of $1,400 for each hearing impaired ear every 36 months

All charges in excess of $1,400 for each hearing impaired ear every 36 months

Not covered:

� Hearing aids, tests to determine their effectiveness, and examinations for them for all persons 18 and over

� All other hearing testing

All charges

All charges

Vision services (testing, treatment, and supplies)

You pay

High Option

You pay

Standard Option

� Eye exam in the Optometry Department

� Eye refractions in the Optometry Department

Note: Vision services performed outside the Optometry Department will be at the specialty copayment.

$10 per visit

$30 per visit

� Diagnosis and treatment of diseases of the eye

Note: These services are performed in a specialist department

$20 per visit in a specialty care department

$30 per visit in a specialty care department

� Eyeglass frames purchased at Plan Optical Shops

� Eyeglass lenses purchased at Plan Optical Shops

75% of our allowance

75% of our allowance

Total contact lens package at a Plan facility including

� Initial fitting for contact lenses

� Initial pair of contact lenses

� Insertion and removal of contact lens training

� Three months of follow-up office visits

Note: These services are provided only as a total package

85% of our allowance

85% of our allowance

Not covered:

� Eye exercises and orthoptics

� Radial keratotomy and other refractive surgery

� Eye surgery solely for the purpose of correcting refractive defects of the eye, such as near-sightedness (myopia), far-sightedness (hyperopia), and astigmatism

� Cosmetic contact lenses

� Cost of eyewear not purchased at Plan facilities

� Sunglasses without corrective lenses

All charges

All charges

Foot care

� Routine foot care when you are under active treatment for a metabolic or peripheral vascular disease

Note: See orthopedic and prosthetic devices for information on podiatric shoe inserts.

$10 per visit in a primary care department

$20 per visit in a specialty care department

$30 per visit in a primary care department

$30 per visit in a specialty care department

Not covered:

� Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above

� Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges

All charges

Orthopedic and prosthetic devices

You pay

High Option

You pay

Standard Option

� Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy

50% of our allowance

50% of our allowance

� Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implants following mastectomy.

Notes:

� See 5(b) for coverage of the surgery to insert the device.

� These items are covered only when preauthorized in writing by the Plan and when obtained through sources designated by the Plan.

Nothing

Nothing

� One hair prosthesis if your hair loss results from chemotherapy or radiation treatment for cancer

All charges in excess of $350

All charges in excess of $350

Not covered:

� Comfort, convenience, or luxury equipment or features

� External prosthetic and orthopedic devices, such as braces, foot orthotics, artificial limbs, and lenses following cataract removal

� Devices, equipment, supplies and prosthetics related to sexual dysfunction

� Orthopedic and corrective shoes

� Arch supports

� Foot orthotics

� Heel pads and heel cups

� Lumbosacral supports

� Corsets, trusses, elastic stockings, support hose, and other supportive devices

All charges

All charges

Durable medical equipment (DME)

You pay

High Option

You pay

Standard Option

We cover prescribed DME for home use.

Covered items include

� Hospital beds

� Wheelchairs

� Canes

� Walkers

� Portable commodes

� Crutches

� Bilirubin lights and apnea monitors for infants up to age 3 for a period not to exceed 6 months

� Continuous Positive Airway Pressure (CPAP) and Bilevel Pressure device (BIPAP) equipment

� Oxygen and equipment for home use

50% of our allowance

50% of our allowance

Notes:

� These items are covered only when preauthorized in writing by the Plan and when obtained through sources designated by the Plan.

� Your Plan physician must recertify your medical need for oxygen and oxygen equipment every 30 days.

� We decide whether to rent or purchase the equipment, and we select the vendor. We will repair the equipment without charge, unless the repair is due to loss or misuse. You must return the equipment to us or pay us the fair market price of the equipment when it is no longer prescribed.

� Asthma-related equipment (spacers, peak-flow meters, and nebulizers) for adults and children, when purchased at a Plan pharmacy.

Spacers: $5 per spacer

Peak-Flow Meters: $10 per meter

Nebulizers: $30 per nebulizer

Spacers: $5 per spacer

Peak-Flow Meters: $10 per meter

Nebulizers: $30 per nebulizer

Durable medical equipment (DME) (continued)

You pay

Standard Option

We cover Diabetic Equipment and Supplies when purchased at a Plan pharmacy including:

� Diabetic equipment

� Insulin pumps

� Disposable needles and syringes (up to 3 boxes)

� Glucose test strips (up to 6 boxes of 50 count)

20% of our allowance

20% of our allowance

� Glucose meter

� Replacement batteries

� Control solutions

� Lancets

Note: Lancets, disposable needles and syringes and glucose test strips are available by Plan mail delivery or through Plan pharmacies. Other diabetic supplies in this section are available only at Plan pharmacies.

Refer to Section 5(f), Prescription drug benefits, for information about insulin coverage.

$10 per meter

$5 per package

$8 per package

$8 per package

$10 per meter

$5 per package

$8 per package

$8 per package

Not covered:

� Oxygen tents

� Motorized wheelchairs

� Comfort, convenience, or luxury equipment or features

� Exercise or hygiene equipment

� Non-medical items such as sauna baths or elevators

� Modifications to your home or car

� Electronic monitors of bodily functions, except apnea monitors and blood glucose monitors

� Disposable supplies except as specifically listed in this section

� Replacement of lost equipment

� Repairs, adjustments, or replacements necessitated by misuse

� More than one piece of durable medical equipment serving essentially the same function, except for replacements other than those necessitated by misuse or loss

� Devices, equipment, supplies, and prosthetics for the treatment of sexual dysfunction disorders

� External and internally implanted hearing aids for all persons age 18 and over

� Experimental or research equipment

� Dental appliances

Home health services

You pay

Standard Option

If you are homebound and reside in the service area, we cover home health care ordered by a Plan physician and provided by a registered nurse, licensed practical nurse, licensed vocational nurse, physical therapist, occupational therapist, speech and language pathologist, or home health aide

� Services include oxygen therapy, intravenous therapy and medications

Note: Your Plan physician will periodically review the home health services for continuing appropriateness and medical need.

Nothing

Nothing

Not covered:

� Nursing care requested by, or for the convenience of, the patient or the patient�s family

� Custodial care

� Homemaker services

� Services outside the service area

� Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative

� General maintenance care of colostomy, ileostomy, and ureterostomy

� Medical supplies or dressings applied by you or a family caregiver

� Care that a Plan physician determines may be provided in a Plan facility or skilled nursing facility if we provide or offer to provide that care in one of those facilities

� Transportation and delivery service costs of durable medical equipment, medications, drugs, medical supplies, and supplements to the home

� Personal care items

All charges

All charges

Chiropractic

You pay

Standard Option

Chiropractic services, including spinal manipulation of the neck and back, up to 20 visits per calendar year, for the following services

� Evaluation and management

� Routine chiropractic x-rays provided in the chiropractor�s office

� Chiropractic adjustments

� Adjunctive therapies (e.g., hot and cold packs)

� Educational materials

Note: You receive these services when your Plan physician, in consultation with the Complementary and Alternative Medicine Department, determines that such care will result in improvement in your condition.

$20 per office visit

All charges

Not covered:

� Structural supports

� Nutritional supplements

All charges

All charges

Alternative treatments

Acupuncture services up to 20 visits per calendar year, for the following services:

� Evaluation and management

� Note: You receive these services when your Plan physician, in consultation with the Complementary and Alternative Medicine Department, determines that such care will result in improvement in your condition.

$20 per visit

All charges

Not covered:

� Herbal and nutritional supplements

All charges

All charges

Educational classes and programs

� Health education for conditions such as diabetes, post-coronary, and nutritional counseling

$10 per visit in a primary care department

$20 per visit in a specialty care department

$30 per visit in a primary care department

$30 per visit in a specialty care department

� General health education classes such as prenatal, weight management, smoking cessation, and stress management

Nominal fees ranging from $10 to $75 per class

Nominal fees ranging from $10 to $75 per class

Not covered:

� Educational classes and programs not offered through this Plan

All charges

All charges

I

M

P

O

R

T

A

N

T

Here are some important things you should keep in mind about these benefits:

� Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

� Plan physicians must provide or arrange your care.

