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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Natural children, adopted children, and stepchildren

Coverage: Natural children, adopted children and stepchildren are covered until their 26th birthday.

Foster children

Coverage: Foster children are eligible for coverage until their 26th birthday if you provide documentation of your regular and substantial support of the child and sign a certification stating that your foster child meets all the requirements. Contact your human resources office or retirement system for additional information.

Children incapable of self-support

Coverage: Children who are incapable of self-support because of a mental or physical disability that began before age 26 are eligible to continue coverage. Contact your human resources office or retirement system for additional information.

Married children

Coverage: Married children (but NOT their spouse or their own children) are covered until their 26th birthday.

Children with or eligible for employer-provided health insurance

Coverage: Children who are eligible for or have their own employer-provided health insurance are covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000. This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the FEHB Program, if you are an employee subject to a court or administrative order requiring you to provide health benefits for your child(ren).

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

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

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

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

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2023 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2022 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

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

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

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

Any person covered under the 31-day extension of coverage who is confined in a hospital or other institution for care or treatment on the 31st day of the temporary extension is entitled to continuation of the benefits of the Plan during the continuance of the confinement but not beyond the 60th day after the end of the 31-day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage (TCC), or a conversion policy (a non-FEHB individual policy).

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

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

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

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

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

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

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

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 877-574-3337 (TTY: 711) or visit our website at www.kp.org/feds.

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call our Member Services Department at 877-KP4-FEDS (877-574-3337) (TTY: 711) or write to us at: Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., Attention: Member Services Department, 2101 East Jefferson Street, Rockville, Maryland, 20852. After registering on our website at www.kp.org/feds, you may also request replacement cards electronically.

You get care from "Plan providers" and "Plan facilities." You will only pay cost-sharing as defined in Section 10. Definitions of Terms We Use in This Brochure.

FEHB Carriers must have clauses in their plan provider agreements. These clauses provide that, for a service that is a covered benefit in the plan brochure or for services determined not medically necessary, the plan provider agrees to hold the covered individual harmless (and may not bill) for the difference between the billed charge and the in network contracted amount. If a plan provider bills you for covered services over your normal cost share (deductible, copay, co-insurance), contact your Carrier to enforce the terms of its provider contract.

Plan providers are physicians and other healthcare professionals in the Mid-Atlantic Permanente Medical Group, PC that we contract with to provide or arrange for covered services to our members. Medical care is provided through physicians, nurse practitioners, physician assistants, and other skilled medical personnel. Consultation and treatment in most major specialties will be provided through the Plan provider.

We list certain Plan providers in the provider directory, which we update periodically. Directories are available at the time of enrollment or upon request by calling our Member Services Department at 877-KP4-FEDS (877-574-3337) (TTY: 711). The list is also on our website at www.kp.org/feds.

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

Kaiser Permanente primary care physicians provide care coordination for complex conditions, for assistance please contact your provider or  Member Services Department at 877-KP4-FEDS (877-574-3337) (TTY: 711).

Plan facilities are hospitals, medical offices, and other facilities in our service area with which we contract and to which the Plan provider refers members to receive covered services. Kaiser Permanente offers comprehensive healthcare at Plan facilities conveniently located throughout our service area. 

We list Plan facilities in our physician directory, with their locations and phone numbers. Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling our Member Services Department at 877-KP4-FEDS (877-574-3337) (TTY: 711). The list is also on our website at www.kp.org/feds.

You must receive your health services at Plan facilities, except if you have an emergency, authorized referral, or out-of-area urgent care. If you are visiting another Kaiser Permanente or allied plan service area, you may receive healthcare services at those Kaiser Permanente facilities. See Section 5(h). Wellness and Other Special Features, for more details. Under the circumstances specified in this brochure you may receive follow-up or continuing care while you travel anywhere.

You and each covered family member should choose a primary care physician from a list of the Plan providers that practice at Kaiser Permanente medical facilities. This decision is important since your primary care physician provides or arranges for most of your healthcare.

We encourage you to choose a primary care physician when you enroll. Your primary care physician will provide most of your healthcare. You may select a primary care physician from any of our available Plan providers who practice as generalists in these specialties: internal medicine, pediatrics, or family practice. If you do not select a primary care physician, one may be selected for you. Parents may choose a pediatrician as the Plan physician for their child. In the event you require services of a specialist, please refer to the section below.

To choose or change your primary care physician, you can either select one from our Provider Directory, from our website, www.kp.org/feds, or you can call our Federal Member Services Department at 877-KP4-FEDS (877-574-3337) (TTY: 711).

Please notify us of the primary care physician you choose. If you need help choosing a primary care physician, call us. You may change your primary care physician at any time. You are free to see other Plan primary care physicians if your primary care physician is not available, and to receive care at Kaiser Permanente medical facilities other than the one where your primary care physician practices.