� We have no calendar year deductible for Surgical and anesthesia services.

� 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 PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification and identify which surgeries require precertification.

I

M

P

O

R

T

A

N

T

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

� Foot surgery including open cutting surgery to remove bunions and spurs

� Correction of congenital anomalies (see Reconstructive surgery)

$20 per visit in a specialty care department

$50 per outpatient surgery

$100 per inpatient admission for hospital charges

$30 per visit in a specialty care department

$100 per outpatient surgery

$250 per day up to $750 maximum per inpatient admission for hospital charges

Surgical procedures(continued)

You pay

Standard Option

� Surgical treatment of morbid obesity -- a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must be age 18 or over

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

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

� Treatment of burns

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

� Insertion of other implanted time-release drugs. Note: We cover the cost of these devices under the prescription drug benefit (see Section 5(f))

Not covered:

� Reversal of voluntary sterilization

� Routine treatment of conditions of the foot; see Foot care

All charges

All charges

Reconstructive surgery

You pay

Standard Option

� Surgery to correct a functional defect

� Surgery to correct a condition caused by injury or illness if:

� it produced a major effect on the member�s appearance; and

� the condition can reasonably be expected to be corrected by such surgery

� Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are protruding ear deformities, cleft lip, cleft palate, birth marks, webbed fingers, and webbed toes.

� All stages of breast reconstruction surgery following a mastectomy, such as:

� surgery to produce a symmetrical of breasts;

� treatment of any physical complications, such as lymphedemas; and

� breast prostheses and surgical bras and replacements (see Orthopedic and 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.

$20 per visit in a specialty care department

$50 per outpatient surgery

$100 per inpatient admission for hospital charges

$30 per visit in a specialty care department

$100 per outpatient surgery

$250 per day up to $750 maximum per inpatient admission for hospital charges

Not covered:

� Cosmetic surgery � any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance and/or treat a mental condition through change in bodily form

� Surgeries related to sex transformation

All charges

All charges

Oral and maxillofacial surgery

Oral surgical procedures, limited to:

� Reduction of fractures of the jaws or facial bones

� Surgical correction of cleft lip, cleft palate, or severe functional malocclusion

� Removal of stones from salivary ducts

� Excision of leukoplakia or malignancies

� Excision of cysts and incision of abscesses when done as independent procedures

� Medical and surgical treatment of TMJ (non-dental)

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

$20 per visit in a specialty care department

$50 per outpatient surgery

$100 per inpatient admission for hospital charges

$30 per visit in a specialty care department

$100 per outpatient surgery

$250 per day up to $750 maximum per inpatient admission for hospital charges

Oral and maxillofacial surgery (continued)

You pay

Standard Option

Not covered:

� Oral implants and transplants

� Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone) except as covered under the accidental dental benefit.

� Shortening of the mandible or maxillae for cosmetic purposes and correction of malocclusion.

All charges

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; testicular, mediastinal, retroperitoneal and ovarian germ cell tumors, breast cancer; multiple myeloma and epithelial ovarian cancer

� Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas

Unless otherwise authorized by your physician, transplants are covered only at institutions that we designate as �Centers of Excellence� for that specific transplant. If your physician or the transplant facility determines that you do not satisfy the criteria for receiving the transplant, we will pay only for the covered services and supplies you receive before you are notified of that determination.

$20 per visit in a specialty care department

$50 per outpatient surgery

$100 per inpatient admission for hospital charges

$30 per visit in a specialty care department

$100 per outpatient surgery

$250 per day up to $750 maximum per inpatient admission for hospital charges

Organ/tissue transplants (continued)

You pay

Standard Option

Limited Benefits: Treatment for breast cancer, multiple myeloma, and epithelial ovarian cancer may be provided in a National Cancer Institute (NCI) � or National Institutes of Health (NIH)-approved clinical trial at a Plan-designated center of excellence and if approved by the Plan�s medical director in accordance with the Plan�s protocols.

Note: We cover related medical and hospital expenses for a living donor when those expenses are directly related to your covered transplant.

Not covered:

� Donor screening tests and donor search expenses, except screening blood tests and advanced testing performed for the actual donor

� Implants of non-human or artificial organs

� Transplants not listed as covered except when approved by the Clinical Management Committee of the National Transplant Network

All charges

All charges

Anesthesia

Professional services provided in:

� Hospital (inpatient)

� Hospital outpatient department

� Ambulatory surgical center

� Office

Nothing

Nothing

I

M

P

O

R

T

A

N

T

Here are some important things you should keep in mind about these benefits:

� Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are 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 for Services provided by a hospital or other facility, and ambulance charges.

� 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 in Sections 5(a) or (b).

� YOUR PHYSICIAN MUST GET PRECERTIFICATION OF HOSPITAL STAYS (except for Maternity stays). Please refer to Section 3 to be sure which services require precertification.

I

M

P

O

R

T

A

N

T

Inpatient hospital

Room and board, such as:

� Ward, semiprivate, or intensive care accommodations

� General nursing care

� Medically necessary special duty nursing

� Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$100 per inpatient admission

$250 per day up to $750 maximum per inpatient admission

Inpatient hospital (continued)

You pay

Standard Option

Other hospital services and supplies, such as:

� Operating, recovery, maternity, and other treatment rooms

� Prescribed drugs and medicines

� Diagnostic laboratory tests, X-rays, and pathology services

� Procurement and storage for approved medically necessary cord blood for a designated recipient

� Administration of blood and blood products

� Blood or blood plasma, if donated or replaced

� Dressings, splints, casts, and sterile tray services

� Medical supplies and equipment, including oxygen

� Anesthetics and anesthesia services

� Take home items

� Hospitalization for inpatient foot treatment

Note: You may receive covered medical hospital services for certain dental procedures if a Plan physician determines that you need to be hospitalized. Section 5(h), Dental benefits, includes more information on the requirements.

$100 per inpatient admission

$250 per day up to $750 maximum per inpatient admission

Not covered:

� Custodial care

� Non-covered facilities

� Personal comfort items, such as telephone, television, barber services, guest meals and beds

� Private nursing care

� Whole blood and packed red blood cells not replaced by the member

� Procurement and storage of cord blood for possible future need or for yet to be determined Member recipient

All charges

All charges

Outpatient hospital or ambulatory surgical center

You pay

Standard Option

� Operating, recovery, and other treatment rooms

� Prescribed drugs and medicines

� Diagnostic laboratory tests, X-rays, and pathology services

� Procurement and storage of cord blood for approved medically necessary procedures requiring cord blood for a designated recipient

� Administration of blood and blood products

� Blood and blood plasma, if not donated or replaced

� Pre-surgical testing

� Dressings, casts, and sterile tray services

� Medical supplies, including oxygen

� Anesthetics and anesthesia service

$50 per outpatient surgery

$100 per outpatient surgery

Not covered:

� Whole blood and packed red blood cells not replaced by the member

� Procurement and storage of cord blood for possible future need or for yet to be determined member recipient

All charges

All charges

Skilled nursing care benefits

Up to 100 days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate. We cover the following:

� Physician and nursing services

� Room and board

� Medical social services

� Administration of blood, blood products, and derivatives

� Durable medical equipment ordinarily furnished by a skilled nursing facility, including oxygen-dispensing equipment and oxygen

� Respiratory therapy

� Biological supplies

� Medical supplies

Note: We waive the additional admission charge if you are admitted to an extended care or skilled nursing facility directly from a hospital inpatient stay.

$100 per inpatient admission

$250 per day up to $750 maximum per inpatient admission

Skilled nursing care benefits (continued)

You pay

Standard Option

Not covered:

� Custodial care

� Care in an intermediate care facility

All charges

All charges

Hospice care

Supportive and palliative care for a terminally ill member

� You must reside in the service area

� Services are provided in your home, or

� Services are provided 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.

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

Nothing

Not covered:

� Private duty nursing (independent nursing)

� Homemaker services

All charges

All charges

Ambulance

� Local professional ambulance service when medically appropriate

Nothing

$100 per trip

I

M

P

O

R

T

A

N

T

Here are some important things you should keep in mind about these benefits:

� Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

� We have no calendar year deductible for Emergency services/accidents.

� 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 the local emergency system (e.g., the local 911 telephone system). When the operator answers, stay on the phone and answer all questions. If you are not sure whether you are experiencing a medical emergency, please contact our Emergency Line at 800/677-1112.

Emergencies within our service area:

Emergency care is provided at Plan Hospitals 24 hours a day, seven days a week.

If you think you have a medical emergency condition and you cannot safely go to a Plan Hospital, call 911 or go to the nearest hospital. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member must notify us within 48 hours, or as soon as is reasonably possible, by calling 703/359-7878 inside the Washington, DC metropolitan area or toll free 800/777-7904. Our TTY is 703/359-7616 or 800/700-4901.

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 us within that time. If you are hospitalized in non-Plan facilities and Plan physicians believe care can be better provided in a Plan Hospital, we will transfer you when medically feasible, with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

Emergencies outside our service area:

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 as soon as is reasonably possible. If a Plan physician believes care can be better provided in a Plan Hospital, we will transfer you when medically feasible, with any ambulance charges covered in full.

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 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 301/468-6000 inside the Washington, DC metropolitan area or at 800/777-7902 outside the Washington, DC metropolitan area. Our TTY telephone number is 301/879-6380.

Benefit Description

You pay

Standard Option

Emergency within our service area

� Emergency care at a Plan urgent care department

$20 per visit

$30 per visit

� Emergency care in a hospital emergency room

Note: Your hospital emergency room visit copayment is waived if you are admitted to a Plan Hospital. Your hospital inpatient copayment will apply (See Section 5(c)).

$50 per visit

$100 per visit

Not covered:

� Elective care or non-emergency care

All charges

All charges

Emergency outside our service area

� Emergency care at an urgent care center

$20 per visit

$30 per visit

� Emergency care in a Kaiser Foundation hospital in another Kaiser Foundation Health Plan service area

� Emergency care in a non-Plan hospital emergency room

Note: We waive your hospital emergency room visit copayment if you are admitted to a Plan Hospital. Your hospital inpatient copayment will apply (See Section 5(c)). See the Travel Benefit for coverage of continuing or follow-up care.

$50 per visit

$100 per visit

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

All charges

Ambulance

Professional ambulance service, including air ambulance, when approved by the Plan.

Note: See Section 5(c) for non-emergency ambulance service.

Nothing

$100 per trip

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 you should keep in mind about these benefits:

� Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are clinically appropriate to treat your condition.

� We have no calendar year deductible for Mental health and substance abuse benefits.

� 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.

� Plan physicians must provide or arrange your care.

I

M

P

O

R

T

A

N

T

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.

Notes:

� 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.

� 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 no greater than for other illnesses or conditions.

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

Mental health and substance abuse benefits (continued)

You pay

Standard Option

Diagnosis and treatment of psychiatric conditions, mental illness, or disorders of children, adolescents, and adults. Outpatient services include:

� Diagnostic evaluation

� Crisis intervention and stabilization for acute episodes

� Psychological testing necessary to determine the appropriate psychiatric treatment

� Outpatient psychiatric treatment (including individual and group therapy visits)

� 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) as part of intensive outpatient programs

� Intensive day treatment

� Methadone treatment

Notes:

� You may see a Plan provider for outpatient treatment without a referral from your primary care physician.

� Your Plan 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.

$10 per visit in a primary care department

$20 per visit in a specialty care department

$30 per visit in a primary care department

$30 per visit in a specialty care department

Mental health and substance abuse benefits (continued)

You pay

Standard Option

� Inpatient psychiatric care

� Inpatient detoxification

� Acute inpatient substance abuse rehabilitation

Note: All inpatient admissions and hospital alternative services treatment programs require approval by a Plan physician. Inpatient services will only be part of a treatment plan when services cannot be provided safely on an outpatient basis or in a less intensive setting than an acute care hospital.

$100 per inpatient admission for hospital charges

$250 per day up to $750 maximum per inpatient admission for hospital charges

� Hospital alternative services: partial hospitalization, intensive outpatient psychiatric treatment programs and residential crisis services.

$20 per visit; or $100 per inpatient admission if your treatment is more than 24 continuous hours

$30 per visit; or $250 per day up to $750 maximum per inpatient admission if your treatment is more than 24 continuous hours

Not covered:

� Care that is not clinically appropriate for the treatment of your condition

� Services we have not approved

� Intelligence, IQ, aptitude ability, learning disabilities, or interest testing not necessary to determine the appropriate treatment of a psychiatric condition

� Evaluation or therapy on court order or as a condition of parole or probation, or otherwise required by the criminal justice system, unless determined by a Plan physician to be medically necessary and appropriate

� Services that are custodial in nature

� Marital, family, or educational services

� Services rendered or billed by a school or a member of its staff

� Services provided under a federal, state, or local government program

� Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms that may be present

All charges

All charges

Limitation We may limit your benefits if you do not obtain a treatment plan.

I

M

P

O

R

T

A

N

T

Here are some important things you should keep in mind about these benefits:

� We cover prescribed drugs and medications, as described in the chart beginning on page xx.

� 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.

� Under the High Option Plan, we have no calendar year deductible.

� Under the Standard Option Plan, we have a calendar year deductible of $100 for outpatient prescription drugs.

� 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 physician, authorized provider, or licensed contracted dentist must write the prescription.

� Where you can obtain them. If you are enrolled in the High Option plan, you must fill the prescription at a Plan pharmacy, an affiliated network pharmacy, or by the Plan mail service delivery program. If you are enrolled in the Standard Option plan, you must fill the prescription at a Plan pharmacy or by the Plan mail service delivery program. You do not have coverage for prescriptions obtained at an affiliated network pharmacy. We will pay for prescriptions written by a non-Plan physician and filled at a non-Plan pharmacy only when the prescription was given during a hospital emergency room visit or an urgent care visit outside the service area.

� We use a preferred drug list . Our preferred drug list (formulary) is a list of prescribed drugs (generic and preferred brand name) and accessories that have been approved by our Pharmacy and Therapeutics Committee for our Members. The preferred drug list contains both generic and brand name drugs. Brand name drugs that are not on our preferred drug list, known as non-preferred drugs, are available under the benefit at a higher copayment. Whether you or your Plan physician makes the request, you will be charged according to the type of drug you receive � generic, preferred brand name, or non-preferred brand name.

Our Pharmacy and Therapeutics Committee, which is comprised of Plan physicians, Plan providers, and our pharmacists, selects prescription drugs and accessories for the preferred drug list (formulary) based on a number of factors, including safety and effectiveness as determined from a review of medical literature and research. In addition, the Committee sets dispensing limitations in accord with therapeutic guidelines based on the medical literature and research. The Pharmacy and Therapeutics� Committee meets periodically to consider adding and removing prescribed drugs and accessories on the preferred drug list (formulary).

If you would like information about whether a particular drug or accessory is included in our preferred drug list (formulary), please visit us on line at my.kaiserpermanente.org/federalemployees, or call our Member Services Department at 301/468-6000 inside the Washington, DC metropolitan area or at 800/777-7902 outside the Washington, DC metropolitan area. Our TTY telephone number is 301/879-6380.

� These are the dispensing limitations. We provide up to a 30-day supply for one copayment based upon (a) the prescribed quantity, (b) the standard manufacturer�s package size, (c) specified dispensing limits, (d) the type of drug, and (e) the place of purchase. We provide up to a 90-day supply of maintenance drugs for two copayments when ordered through our Plan�s mail service delivery program. A maintenance drug is a drug that your physician anticipates you will require for 6 months or more to treat a chronic condition. Plan members called to active military duty (or members in time of national emergency) who need to obtain prescribed medications should call our Member Services Department at 301/468-6000.