Specialty care is care you receive from providers other than a primary care physician. When your primary care physician believes you may need specialty care, they will request authorization from us. If specialty care is necessary, we will authorize a referral to a particular specialist for an initial consultation and/or for a certain number of visits. If we authorize a referral, you may seek that care from the specialist to whom you were referred. Unless we have authorized additional visits without the need to obtain another referral you must return to your primary care physician after the consultation. Do not go to a specialist for return visits unless we have given you an authorized referral for visits beyond the initial consultation. You may see the following Plan providers without first obtaining authorization: obstetrical and gynecologists, optometrists, or mental health and substance use. You may obtain mental health and substance use services from the Plan's mental health or substance use disorder treatment providers 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 in consultation with us and your attending specialist may develop a treatment plan that allows you to see the specialist for visits without additional referrals. Your primary care physician must contact us and use our criteria when creating your treatment plan (the physician will have to get authorization beforehand).
• If you are seeing a specialist when you enroll in our Plan, in almost all cases you will be required to switch to a Plan specialist. Generally, we will not pay for you to see a specialist who is not a member of the Plan unless you have an authorized referral.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will request permission from us for you to see another specialist. Under certain circumstances for certain conditions, you may receive authorized services from your current specialist until we can make arrangements for you to see a Plan specialist.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for a reason other than cause;
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
  • reduce our service area and you enroll in another FEHB plan

You may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.

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

If you require emergency care, please go to the nearest hospital. After your condition has stabilized, we may choose to move you to a hospital where Plan physicians are on duty 24 hours a day, 7 days a week.

For non-emergency admissions, your care will be coordinated through the Plan. This includes admission to a skilled nursing or other facility. The Plan determines the most appropriate facility for care for any admission to a non-hospital facility.

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Member Services Department immediately at 877-KP4-FEDS (877-574-3337) (TTY: 711). If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 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 cases, the hospitalized family member's benefits under the new plan begin on the effective date of enrollment.

Your primary care physician arranges most referrals to specialists. For certain services your physician must obtain approval from us. Before we approve a referral, we may consider if the service or item is medically necessary and meets other coverage requirements. We call this review and approval process “prior authorization” although we often use the term “referral” for this process as well. Once the referral is approved, we will notify you that we have authorized your referral.

Your physician must obtain authorization for all covered items or services, except:

• Routine primary care services
• Routine obstetrical and gynecological services (excluding infertility diagnosis and treatment; treatment and management of gynecological malignancies; urogynecology; prenatal diagnostic tests performed outside of the doctor’s office; and other specialized gynecological services)
• Care received in an emergency room, designated Kaiser Permanente urgent care centers, or designated Kaiser Permanente minor injury clinics
• Emergency ambulance transport
• Certain prescription medications as identified on our formulary 
• Self-referrals to designated Plan Behavioral Health (mental health and substance use disorder care) providers
• Optometry services

To confirm if a referral has been approved for a service or item that requires prior authorization, please call our Member Services Department at 877-KP4-FEDS (877-574-3337) (TTY: 711). 

We must provide or arrange for your mental health and substance use disorder care. Call our Behavioral Health Access Unit at 866-530-8778 to make arrangements.

Finally, except for services from Plan primary care providers, all services performed by non-Plan providers and non-Kaiser Permanente facilities must be authorized in advance.

You should call our Member Services Department if you have not been notified of the outcome of our review. If we do not authorize a request, you have the right to ask us in writing to reconsider our initial decision (see Section 8. The Disputed Claims Process).

Prior authorization determinations are made based on the information available at the time the service or item is requested. We will not cover a service or item unless you are a Plan member on the date you receive the service or item. Prior authorization is a certification of medical necessity. In order for the Plan to pay for an authorized service, the service must be a covered service.

For non-urgent care claims, we will tell the physician and/or hospital the number of approved inpatient days, or the care that we approve for other services that must have prior authorization. We will make our decision within 15 days of receipt of the pre-service claim. If matters beyond our control require an extension of time, we may take up to an additional 15 days for review and we will notify you of the need for an extension of time before the end of the original 15-day period. Our notice will include the circumstances underlying the request for the extension and the date when a decision is expected.

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

If you have an urgent care claim (i.e., when waiting for the regular time limit for your medical care or treatment could seriously jeopardize your life, health, or ability to regain maximum function, or in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without this care or treatment), we will expedite our review and notify you of our decision within 72 hours. If you request that we review your claim as an urgent care claim, we will review the documentation you provide and decide whether or not it is an urgent care claim by applying the judgment of a prudent layperson that possesses an average knowledge of health and medicine.

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 877-KP4-FEDS (877-574-3337) (TTY: 711).  You may also call OPM’s FEHB 3 at 202-606-0755 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 877-KP4-FEDS (877-574-3337) (TTY: 711). If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

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

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

Emergency services do not require authorization. However, if you are admitted to a hospital or other facility, you or your family member must notify us within 48 hours, or as soon as reasonably possible, or your claims may be denied.

You must also obtain authorization from us for post-stabilization care you receive from non-Plan providers.

See Section 5(d). Emergency Services/Accidents for more information.

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

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

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

If you have a pre-service claim and you do not agree with our prior approval decision, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call our Member Services Department at 877-KP4-FEDS (877-574-3337) (TTTY:711).

If you have already received the service, supply, or treatment, then you have a post-service claim and must follow the entire disputed claims process detailed in Section 8.