Prescription drugs (continued)

� Why use generic drugs? Unless otherwise specified by your Plan physician or dentist, generic drugs may be used to fill prescriptions. Kaiser Permanente providers have successfully included the use of generic drugs as part of patient care without compromising quality. Generic drugs offer a safe and economic way to meet your medication needs. They are less expensive than brand name drugs - therefore you may reduce your out-of-pocket costs by choosing to use a generic drug. Generic drugs must contain the same active ingredients and be equivalent in strength and dosage to the original brand name product. The U.S. Food and Drug Administration and also Kaiser Permanente set criteria for the use of generic drugs to ensure that they meet the same standards of purity, strength and quality as brand-name drugs. They are expected to have the same therapeutic effect as the brand name product. Not all drugs have a generic equivalent. If a generic drug is unavailable, the appropriate brand copayment will apply.

� 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. To file a claim, you should contact the Plan�s Member Services Department at 301/468-6000 inside the Washington, DC metropolitan area or at 800/777-7902 outside the Washington, DC metropolitan area and obtain a claim form. Our TTY is 301/879-6380. A claim for reimbursement must be submitted to the Plan within 12 months after you purchased the prescribed drugs. Members must pay full price for the drug and then submit a claim for reimbursement subject to the terms and conditions of the Plan.

Benefit Description

You pay

High Option

You pay

Standard Option

Note: Under the Standard Option Plan, the $100 outpatient prescription drug calendar year deductible applies to all benefits in this section.

Covered medications and supplies

There is no deductible

After the calendar year deductible�.

We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy, an affiliated network pharmacy, or through the Plan�s mail service delivery program:

� Drugs for which a prescription is required by law

� Insulin (up to six (6) vials)

� Disposable needles and syringes for the administration of covered medications

� Contraceptive drugs

� Intrauterine devices (IUDs) and diaphragms

� Implanted time-release contraceptive drugs

� Other implanted time-release drugs

� Injectable contraceptive drugs

� Self-injectable drugs, other than ovulation stimulants

� Self-administered chemotherapeutic drugs and oral chemotherapeutic agents

� Self-administered post-surgical immunosuppressant outpatient drugs required as a result of a covered transplant

� Growth hormone therapy (GHT) � for treatment of children with growth hormone deficiency

Notes:

� Compounded preparations must contain at least one ingredient requiring a prescription.

� For example, you may receive a maintenance medication for up to a 90-day supply through our mail service delivery program at $20 per prescription or refill for generic drugs for the High Option Plan and $30 per prescription or refill for generic drugs for the Standard Option Plan.

At a Plan medical center pharmacy:

$10 per prescription or refill for generic drugs; or

$20 per prescription or refill for preferred brand-name drugs; or

$35 per prescription or refill for non-preferred brand-name drugs

Through our mail service delivery program:

$8 per prescription or refill for generic drugs; or

$18 per prescription or refill for preferred brand-name drugs; or

$33 per prescription or refill for non-preferred brand-name drugs

At an affiliated network pharmacy:

$20 per prescription or refill for generic drugs; or

$40 per prescription or refill for preferred brand-name drugs; or

$55 per prescription or refill for non-preferred brand-name drugs

At a Plan medical center pharmacy:

$15 per prescription or refill for generic drugs; or

$25 per prescription or refill for preferred brand-name drugs; or

$40 per prescription or refill for non-preferred brand-name drugs

Through our mail service delivery program:

$13 per prescription or refill for generic drugs; or

$23 per prescription or refill for preferred brand-name drugs; or

$38 per prescription or refill for non-preferred brand-name drugs

At an affiliated network pharmacy:

All charges if you get prescriptions filled at an affiliated network pharmacy.

� Clinically administered post-surgical immunosuppressant outpatient drugs required as a result of a covered transplant

� Intravenous fluids and medications for home use

� Clinically administered chemotherapy drugs

Nothing

Nothing

Covered medications and supplies (continued)

You pay

Standard Option

� Amino acid modified products used to treat congenital errors of amino acid metabolism (PKU)

25% of our allowance

25% of our allowance

Note:See Section 5(a) � Medical services and supplies provided by physicians and other health care professionals for coverage of diabetic equipment and supplies including glucose test strips, disposable needles and syringes, lancets, and control solutions.

�  

� Smoking cessation products are provided for one course of therapy per calendar year, when prescribed by Plan provider

� Weight management drugs for treatment of morbid obesity

� Drugs for covered infertility treatments

� Drugs for sexual dysfunction

Note: Drugs to treat sexual dysfunction have dispensing limitations. Please contact the Plan for details.

50% of our allowance

50% of our allowance

Not covered:

� Drugs obtained at either a non-Plan pharmacy or non-affiliated network pharmacy except for emergencies inside and outside the service area

� Drugs or supplies for cosmetic purposes

� Vitamins and nutritional supplements that can be purchased without a prescription

� Nonprescription drugs

� Prescription drugs for which there is a nonprescription equivalent available

� Medical supplies such as dressings and antiseptics

� Drugs to enhance athletic performance

� Drugs related to non-covered infertility services

� Drugs for non-covered services

� Dental prescriptions other than those prescribed for pain relief or antibiotics

� Replacement prescriptions necessitated by theft, loss, or damage

� Drugs to shorten the duration of the common cold

� Special packaging (e.g., blister pack, unit dose, unit-of-use packaging) different from Plan�s standard packaging

All charges

All charges

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 treatments as a less costly alternative benefit.

� Alternative treatments are subject to our ongoing review.

� By approving an alternative treatment, we cannot guarantee you will get it in the future.

� The decision to offer an alternative treatment is solely ours, and we may withdraw it at any time and resume regular contract benefits.

� Our decision to offer or withdraw alternative treatments is not subject to OPM review under the disputed claims process.

24 hour nurse line

For any of your health concerns, 24 hours a day, 7 days a week, you may call 703/359-7878 inside the Washington, DC metropolitan area or 800/777-7904 outside the Washington, DC metropolitan area or call our TTY at 703/359-7616 or 800/700-4901 and talk with a registered nurse who will discuss treatment options and answer your health questions.

Services for deaf and hearing impaired

For any of your health concerns, 24 hours a day, 7 days a week, you may call 703/359-7616 inside the Washington, DC metropolitan area or 800/700-4901 outside the Washington, DC metropolitan area and talk with a registered nurse who will discuss treatment options and answer your health questions.

During regular business hours Monday through Friday, you may contact our Member Services Department with any questions concerning the Plan and how to obtain services by calling 301/879-6380.

Centers of Excellence

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

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

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 or 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 covered services 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. This amount will be deducted from the payment we make to you.

� Your benefit is limited to $1200 each calendar year.

� For more information about this benefit you should contact the Plan�s Member Services Department at 301/468-6000 inside the Washington, DC metropolitan area or at 800/777-7902 outside the Washington, DC metropolitan area. Our TTY is 301/879-6380.

� File claims as shown in Section 7.

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

� Non-emergency hospitalization

� Infertility treatments

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

� Transplants

� DME

� Prescription drugs

� Home health services

Services from other Kaiser Permanente plans

When you are visiting in the service area of another Kaiser Permanente plan, you are entitled to receive virtually all the services 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 charges imposed by the Plan you are visiting. If the Plan you are visiting has a services that is different from the services of this Plan, you are not entitled to receive that service.

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 service 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 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 services available to you from the Kaiser Permanente plan, please call Membership Services at 301/468-6000 inside the Washington, DC metropolitan area or at 800/777-7902 outside the Washington, DC metropolitan area. Our TTY is 301/879-6380.

We cover restorative services and supplies necessary to promptly repair (but not replace) your sound natural teeth that you have injured as the result of an external force (not chewing). A sound natural tooth is one that has not been weakened by existing dental pathology such as, decay or periodontal disease, or previously restored with a crown, inlay, onlay or porcelain restoration, or treatment by endodontics.

Note: You must start to receive services within 60 days of your accident and complete them within 12 months of your accident. You are only covered for the most cost effective procedure that will produce a satisfactory result.

$10 per visit in a primary care department

$20 per visit in a specialty care department

All charges in excess of $2,000 per member per accident

$30 per visit in a primary care department

$30 per visit in a specialty care department

All charges in excess of $2,000 per member per accident

Not covered:

� Injuries to non-sound natural teeth

� Services required after the 12-month period

� Services that are needed, but did not start until later than 60 days after the accident

� Services for teeth that have been so severely damaged that restoration is impossible, in the opinion of the Plan dental provider

� Services for teeth that have been knocked-out

All charges

All charges

We cover general anesthesia and associated hospital or ambulatory surgery facility charges in conjunction with dental care provided by a fully accredited specialist in pediatric dentistry, fully accredited specialist in oral and maxillofacial surgery, or a dentist for whom hospital privileges has been granted, for the following members.

� Children, 7 years of age or younger, who are developmentally disabled, for whom a successful result cannot be expected from dental care provided under local anesthesia because of a physical, intellectual, or other medically compromising condition, for whom a superior result can be expected from dental care provided under general anesthesia

� Children, 17 years of age or younger, and extremely uncooperative, fearful, or uncommunicative with dental needs of such magnitude that treatment should not be delayed or deferred; and whom a lack of treatment can be expected to result in oral pain, infection, loss of teeth, or other increased oral or dental morbidity

� Adults, age 17 and older, whose medical condition requires that dental service be performed in a hospital or ambulatory surgical center for their safety (e.g., heart disease and hemophilia)

$10 per visit in a primary care department

$20 per visit in a specialty care department

$50 per outpatient surgery

$100 per inpatient admission

$30 per visit in a primary care department

$30 per visit in a specialty care department

$100 per outpatient surgery

$250 per day up to $750 maximum per inpatient admission

Not covered:

� The dentist�s or specialist�s professional services

� Dental care for temporal mandibular joint (TMJ) disorders

All charges

All charges

Discounted Fee - Dental Benefits

For High Option plan members, Kaiser Permanente has entered into an Agreement with Dental Benefit Providers, Inc. (�DBP�), under which DBP will provide or arrange for the administration of covered dental services to you through Participating Dental Providers.

� All procedures listed in the following schedule of dental services and fees are covered dental services. When you receive any of the listed procedures from a Participating Dental Provider, you will pay the fee listed next to the procedure description for that service. The Participating Dental Provider has agreed to accept that fee as payment in full for that procedure. Neither Kaiser Permanente nor DBP are liable for payment of these fees or for any fees incurred as the result of receipt of non-covered dental services.

� You will pay a fixed rate of $30 per office visit for procedures with an �FC $30� fee indication in the schedule below. We waive the $5 sterilization fee for any office visit in which FC $30 applies. �NB� indicates there is no benefit available and you must pay the full cost of these services.

� You may select a Participating Dental Provider, who is a �general dentist,� from whom you will receive covered dental services. With a large network of general dentists in our service area, you may select a general dentist from our Dental Provider Directory for yourself and your family. You can obtain a Dental Provider Directory by calling our Member Services Department at 301/468-6000 inside the Washington, DC metropolitan area or at 800/777-7902 outside the Washington, DC metropolitan area. Our TTY is 301/879-6380.

� Specialty care is also available should further covered services be necessary; however, you must be referred to a Participating Dental Provider who is a specialist by your general dentist. Your discounted fees are slightly higher for care received by a Participating Dental Provider who is a specialist. Please refer to the following schedule of dental services and fees for those discounted fees.

� When a dental emergency occurs outside our service area, Kaiser Permanente will reimburse you for the reasonable charges, less any discounted fee, upon proof of payment, not to exceed $50 per incident. We cover emergency dental treatment required to alleviate pain, bleeding, or swelling. If post-emergency care is required, you must receive all post-emergency care from your Participating Dental Provider.

Diagnostic Services

D0120

Periodic Oral Evaluation (every 6 months)

FC $30

NB

D0140

Limited Oral Evaluation � Problem Focused

FC $30

NB

D0150

Comprehensive Oral Evaluation

FC $30

NB

D0180

Comprehensive Periodontal Evaluation

FC $30

NB

D0210

Intraoral-Complete Series Including Bitewings

$34

$37

D0220

Intraoral-Periapical 1^st Film

FC $30

$9

D0230

Intraoral-Periapical Each Additional Film

FC $30

$9

D0240

Intraoral Occlusal Film

FC $30

$9

D0270

Bitewing-Single Film

FC $30

$9

D0272

Bitewings-Two Films

FC $30

$9

D0274

Bitewings-Four Films

FC $30

$25

D0277

Vertical Bitewings, 7-8 Films

FC $30

$25

D0330

Panoramic Film

$28

$31

D0460

Pulp Vitality Tests

FC $30

$16

D0470

Diagnostic Casts

FC $30

NB

D0999

Unspecified Diagnostic Procedure, by Report

$5

$5

Preventive Services

D1110

Prophylaxis Adult (every 6 months)

FC $30

NB

D1120

Prophylaxis Child (every 6 months)

FC $30

NB

D1201

Topical Fluoride Including Prophy � Under age 16

FC $30

NB

D1203

Topical Fluoride Excluding Prophy � Under age 16

FC $30

NB

D1330

Oral Hygiene Instruction

FC $30

NB

D1351

Sealant - Per Tooth �Under age 16

$17

NB

D1510

Space Maintainer � Fixed Unilateral

$184

NB

D1515

Space Maintainer � Fixed Bilateral

$184

NB

D1520

Space Maintainer � Removable Unilateral

$226

NB

D1525

Space Maintainer � Removable Bilateral

$141

NB

D1550

Recementation of Space Maintainer

$21

NB

Restorative Services

D2140

Amalgam � One Surface, Primary or Permanent

$30

NB

D2150

Amalgam � Two Surfaces, Primary or Permanent

$41

NB

D2160

Amalgam � Three Surfaces, Primary or Permanent

$51

NB

D2161

Amalgam � Four or More Surfaces, Primary or Permanent

$60

NB

D2330

Resin � One Surface Anterior

$37

NB

D2331

Resin � Two Surfaces Anterior

$51

NB

D2332

Resin � Three Surfaces Anterior

$52

NB

D2335

Resin -Four or More Surfaces or Inv Incisal Angle, Anterior

$66

NB

D2391

Resin - One Surface, Posterior

$35

NB

D2392

Resin - Two Surfaces, Posterior

$56

NB

D2393

Resin - Three Surfaces, Posterior

$70

NB

D2394

Resin � Four or More Surfaces, Posterior

$70

NB[1]

D2510

Inlay-Metallic - One Surface

$307

NB

D2520

Inlay-Metallic -Two Surfaces

$334

NB

D2530

Inlay-Metallic-Three or More Surfaces

$371

NB

D2542

Onlay-Metallic-Two Surfaces

$408

NB

D2543

Onlay-Metallic-Three Surfaces

$408

NB

D2544

Onlay-Metallic-Four or More Surfaces

$408

NB

D2610

Inlay-Porcelain/Ceramic-One Surface

$498

NB

D2620

Inlay-Porcelain/Ceramic � Two Surfaces

$498

NB

D2630

Inlay-Porcelain/Ceramic � Three or More Surfaces

$498

NB

D2642

Onlay-Porcelain/Ceramic-Two Surfaces

$498

NB

D2643

Onlay-Porcelain/Ceramic-Three Surfaces

$498

NB

D2644

Onlay-Porcelain/Ceramic-Four or More Surfaces

$498

NB

D2650

Inlay-Composite/Resin-One Surface (Lab)

$498

NB

D2651

Inlay-Composite/Resin-Two Surfaces (Lab)

$498

NB

D2652

Inlay-Composite/Resin-Three or More Surfaces (Lab)

$498

NB

D2710

Crown-Resin (Lab)