Within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

In the case of a pre-service claim and subject to a request for additional information, we have 30 days from the date we receive your written request for reconsideration to do one of the following:

1. Precertify your hospital stay or, if applicable, arrange for the healthcare provider to give you the care or grant your request for prior approval for a service, drug, or supply.
2. Ask you or your provider for more information.       
   • You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.         
   • If we do not receive the information within 60 days, we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision.
3. Write to you and maintain our denial.

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request. We will expedite the review process, which allows oral or written request for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

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

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

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive certain services. The amount of copayment will depend upon whether you are enrolled in the High Option, Standard Option or Prosper, the type of provider, and the service or supply that you receive.

You pay a primary care provider copayment when you visit any primary care provider as described in Section 3. How You Get Care. You pay a specialist copayment when you receive care from a specialist as described in Section 3. 

For example, for diagnostic and treatment services as described in Section 5(a):

• Under the High Option, you pay a $10 copayment when you receive diagnostic and treatment services from a primary care provider and a $20 copayment when you receive these services from a specialty care provider.
• Under the Standard Option, you pay a $20 copayment when you receive diagnostic and treatment services from a primary care provider and a $30 copayment when you receive these services from a specialty care provider.
• Under Prosper, you pay a $30 copayment when you receive diagnostic and treatment services from a primary care provider and a $40 copayment when you receive these services from a specialty care provider.

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

The High and Standard Options have no deductible. The calendar year deductible is $100 per person for Prosper. Under a Self Plus One or Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $200.

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

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

Coinsurance is the percentage of our allowance that you must pay for your care. Example: In our Plan, you pay 50% of our allowance for infertility services, ovulation stimulants, and oxygen and equipment for home use.

After your cost-sharing totals $2,250 per person up to $4,500 per family enrollment (High Option) or $3,500 per person up to $7,000 per family enrollment (Standard Option) or $4,000 per person up to $8,000 per family enrollment (Prosper) in any calendar year, you do not have to pay any more for certain covered services. This includes any services required by group health plans to count toward the catastrophic protection out-of-pocket maximum by federal healthcare reform legislation (the Affordable Care Act and implementing regulations).

Example: Your plan has a $2,250 per person up to $4,500 per family maximum out-of-pocket limit. If you or one of your covered family members has out-of-pocket qualified medical expenses of $2,250 in a calendar year, any cost-sharing for qualified medical expenses for that individual will be covered fully by your health plan for the remainder of the calendar year. With a family enrollment, the out-of-pocket maximum will be satisfied once two or more family members have out-of-pocket qualified medical expenses of $4,500 in a calendar year, and any cost–sharing for qualified medical expenses for all enrolled family members will be covered fully by your health plan for the reminder of the calendar year.

However, cost-sharing for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay cost-sharing for these services:

• Dental services, except accidental injury dental benefit services
• Eyeglass lenses and frames and contact lenses for adults
• Routine eye exams for members age 19 and older
• Travel benefit

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

If you changed to this Plan during Open Season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your prior plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your prior plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your prior plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your prior option to the catastrophic protection limit of your new option.

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

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a non-Plan healthcare provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at plan facilities, but you receive some care from non-Plan providers.

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

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

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.kp.org/feds or contact the health plan at 877-KP4-FEDS (877-574-3337) (TTY:711)

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

Professional services of physicians and other healthcare professionals

• In physician’s office
• Office medical consultations
• Second surgical opinion
• Advance care planning

$30 per primary care office visit (nothing from infancy through age 4)

$40 per specialty care office visit

Professional services of physicians and other healthcare professionals

• During a hospital stay
• In a skilled nursing facility
• In a rehabilitation facility
• At home

Nothing

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

• Interactive video visits
• Phone visits
• Email

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

Nothing

Nothing

Nothing

Tests, such as:

• Blood test
• Urinalysis
• Non-routine Pap test
• Pathology
• Non-routine mammogram
• Ultrasound
• Electrocardiogram and EEG

Note: You pay the diagnostic and treatment cost-sharing for diagnostic tests when received as a part of a non-invasive vascular diagnostic study or echocardiogram. See Section 5(a), Diagnostic and treatment services.

Nothing

• X-ray

Nothing

Nothing

$40 per procedure

• CT/CAT scan
• MRI
• Nuclear medicine
• PET scan
• Sleep lab
• Interventional radiology procedures

Note: Interventional radiology uses guided imagery to visualize, treat, or diagnose organ or circulatory function.