$235

NB

D2740

Crown-Porcelain/Ceramic Substrate

$526

NB

D2750

Crown-Porcelain Fused to High Noble Metal

$531

NB

D2751

Crown-Porcelain Fused to Predominately Base Metal

$472

NB

D2752

Crown-Porcelain Fused to Noble Metal

$502

NB

D2780

Crown-3/4 Cast High Noble Metal

$521

NB

D2781

Crown- 3/4 Cast Base Metal

$521

NB

D2782

Crown-3/4 Cast Fused to Noble Metal

$521

NB

D2790

Crown-Full Cast High Noble Metal

$510

NB

D2791

Crown-Full Cast Predominately Base Metal

$442

NB

D2792

Crown-Full Cast Noble Metal

$465

NB

D2910

Recement Inlay

$34

NB

D2920

Recement Crown

$34

NB

D2930

Prefabricated Stainless Steel Crown-Primary Tooth

$101

NB

D2931

Prefabricated Stainless Steel Crown-Permanent Tooth

$106

NB

D2932

Prefabricated Resin Crown

$157

NB

D2940

Sedative Filling

$34

NB

D2950

Core Buildup w/Pins

$101

NB

D2951

Pin Retention-per Tooth in Addition to Restoration

$22

NB

D2952

Cast Post & Core In Addition to Crown

$146

NB

D2954

Prefabricated Post & Core in Addition to Crown

$129

NB

D2970

Temporary Crown (fractured tooth)

$84

NB

D2980

Crown Repair by Report

$84

NB

Endodontic Services

D3110

Pulp Cap-Direct (excluding final restoration)

$22

NB

D3120

Pulp Cap-Indirect (excluding final restoration)

$22

NB

D3220

Therapeutic Pulpotomy (excluding final restoration)

$62

$67

D3310

Root Canal Therapy - Anterior (excluding final restoration)

$253

$319

D3320

Root Canal Therapy -Bicuspid (excluding final restoration)

$294

$496

D3330

Root Canal Therapy - Molar (excluding final restoration)

$313

$614

D3346

Retreatment of Previous Root Canal - Anterior

NB

$378

D3347

Retreatment of Previous Root Canal - Bicuspid

NB

$584

D3348

Retreatment of Previous Root Canal - Molar

NB

$732

D3351

Apexification/Recalcification-1st Visit

$118

$164

D3352

Apexification/Recalcification-Interim Medication Replacement

$118

$164

D3353

Apexification/Recalcification-Final Visit

$118

$164

D3410

Apicoectomy/Periradicular Surgery-Anterior

$148

$381

D3421

Apicoectomy/Periradicular Surgery-Bicuspid-1st Root

$148

$465

D3425

Apicoectomy/Periradicular Surgery-Molar-1st Root

$148

$487

D3426

Apicoectomy/Periradicular Surgery-Molar-Each Additional Root

$49

$185

D3430

Retrograde Filling-per Root

$104

$196

D3450

Root Amputation-per Root

$104

$252

D3920

Hemisection w/Root Removal w/o Root Canal Therapy

$125

$224

Periodontic Services

D4210

Gingivectomy/Gingivoplasty - Four or More Contiguous or Bounded Teeth per Quad

$222

$297

D4211

Gingivectomy/Gingivoplasty � One to Three Teeth per Quad

$59

$90

D4240

Gingival Flap Including Root Planing - Four or More Contiguous or Bounded Teeth per Quad

$222

$381

D4241

Gingival Flap Including Root Planing � One to Three Teeth per Quad

$111

$191

D4249

Clinical Crown Lengthening, Hard Tissue

$260

$358

D4260

Osseous Surgery Including Flap Entry & Closure � Four or More Contiguous/Bounded Teeth per Quad

$371

$661

D4261

Osseous Surgery Including Flap Entry & Closure � One to Three Teeth per Quad

$185

$331

D4263

Bone Replacement Graft�1^st Site in Quad

$185

$330

D4265

Biologic Materials to Aid in Soft and Osseous Surgery

$93

$165

D4268

Surgical Revision Procedure, per Tooth

$358

$358

D4270

Pedicle Soft Tissue Graft Procedure

$178

$420

D4271

Free Soft Tissue Graft & Donor Site

$260

$510

D4275

Soft Tissue Allograft

$260

$510

D4276

Combined Connective Tissue and Double Pedicle

$178

$420

D4320

Provisional Splinting � Intracoronal

$106

$130

D4321

Provisional Splinting � Extracoronal

$74

$134

D4341

Periodontal Scaling/Root Planing - Four or More Contiguous or Bounded Teeth per Quad

$71

$140

D4342

Periodontal Scaling/Root Planing - One to Three Teeth per Quad

$36

$70

D4355

Full Mouth Debridement for Comprehensive Evaluation

$67

$140

D4910

Periodontal Maintenance Procedures

$45

$67

Prosthetics-Removable

D5110

Complete Denture � Upper

$525

NB

D5120

Complete Denture � Lower

$525

NB

D5130

Immediate Denture � Upper

$525

NB

D5140

Immediate Denture � Lower

$525

NB

D5211

Upper Partial Denture-Resin Base

$470

NB

D5212

Lower Partial Denture-Resin Base

$470

NB

D5213

Upper Partial Denture- Cast Metal

$567

NB

D5214

Lower Partial Denture- Cast Metal

$567

NB

D5281

Removable Unilateral Partial Denture � One Piece Cast Metal

$269

NB

D5410

Adjust Complete Denture � Upper

$73

NB

D5411

Adjust Complete Denture � Lower

$73

NB

D5421

Adjust Partial Denture Upper

$73

NB

D5422

Adjust Partial Denture Lower

$73

NB

D5510

Repair Broken Complete Denture Base

$56

NB

D5520

Replace Missing/Broken Teeth-Complete Denture-Each Tooth

$45

NB

D5610

Partial Denture-Repair Resin Base

$56

NB

D5620

Partial Denture-Repair Cast Framework

$62

NB

D5630

Partial Denture-Repair or Replace Broken Clasp

$50

NB

D5640

Partial Denture-Replace Broken Teeth-per Tooth

$50

NB

D5650

Add Tooth to Existing Partial Denture

$73

NB

D5660

Add Clasp to Existing Partial Denture

$101

NB

D5670

Replace all Teeth and Acrylic on Cast Metal - Upper

$282

NB

D5671

Replace all Teeth and Acrylic on Cast Metal - Lower

$282

NB

D5710

Rebase Compete Denture Upper

$196

NB

D5711

Rebase Compete Denture Lower

$196

NB

D5720

Rebase Partial Denture Upper

$196

NB

D5721

Rebase Partial Denture Lower

$196

NB

D5730

Reline Compete Denture - Upper (Chairside)

$134

NB

D5731

Reline Compete Denture - Lower (Chairside)

$134

NB

D5740

Reline Partial Denture - Upper (Chairside)

$134

NB

D5741

Reline Partial Denture Lower (Chairside)

$134

NB

D5750

Reline Compete Denture - Upper (Lab)

$148

NB

D5751

Reline Compete Denture - Lower (Lab)

$148

NB

D5760

Reline Partial Denture - Upper (Lab)

$148

NB

D5761

Reline Partial Denture Lower (Lab)

$148

NB

D5820

Interim Partial Denture (Upper)

$207

NB

D5821

Interim Partial Denture (Lower)