$100 per procedure after the deductible

Routine physical exam, including for school and camp

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

Including:

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

Nothing

• Routine mammogram - covered

Nothing

Nothing

Nothing

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

Nothing

Nothing

Nothing

$10 per primary care office visit 

$20 per primary care office visit

$30 per primary care office visit

$40 per specialty care office visit

Notes:

• You may pay cost-sharing for any procedure, injection, diagnostic service, laboratory or X-ray service that is provided in conjunction with a routine physical exam and is not included in the preventive recommended listing of services.
• You should consult with your physician to determine what is appropriate for you.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered: 

• Physical exams and immunizations required for:
  • Obtaining or continuing employment
  • Insurance or licensing
  • Participating in employee programs
  • Court ordered parole or probation

All charges

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

Nothing

Travel consultations, immunizations, and vaccines

$10 per primary care office visit (nothing from infancy through age 4)

$20 per specialty care office visit

$20 per primary care office visit (nothing from infancy through age 17)

$30 per specialty care office visit

$30 per primary care office visit (nothing from infancy through age 4)

$40 per specialty care office visit

Notes: 

• You may pay cost-sharing for any procedure, injection, diagnostic service, laboratory or X-ray service that is provided in conjunction with a routine physical exam and is not included in the recommended listing of services.
• Hearing Screenings are provided by a primary care physician as part of a well-child care visit. For other hearing exams or tests, see Section 5(a), Diagnostic and treatment services or Section 5(a), Hearing services.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

• Physical exams required for:
  • Obtaining or continuing employment
  • Insurance or licensing
  • Participating in employee programs
  • Court ordered parole or probation
• All other hearing testing, except as may be covered in Section 5(a), Diagnostic and treatment services or Section 5(a), Hearing services

All charges

Routine maternity (obstetrical) care, such as:

• Prenatal care visits
• Screening for gestational diabetes
• Postpartum care

Nothing

Nothing

• Delivery

Nothing for inpatient professional delivery services

Nothing for inpatient professional delivery services

Nothing for inpatient professional delivery services

• Breastfeeding support, supplies, and counseling for each birth

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

Nothing

Nothing

Nothing

 Notes:

• Routine maternity care is covered after confirmation of pregnancy.
• Your Plan provider does not have to obtain prior approval from us for your vaginal delivery. See Section 3, You need prior Plan approval for certain services, for prior approval guidelines.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment.
• When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• You pay cost-sharing for other services, including:
  • Diagnostic and treatment services for illness or injury received during a non-routine maternity care as described in this section
  • Lab, X-ray and other diagnostic tests (including ultrasounds), Durable medical equipment as described in this section
  • Surgical services (including circumcision of an infant if performed after the mother’s discharge from the hospital) as described in Section 5(b). Outpatient hospital or ambulatory surgical center
  • Hospitalization (including room and board and delivery) as described in Section 5(c). Inpatient hospital

Applies to this benefit

Applies to this benefit

Applies to this benefit

A range of voluntary family planning services, limited to:

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

Note:

See Section 5(b), Surgical and Anesthesia Services for coverage of voluntary sterilization for males and females and section 5(f), Prescription Drug Benefits for oral contraceptives and devices such as diaphragms.

Nothing

• Genetic counseling

$10 per primary care office visit

$20 per specialty care office visit

$20 per primary care office visit

$30 per specialty care office visit

$30 per primary care office visit

$40 per specialty care office visit

Not covered:

• Reversal of voluntary surgical sterilization

All charges

Diagnosis and treatment of infertility, such as:

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

50% of our allowance

50% of our allowance

50% of our allowance after the deductible

Notes:

• See Section 5(f). Prescription Drug Benefits, for coverage of fertility drugs.
• Infertility is the inability of an individual to conceive or produce conception during a period of 1 year if the female is age 35 or younger, or during a period of 6 months if the individual is over the age of 35, or having a medical or other demonstrated condition that is recognized by a Plan Physician as a cause of infertility.
• Infertility services are covered for individuals over the age of 18 who meet medically necessary criteria and are authorized by the Plan. See Section 3, You need prior Plan approval for certain services, for more information.
• A Plan physician will determine the appropriate treatment and number of attempts for infertility treatment.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Standard fertility preservation for iatrogenic infertility

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

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

$20 per specialty care office visit

$30 per specialty care office visit

$40 per specialty care office visit

Not covered:

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

• Assisted reproductive technology (ART) procedures, including related services and supplies, such as
  • in vitro fertilization (IVF) and
  • embryo transfer, gamete intra- fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
• Any charges associated with donor eggs, donor sperm or donor embryos
• Any charges associated with cryopreservation, except for standard fertility preservation for iatrogenic infertility
• Any charges associated with thawing and storage of frozen sperm, eggs, and embryos
• Ovum transplants
• Infertility services when either member of the family has been voluntarily, surgically sterilized
• Services to reverse voluntary, surgically induced infertility
• Services related to surrogate arrangements

All charges

All charges

All charges

• Testing and treatment

$10 per primary care office visit (nothing from infancy through age 4)

$20 per specialty care office visit

$20 per primary care office visit (nothing from infancy through age 17)

$30 per specialty care office visit

$30 per primary care office visit (nothing from infancy through age 4)

$40 per specialty care office visit

• Injections

$20 per office visit

$30 per office visit

• Serum

Nothing

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

All charges

• Chemotherapy and radiation therapy

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

• Respiratory and inhalation therapy
• Cardiac rehabilitation following a qualifying event/condition is provided for up to 12 weeks or 36 sessions, whichever is less.
• Dialysis – hemodialysis performed in a doctor's office or Plan facility 
• Intravenous (IV)/Infusion Therapy – Home (IV) and antibiotic therapy
• Ultraviolet light treatments
• 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

 Note: Growth hormone requires our prior approval and is covered under the prescription drug benefit. See Section 3, You need prior Plan approval for certain services, and Section5(f), Prescription Drug Benefits.