$207

NB

D5850

Tissue Conditioning Upper

$50

NB

D5851

Tissue Conditioning Lower

$56

NB

Prosthetics-Fixed

D6210

Pontic-Cast High Noble Metal

$525

NB

D6211

Pontic-Cast Predominately Base Metal

$484

NB

D6212

Pontic-Cast Noble Metal

$459

NB

D6240

Pontic-Porcelain Fused to High Noble Metal

$493

NB

D6241

Pontic-Porcelain Fused to Predominately Base Metal

$431

NB

D6242

Pontic-Porcelain Fused to Noble Metal

$465

NB

D6545

Retainer-Cast Metal Resin Bonded Bridge

$224

NB

D6602

Inlay- Cast High Noble Metal, Two Surfaces

$388

NB

D6603

Inlay- Cast High Noble Metal, Three or More Surfaces

$431

NB

D6604

Inlay- Cast Predominately Base Metal, Two Surfaces

$388

NB

D6605

Inlay- Cast Predominately Base Metal, Three or More Surfaces

$372

NB

D6606

Inlay- Cast Noble Metal, Two Surfaces

$353

NB

D6607

Inlay- Cast Noble Metal, Three or More Surfaces

$392

NB

D6610

Onlay- Cast High Noble Metal, Two Surfaces

$461

NB

D6611

Onlay- Cast High Noble Metal, Three or More Surfaces

$504

NB

D6612

Onlay- Cast Predominately Base Metal, Two Surfaces

$397

NB

D6613

Onlay- Cast Predominately Base Metal, Three or More Surfaces

$440

NB

D6614

Onlay- Cast Noble Metal, Two Surfaces

$418

NB

D6615

Onlay- Cast Noble Metal, Three or More Surfaces

$461

NB

D6750

Crown-Porcelain Fused to High Noble Metal

$504

NB

D6751

Crown-Porcelain Fused to Predominately Base Metal

$420

NB

D6752

Crown-Porcelain Fused to Nobel Metal

$454

NB

D6780

Crown-3/4 Cast High Noble Metal

$476

NB

D6781

Crown-3/4 Cast Predominately Base Metal

$476

NB

D6782

Crown-3/4 Cast Noble Metal

$476

NB

D6790

Crown-Full Cast High Noble Metal

$537

NB

D6791

Crown-Full Cast Predominately Base Metal

$478

NB

D6792

Crown-Full Cast Noble Metal

$465

NB

D6930

Recement Bridge

$39

NB

Oral Surgery

D7111

Coronal Remnants � Deciduous Tooth

$24

$27

D7140

Extraction, Eruted Tooth or Exposed Root

$47

$53

D7210

Surgical Removal of Erupted Tooth

$59

$106

D7220

Remove Impacted Tooth-Soft Tissue

$52

$129

D7230

Remove Impacted Tooth-Part Bony

$67

$162

D7240

Remove Impacted Tooth � Complete Bony

$111

$190

D7250

Surgical Remove Residual Tooth Roots-Cutting Procedure

$59

$106

D7260

Oroantral Fistula Closure

$170

$213

D7261

Primary Closure of a Sinus Perforation

$170

$213

D7270

Tooth Reimplantation and/or Stabilization of Accidentally Evulsed or Displaced Tooth

$104

$241

D7280

Surgical Access of Unerupted Tooth-Ortho

$125

$207

D7281

Surgical Exposure of Impacted/Unerupted Tooth-Aid Eruption

$88

$168

D7282

Mobilization of Erupted or Malpositioned Tooth

$88

$168

D7285

Biopsy of Oral Tissue-Hard (Bone, Tooth)

$74

$129

D7286

Biopsy of Oral Tissue-Soft (All Other) )

$74

$112

D7287

Cytology Sample Collection

$37

$56

D7291

Transseptal Fiberotomy/Supra Crestal Fiberotomy, by Report

$34

$34

D7310

Alveoloplasty in Conjunction w/Extraction-per Quad

$59

$118

D7320

Alveoloplasty w/o Extraction-per Quad

$74

$134

D7410

Excision of Benign Lesion up to 1.25cm

$111

$168

D7411

Excision of Benign Lesion 1.25cm or Greater

$140

$281

D7412

Excision of Benign Lesion, Complicated

$155

$309

D7450

Remove Benign Odontogenic Cyst/Tumor up to 1.25cm

$105

$170

D7451

Remove Benign Odontogenic Cyst/Tumor 1.25cm or Greater

$140

$281

D7460

Remove Non-Odontogenic Cyst/Tumor up to 1.25cm

$111

$179

D7461

Remove Non-Odontogenic Cyst/Tumor 1.25cm or Greater

$148

$297

D7471

Remove Lateral Exostosis-per Site

$193

$280

D7472

Removal of Torus Palatinus

$193

$280

D7473

Removal of Torus Mandibuaris

$193

$280

D7485

Surgical Reduction of Osseous Tuberosity

$193

$280

D7510

Incision & Drainage of Abscess-Intraoral Soft Tissue

$59

$78

D7520

Incision & Drainage of Abscess-Extraoral Soft-Tissue

$59

$78

D7530

Remove Foreign Body from Mucosa, Skin, or Subcutaneous Alveolar Tissue

$120

$179

D7550

Partial Ostectomy/Sequestrectomy - Removal of Non-Vital Bone

$162

$162

D7910

Suture of Recent Small Wounds up to 5cm

$39

$39

D7911

Complicated Suture up to 5cm

$78

$78

D7960

Frenulectomy (Frenectomy/Frenotomy)-Separate Procedure

$91

$196

D7970

Excision of Hyperplastic Tissue-per Arch

$56

$148

D7971

Excision of Periocoronal Gingiva

$67

$95

D7972

Surgical Reduction of Fibrous Tuberosity

$72

$148

Orthodontics

D8070

Comprehensive Ortho Treatment-Transitional Dentition

NB

$2375

D8080

Comprehensive Ortho Treatment-Adolescent Dentition

NB

$2375

D8090

Comprehensive Ortho Treatment-Adult Dentition

NB

$2675

Additional Procedures

D9110

Palliative-Emergency Treatment of Dental Pain, Minor Procedure

$28

NB

D9210

Local Anesthesia w/no Other Procedures

$0

$0

D9220

Deep Sedation/General Anesthesia-1^st 30 Minutes

$74

$185

D9221

Deep Sedation/General Anesthesia-Each Additional 15 Minutes

$37

$123

D9230

Analgesia Anxiolysis, Inhalation of Nitrous Oxide

$17

$22

D9241

IV Conscious Sedation/Analgesia � 1^st 30 Minutes

$111

$179

D9242

IV Conscious Sedation/Analgesia � Each Additional 15 Minutes

$0

$0

D9310

Consultation (diagnostic service by other than treating provider)

$45

$49

D9440

Office Visit After Regularly Scheduled Hours

$25

$25

D9910

Application of Desensitizing Medication

$28

$28

D9940

Occlusal Guards by Report

$162

$269

D9951

Occlusal Adjustment � Limited

$37

$57

D9952

Occlusal Adjustment Complete

$148

$244

D9999

Missed Appointment Fee, per each � hour

$15

$17

Not covered:

� Services of dentists or other practitioners of healing arts not associated with Kaiser Permanente and DBP except upon referral arranged by a Participating Dental Provider and authorized by us, or when required in a covered emergency. Such excluded services mean any kind of dental care and anything prescribed in connection therewith.

� Hospitalization for any dental procedure, except as may otherwise be covered by the Plan

� Any cosmetic, beautifying, or elective procedure

� Any procedure not performed in a dental office setting

� Experimental procedures, implantations, or pharmacological regimens

� Services for injuries or conditions which are covered under Workers� Compensation or Employer�s Liability laws; services which are provided without cost to the Member by any municipality, county, or other political subdivision. This exclusion does not apply to any services that are covered by Medicaid.

� Replacement of denture, bridgework, and/or dental appliances previously supplied under this benefit, due to loss or theft, or for any reason within sixty (60) months of initial insertion

� Services which, in the opinion of the attending Participating Dental Provider, are not necessary for the member�s dental health

� Dental services pertaining, or related, to the Temporomandibular Joint (TMJ), except when those services are included on the attached dental fee schedule and are performed by the member�s Participating Dental Provider in that provider�s office

� Charges for failure to keep a scheduled dental appointment. The charges are listed in the attached dental fee schedule, and are charged by the general dentist and/or specialist, for each missed � hour appointment without twenty-four (24) hours notice.

� Services of Pedodontists and/or Prosthodontists

� Charges for second opinions, unless previously authorized by the Plan

� Not covered (continued)

� Occlusal guards are excluded for any purpose other than habitual grinding

� Procedures requiring fixed prosthodontic restoration, which are necessary for complete oral rehabilitation or reconstruction

� Procedures relating to the change and maintenance of vertical dimension or the restoration of occlusion

� Dental lab fees for excisions and biopsies. Procedures requiring lab fees are shown with asterisks ("**").

� Drugs obtainable with or without a prescription (see your prescription drug benefit as described in Section 5(f) for coverage of dental prescriptions)

� The setting of fractures or dislocations (see your medical and surgical benefits as described in Sections 5(a) and 5(b) for coverage of these services)

� Treatment of malignancies, cysts or neoplasm or congenital malformations. (see your medical and surgical benefits as described in Sections 5(a) and 5(b) for coverage of these services)

� Dental expenses incurred in connection with any dental procedure started prior to member�s eligibility with Dental Plan. Examples: orthodontic work in progress, teeth prepared for crowns, root canal therapy in progress.