$10 per primary care office visit (nothing from infancy through age 4)

$20 per specialty care office visit

$20 per primary care office visit (nothing from infancy through age 17)

$30 per primary care office visit (nothing from infancy through age 4)

$40 per specialty care office visit

• Peritoneal Dialysis
  • Training in a doctor’s office or Plan facility
  • Provided at home
• Multidisciplinary nephrology team visits

Nothing

• Applied Behavior Analysis (ABA) for children through the end of the month they turn age 19

Note: Applied Behavior Analysis treatment requires prior authorization. See Section 3. You need prior Plan approval for certain services, for more information.

$30 per visit

Not covered:

• Cognitive therapy
• Sleep therapy
• Thermography and related services

All charges

We cover up to 30 visits per condition per calendar year each for rehabilitative and habilitative physical therapy and occupational therapy, except we cover habilitative services with no visit limits for children until the end of the month they turn age 19.

Notes:

• Physical therapy must be provided by a qualified Plan therapist in consultation with a Plan  physician to attain or restore bodily function when you have a total or partial loss of bodily function due to illness or injury.
• Occupational therapy must be provided by a Plan therapist in consultation with a Plan physician  to assist you in attaining or 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.

$40 per specialty care office visit

Not covered:

• Long-term therapy
• Exercise programs
• Maintenance therapy
• Cognitive rehabilitative programs
• Vocational rehabilitative programs
• Therapies done primarily for education purposes
• Services provided by local, state, and federal government agencies, including schools

All charges

We cover up to 30 visits for rehabilitative and habilitative speech therapy per condition per calendar year, except we cover habilitative services with no visit limits for children until the end of the month they turn age 19.

$40 per specialty care office visit

Not covered:

• Therapies done primarily for educational purposes
• Therapy for tongue thrust in the absence of swallowing problems
• Training or therapy to improve articulation in the absence of injury, illness, or medical condition affecting articulation
• Voice therapy for occupation or performing arts
• Services provided by local, state, and federal government agencies including schools

All charges

• For treatment related to illness or injury, including evaluation and diagnostic hearing tests performed by an M.D., D.O., audiologists or other provider in a physician's office
• Otologic and audiological services needed as a result of the congenital defect known as cleft lip and/or cleft palate.

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

$10 per primary care office visit (nothing from infancy through age 21)

$20 per primary care office visit (nothing from infancy through age 21)

$30 per primary care office visit (nothing from infancy through age 21)

$40 per specialty care office visit

Hearing aids, for children through the end of the month they turn age 19, if the hearing aids are prescribed, fitted, and dispensed by a licensed audiologist.

Notes:

• A single hearing aid providing hearing to both ears (binaural hearing aid) is considered two hearing aids for purposes of this benefit.
• For coverage of audible prescription reading and speech generating devices, see Section 5(a), Durable medical equipment.

Nothing (limited to one hearing aid for each hearing impaired ear every 36 months)

Nothing (limited to one hearing aid for each hearing impaired ear every 36 months)

Nothing (limited to one hearing aid for each hearing impaired ear every 36 months)

Not covered:

• All other hearing testing, except as may be covered in Section 5(a), Diagnostic and treatment services, Section 5(a), Preventive care, children and Section 5(a), Hearing services
• Hearing aids, including testing and examinations for them, for all persons age 19 and over
• Replacement parts, batteries, repair of hearing aids, and replacement of lost or broken hearing aids

All charges

• Diagnosis and treatment of diseases of the eye

$20 per specialty care office visit

$40 per specialty care office visit

For members age 19 and older: Routine eye exam with a Plan optometrist to determine the need for vision correction and provide a prescription for eyeglasses

For children through the end of the month they turn age 19: One routine eye exam each year with a Plan optometrist to determine the need for vision correction and provide a prescription for eyeglasses

$30 per office visit

For children through the end of the month they turn age 19:

• At Plan optical shops:
  • One pair of eyeglasses (lenses and frames) or regular contact lenses (in lieu of lenses and frames) every calendar year; or
  • Up to 2 pairs of medically necessary contact lenses per eye (includes the evaluation, fitting and follow-up) every calendar year; and
  • Unlimited low vision aids from available supply

Notes:

• Coverage for eyeglasses and contact lenses are limited to a specified collection.
• Medically necessary contact lenses are to treat conditions including keratoconus, pathological myopia, aphakia, anisometropia, aniseikonia, aniridia, corneal disorders, post-traumatic disorders, irregular astigmatism or astigmatism

Nothing

Nothing

Nothing

For all members at Plan optical shops:

• Eyeglass frames and lenses
• Contact lenses package, 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. These services are provided only as a total package.

All charges in excess of $100 for eyeglasses or $50 for contact lenses package every 12 months

All charges in excess of $100 for eyeglasses or $50 for contact lenses package every 12 months

All charges in excess of $100 for eyeglasses or $50 for contact lenses package every 12 months

Not covered:

• Non-refractive eyeglasses
• Non-corrective contact lenses, including fitting and follow-up
• Eye surgery solely for the purpose of correcting refractive defects of the eye
• Vision therapy, including orthoptics, visual training and eye exercises

All charges

$10 per primary care office visit (nothing from infancy through age 4)

$20 per specialty care office visit

$20 per primary care office visit (nothing from infancy through age 17)

$30 per specialty care office visit

$30 per primary care office visit (nothing from infancy through age 4)

$40 per specialty care office visit

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges

External prosthetic and orthotic devices, such as:

• Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy (limited to a maximum of four surgical bras per contract year)  
• One hair prosthesis if your hair loss results from chemotherapy or radiation treatment for cancer
• Ostomy and urological supplies
• Replacements for legs, arms or eyes, and their components and repair
• Prosthetic sleeve or sock
• Monofocal intraocular implants following cataract removal

Nothing

Other external prosthetic devices, such as:

• Therapeutic shoes required for conditions associated with diabetes or other vascular disease
• Braces

20% of our allowance

50% of our allowance

50% of our allowance

Internal prosthetic devices, such as

• Artificial joints
• Pacemakers,
• Cochlear implants
• Osseointegrated external hearing devices 
• Surgically implanted breast implants following mastectomy

Note: See 5(b), Surgery benefits, for coverage of the surgery to insert the device and Section 5(c), Hospital benefits, for inpatient hospital benefits.

Nothing after the deductible

Notes:

• Orthopedic and prosthetic equipment or services must be prescribed by a Plan physician; obtained through sources designated by the Plan; medically necessary; and primarily and customarily used to serve a medical or therapeutic purpose in the treatment of an illness or injury.
• We cover only those standard items that are adequate to meet the medical needs of the member
• For coverage of hearing aids, see Section 5(a), Hearing services.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

• Orthopedic devices and corrective shoes, except as listed above
• Foot orthotics and podiatric use devices, such as arch supports, heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Comfort, convenience, or luxury equipment or features
• Prosthetic devices, equipment and supplies related to sexual dysfunction
• Dental prostheses, devices and appliances, except for appliances used for the treatment of temporomandibular joint (TMJ) disorder, or oral and maxillofacial surgery
• Repairs, adjustments, or replacements due to misuse, theft or loss

All charges

All charges

All charges

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

• Oxygen and oxygen dispensing equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Portable commodes
• Canes
• 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 Positive Airway Pressure device (BIPAP) equipment
• Asthma-related equipment (spacers, peak-flow meters, and nebulizers) for adults and children
• Home Prothrombin Time (PT)/International Normalized Ratio (INR) testing machines

50% of our allowance after the deductible

Note: Deductible waived for asthma-related equipment dispensed by the pharmacy.

• One breastfeeding pump per delivery, including any equipment and supplies that are required for pump functionality
• Additional breastfeeding supplies

Nothing for retail-grade pump and breastfeeding supplies

50% of our allowance for hospital-grade pump

Nothing for retail-grade pump and breastfeeding supplies

50% of our allowance for hospital-grade pump

Nothing for retail-grade pump and breastfeeding supplies

50% of our allowance for hospital-grade pump

• Home ultraviolet light treatment equipment

Nothing

Nothing

Nothing

We cover diabetic equipment and supplies when obtained from sources designated by the Plan including:

• Diabetic equipment
• Insulin pumps
• Disposable needles and syringes (up to 3 boxes)
• Blood glucose monitor
• Control solutions
• Lancets
• Test tape and acetone test tablets

20% of our allowance

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

Nothing

Nothing

Nothing

Notes:

• Durable medical equipment (DME) is equipment that is prescribed by a Plan physician; obtained through sources designated by the Plan; medically necessary; intended for repeated use; primarily and customarily used to serve a medical or therapeutic purpose in the treatment of an illness or injury; designed for prolonged use; and appropriate for use in the home.
• We cover only those standard items that are adequate to meet the medical needs of the member.
• We may require you to return the equipment to us, or pay us the fair market price of the equipment, when it is no longer prescribed.
• Your Plan physician must certify your medical need for oxygen and oxygen equipment.
• DME does not include coverage for prosthetic devices such as artificial eyes or legs or orthotic devices such as braces or therapeutic shoes.
• Refer to Section 5(a), Orthopedic and Prosthetic devices, for coverage of internal prosthetic devices and breast prostheses.
• Refer to Section 5(f). Prescription Drug Benefits, for information about insulin coverage.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

• Audible prescription reading devices 
• Speech generating devices
• Comfort, convenience, or luxury equipment or features
• Non-medical items such as sauna baths or elevators
• Exercise and hygiene equipment
• Electronic monitors of the heart, lungs, or other bodily functions, except for apnea monitors, bilirubin blankets, and blood glucose monitors
• Devices, equipment, and supplies related to the treatment of sexual dysfunction disorders
• Modifications to the home or vehicle
• Dental appliances, except for the treatment of cleft lip and/or cleft palate
• More than one piece of durable medical equipment serving essentially the same function
• Disposable supplies
• Replacement batteries for glucose meters 
• Oxygen tents  
• Repairs, adjustments, or replacements due to misuse, theft or loss

All charges

Amino acid-based elemental formula (drugs, supplies and supplements), regardless of delivery method, for the diagnosis and treatment of:

• Congenital errors of amino acid metabolism;
• Immunoglobulin E and non-Immunoglobulin E mediated allergies to multiple food proteins;
• Severe food protein induced enterocolitis syndrome;
• Eosinophilic disorders, as evidenced by the results of a biopsy; and
• Impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length, and motility of the gastrointestinal tract

Nothing after the deductible

Note: Deductible waived for pharmacy-dispensed items only.