� Clinical situations that can be effectively treated by a less costly, clinically acceptable alternative procedure will be assigned a benefit based on the less costly procedure, in accordance with the "Standards of Care" established by DBP for its participating providers.

� Placement of dental implants, implant-supported abutments and prostheses.

� Billing for incision and drainage (ADA Code D7510) is excluded if the involved abscessed tooth is removed on the same date of service.

� Placement of fixed bridgework solely for the purpose of achieving periodontal stability.

� Procedures not shown on the dental service and fees listing

Medical, hospital, and drug benefits

In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form. Facilities will file on the UB-92 form. For claims questions and assistance, call us at 301/468-6000 inside the Washington, DC metropolitan area or at 800/777-7902 outside the Washington, DC metropolitan area. Our TTY telephone number is 301/879-6380.

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

� Covered member�s name and ID number;

� Name and address of the physician or facility that provided the service or supply;

� Dates you received the services or supplies;

� Diagnosis;

� Type of each service or supply;

� The charge for each service or supply;

� A copy of the explanation of benefits, payments, or denial from any primary payer � such as the Medicare Summary Notice (MSN); and

� Receipts, if you paid for your services.

Submit your claims to:

Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.

Attention: Claims Department

P.O. Box 6233

Rockville, Maryland 20849-6233

Deadline for filing your claim

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

When we need more information

Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond.

1

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

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

b) Send your request to us at: Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., 2101 East Jefferson Street, Rockville, MD 20852, Attn: Member Services Appeals Unit; and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms.

2

We have 30 days from the date we receive your request to:

a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or

b) Write to you and maintain our denial - go to step 4; or

c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of our request�go to step 3.

3

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

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

We will write to you with our decision.

4

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

You must write to OPM within:

� 90 days after the date of our letter upholding our initial decision; or

� 120 days after you first wrote to us - if we did not answer that request in some way within 30 days; or

� 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Insurance Services Programs, Health Insurance Group 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:

� A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

� Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;

� Copies of all letters you sent to us about the claim;

� Copies of all letters we sent to you about the claim; and

� Your daytime phone number and the best time to call.

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

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.

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

5

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

If you do not agree with OPM�s decision, your only recourse is to sue. If you decide to 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, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.

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

You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

When you have other health coverage

You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health care expenses without regard to fault. This is called �double coverage�.

When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners� guidelines.

When we are the primary payer, we will pay the benefits described in this brochure.

When we are the secondary payer, we will determine our allowance. After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not pay more than our allowance. If we are the secondary payer, and you receive your services from Plan providers, we may bill the primary carrier.

What is Medicare?

Medicare is a Health Insurance Program for:

� People 65 years of age or older.

� Some people with disabilities under 65 years of age.

� People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:

� Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered employment, you should be able to qualify for premium-free Part A insurance. (Someone who was a Federal employee on January 1, 1983 or since automatically qualifies.) Otherwise, if you are age 65 or older, you may be able to buy it. Contact 1-800-MEDICARE for more information.

� Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social Security check or your retirement check.

If you are eligible for Medicare, you may have choices in how to get your health care. The information in the next few pages shows how we coordinate benefits with Medicare, depending on whether you are in the Original Medicare Plan or a private Medicare managed care plan.

� Should I enroll in Medicare?

The decision to enroll in Medicare is yours. We encourage you to apply for Medicare benefits 3 months before you turn age 65. It�s easy. Just call the Social Security Administration toll-free number 1-800-772-1213 to set up an appointment to apply. If you do not apply for one or both Parts of Medicare, you can still be covered under the FEHB Program.

If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal employees and annuitants are entitled to Medicare Part A at age 65 without cost. When you don�t have to pay premiums for Medicare Part A, it makes good sense to obtain the coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which can help keep FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage. The Social Security Administration can provide you with premium and benefit information. Review the information and decide if it makes sense for you to buy the Medicare Part B coverage.

� If you do enroll in Medicare Part B

If you enroll in Medicare Part B, we require you to assign your Medicare Part B benefits to the Plan for its services. Assigning your benefits means you give the Plan written permission to bill Medicare on your behalf for covered service you receive in network. You do not lose any benefits or entitlements as a result of assigning your Medicare Part B benefits.

� The Original Medicare Plan (Part A or Part B)

The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits and is the way most people get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay your share. Some things are not covered under Original Medicare, such as most prescription drugs (but coverage through private prescription drug plans will be available starting in 2006).

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

Claims process when you have the Original Medicare Plan � You probably will never have to file a claim form when you have both our Plan and the Original Medicare Plan. We will not waive any of our copayments, coinsurance, or deductibles unless you enroll in Kaiser Permanente Medicare Plus.

� When we are the primary payer, we process the claim first.

� When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, please call 301/468-6000 or 800/777-7902 or TTY 301/879-6380.

Primary Payer Chart

A. When you - or your covered spouse - are age 65 or over and have Medicare and you�

1) Have FEHB coverage on your own as an active employee or through your spouse who is an active employee

�

2) Have FEHB coverage on your own as an annuitant or through your spouse who is an annuitant

�

3) Are a reemployed annuitant with the Federal government and your position is excluded from the FEHB (your employing office will know if this is the case) and you are not covered under FEHB through your spouse under #1 above

�

4) Are a reemployed annuitant with the Federal government and your position is not excluded from the FEHB (your employing office will know if this is the case) and �

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

�

You have FEHB coverage through your spouse who is an annuitant

�

5) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and you are not covered under FEHB through your spouse under #1 above

�

6) Are enrolled in Part B only, regardless of your employment status

�for Part B services

� for other services

7) Are a former Federal employee receiving Workers� Compensation and the Office of Workers� Compensation Programs has determined that you are unable to return to duty

�*

B. When you or a covered family member�

1) Have Medicare solely based on end stage renal disease (ESRD) and�

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

�

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

�

2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and�

� This Plan was the primary payer before eligibility due to ESRD

�for 30-month coordination period

� Medicare was the primary payer before eligibility due to ESRD

�

C. When either you or a covered family member are eligible for Medicare solely due to disability and you�

1) Have FEHB coverage on your own as an active employee or through a family member who is an active employee

�

2) Have FEHB coverage on your own as an annuitant or through a family member who is an annuitant

�

D. When you are covered under the FEHB Spouse Equity provision as a former spouse

�

� Medicare managed care plan

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare managed care plan. This is a health care choice (like HMOs) in some areas of the country. In most Medicare managed care plans, you can only go to doctors, specialists, or hospitals that are part of the plan. Medicare managed care plans provide all the benefits that Original Medicare covers. Some cover extras, like prescription drugs. To learn more about enrolling in a Medicare managed care plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www.medicare.gov.

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

This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan, known as Kaiser Permanente Medicare Plus (an 1876 Medicare Cost plan), and remain enrolled in our FEHB plan. To be eligible for Kaiser Permanente Medicare Plus, you must have Medicare Parts A and B or Medicare Part B only.

You may enroll in Medicare Plus at no additional monthly premium cost to you, if you remain enrolled in our FEHB Plan. Our Medicare Plus plan offers you enhanced benefits and additional flexibility in how you receive your medical care. If you enroll in Medicare Plus, you still receive all of your in-network care through Kaiser Permanente contracted Plan Providers, and, when you use Plan Providers, some of your copayments and coinsurance will be lowered.

You can always choose to go to a doctor outside our network. We may not pay for the services you receive outside of our network. If you go to a provider outside of Kaiser Permanente Medicare Plus who accepts Medicare patients, your coverage would be the same as Original Medicare. Original Medicare deductibles and coinsurance apply and are your responsibility to pay.

Under Kaiser Permanente Medicare Plus High Option, when you receive your medical care through Plan Providers, the following copayments and coinsurance have been lowered:

� Physician Office Visits (preventive and non-preventive): $5

� Dialysis: $0