Notes:

• Coverage shall be provided if the ordering physician has issued a written order stating that amino acid-based elemental formula is medically necessary for the treatment of a disease or disorder listed above.
• The Plan may review the ordering physician’s determination of the medical necessity of the amino acid-based elemental formula for the treatment of a disease or disorders listed above.

Applies to this benefit

Applies to this benefit

Applies to this benefit

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.) physical therapist, occupational therapist, speech and language pathologist, or home health aide
• Services include:
  • Oxygen therapy, intravenous therapy and medications
  • A home visit within 24 hours after discharge from the hospital or outpatient facility, and additional home visits if prescribed by the patient’s attending physician, for enrollees who receive less than 48 hours of inpatient hospitalization following a mastectomy or the surgical removal of a testicle, or who undergo a mastectomy or surgical removal of a testicle on an outpatient basis

Nothing after the deductible

Notes:

• We only provide these services in the Plan's service areas.
• Your Plan physician will periodically review the home health services for continuing appropriateness and medical need.
• The services are covered only if you are homebound and a Plan physician determines that it is feasible to maintain effective supervision and control of your care in your home.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
• Custodial care
• Private duty nursing
• Personal care and hygiene items
• Care that a Plan provider determines may be appropriately provided in a Plan facility, hospital, skilled nursing facility, or other facility we designate and we provide
• General maintenance care of colostomy, ileostomy, and ureterostomy
• Medical supplies or dressings applied by you or a family caregiver
• Transportation and delivery service costs of durable medical equipment, medications, drugs, medical supplies, and supplements to the home

All charges

Up to 20 visits per calendar year, including:

• Diagnosis and treatment of neuromusculoskeletal disorders
• Plain film X-rays associated with diagnosis and treatment
• Adjunctive therapies

Note: Your Plan physician must determine that such care will result in improvement in your condition. Chiropractic services require our prior approval. See Section 3, You need prior Plan approval for certain services.

$40 per office visit

Not covered:

• Hypnotherapy, behavior training, sleep therapy and weight programs
• Thermography
• Any radiological exam other than plain film studies such as magnetic resonance imaging, CT scans, bone scans, nuclear radiology
• Treatment for non-neuromusculoskeletal disorders
• Chiropractic appliances, except as covered in Section 5(a), Durable medical equipment and Prosthetics and orthotic devices
• Laboratory services

All charges

Up to 20 acupuncture visits per calendar year.

 Services include:

• Diagnosis and treatment of chronic pain and nausea
• Adjunctive acupuncture therapy

Note: You receive these services when your Plan physician determines that such care will result in improvement in your condition. Acupuncture services require our prior approval. See Section 3, You need prior Plan approval for certain services.

$40 per office visit

Not covered:

• All other form of alternative treatment, such as naturopathic services, behavior training, sleep therapy, weight programs and adjunctive therapy not associated with acupuncture
• Thermography
• Any radiological exam including plain film studies such as magnetic resonance imaging, CT scans, bone scans, nuclear radiology
• Laboratory services

All charges

Individual health education discussions, including:

• Diabetes
• Post-coronary
• Nutritional counseling

$30 per primary care office visit (nothing from infancy through age 4)

$40 per specialty care office visit

Health education classes, including:

• Most group classes
• Tobacco Cessation programs, including individual, group and phone counseling, prescribed over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco cessation.

Nothing

Notes:

• Please call our Member Services Department at 877-KP4-FEDS (877-574-3337) (TTY: 711) for information on classes near you.
• See Section 5(f). Prescription Drug Benefits, for important information about coverage of tobacco cessation and other drugs.

Applies to this benefit

Applies to this benefit

Applies to this benefit

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Diagnostic colonoscopy procedures
• 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)
• Surgical treatment of morbid obesity (bariatric surgery). You must:
  • satisfy the requirements of bariatric surgery nutrition preparation; and
  • not be excluded due to a history alcohol or drug use within the past 2 years or have certain behavioral health diagnoses; and 
  • have a Body Mass Index (BMI) that is greater than 40; or a BMI that is equal to or greater than 35 with a co-morbid medical condition such as hypertension, a cardiopulmonary condition, sleep apnea or diabetes

Note: See Section 3, You need prior Plan approval for certain services, for more information.

• Insertion of internal prosthetic devices. See Section 5(a), Orthopedic and prosthetic devices, for device coverage information
• Treatment of burns
• Insertion of implanted time-release drugs except for contraceptive drugs and IUDs.

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

• Voluntary sterilization including anesthesia (e.g. vasectomy, tubal ligation including confirmation testing following tubal occlusion)
• Insertion of surgically implanted time-release contraceptive drugs and intrauterine devices (IUDs)

Note: We cover the cost of these drugs and devices under the prescription drug benefit (see Section 5(f)).

Nothing

Nothing

Nothing

Not covered:

• Reversal of voluntary sterilization
• Services for the promotion, prevention, or other treatment of hair loss or hair growth
• Cosmetic surgery - any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

All charges

• 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; and webbed fingers and toes.

Note: We cover orthodontia services as a result of cleft lip and/or cleft palate.

• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery and reconstruction on the other breast to produce a symmetrical appearance;
  • treatment of any physical complications, such as lymphedemas; 
  • breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

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

Nothing

Nothing

Nothing

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form except repair of accidental injury
• Gender Affirming Surgery not listed above

All charges

Oral surgical procedures, limited to:

• Reduction of fractures of the 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 temporomandibular joint (TMJ) disorder (non-dental)
• Medically necessary oral and maxillofacial restoration after major reconstructive surgery; and 
• Other surgical procedures that do not involve the teeth or their supporting structures

Nothing

Nothing

Nothing

Not covered:

• Oral implants and transplants, unless covered due to medically necessary major reconstructive surgery
• 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, oral restoration after major reconstructive surgery or for orthodontia services as a result of cleft lip and/or cleft palate
• Shortening of the mandible or maxillae for cosmetic purposes and
• Correction of any malocclusion not listed above 

All charges

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. Refer to Section 3, How you get care, for authorization procedures. Solid organ tissue transplants are limited to:

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

Nothing

Nothing

Nothing

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

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

Nothing

Nothing

Nothing

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

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

Nothing

Nothing

Nothing

Limited benefits The following autologous blood or bone marrow stem cell transplants may be provided in a National Cancer Institute (NCI) or National Institutes of Health (NIH)-approved clinical trial at a Plan-designated Center of Excellence. These limited benefits are not subject to medical necessity.

• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Beta Thalassemia Major
• Breast cancer
• Childhood rhabdomyosarcoma
• Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
• Chronic lymphocytic leukemia
• Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL) relapsed/refractory disease
• Chronic myelogenous leukemia
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Epithelial ovarian cancer
• High-grade (Aggressive) non-Hodgkin’s lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms)
• High-risk Ewing sarcoma
• High risk childhood kidney cancers
• Hodgkin’s lymphoma
• Multiple myeloma
• Multiple sclerosis
• Myeloproliferative Disorders
• Myelodysplasia/Myelodysplastic Syndromes
• Non-Hodgkin’s lymphoma
• Sarcomas
• Sickle Cell
• Systemic lupus erythematosus
• Systemic sclerosis
• Scleroderma
• Scleroderma-SSc (severe, progressive)

Nothing

Nothing

Nothing

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

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

Nothing

Nothing

Nothing

Notes:

• We cover related medical and hospital expenses of the donor when we cover the recipient.
• We cover donor screening tests for potential donors for solid organ transplants. We cover human leukocyte antigen (HLA) typing for potential donors for a bone marrow/stem cell transplant only for parents, children and siblings of the recipient.
• We cover computerized national and international search expenses for prospective unrelated bone marrow/stem cell transplant donors conducted through the National Marrow Donor Program, and the testing of blood relatives of the recipient.
• We cover medically necessary routine dental services required in preparation for a transplant. Covered services may include a routine oral examination, cleaning (prophylaxis), extractions, and X-rays. You pay cost-sharing listed in Section 5 (a) and Section 5 (g) for services performed during an office visit. 
• Please refer to Section 5(h), Special features, for information on our Centers of Excellence.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

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

All charges

Professional services provided in –

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

Nothing

Nothing

Room and board, such as:

• Ward, semiprivate, or intensive care accommodations

• General nursing care

• Meals and special diets

Notes:

• If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.
• You may receive covered medical hospital services for certain dental procedures if a Plan physician determines that you need to be hospitalized. Section 5(g), Dental benefits, includes more information on the requirements.

$100 per inpatient admission

Nothing for maternity care

$500 per inpatient admission

Nothing for maternity care

$750 per inpatient admission after the deductible

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests, X-rays, and pathology services
• Blood and blood products
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics and anesthesia services
• Procurement and storage for approved medically necessary cord blood for a designated recipient

Nothing

Nothing

Nothing

Not covered:

• Custodial care and care in an intermediate care facility
• Non-covered facilities, such as nursing homes
• Personal comfort items, such as phone, television, barber services, and guest meals and beds
• Private nursing care except when medically necessary
• Cord blood procurement and storage for possible future need or for yet to be determined Member recipient

All charges

• Up to 60 days of physical and occupational therapy per condition
• Up to two months of speech therapy per condition

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

$100 per inpatient admission

$500 per inpatient admission

$750 per inpatient admission after the deductible

• Operating, recovery, and other treatment rooms
• Observation care
• Prescribed drugs and medications
• Lab, X-ray and other diagnostic tests
• Procurement and storage of cord blood for approved medically necessary procedures requiring cord blood for a designated recipient
• Blood and blood products
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. Section 5(g), Dental benefits, includes more information on the requirements.

$300 per surgery or procedure in an outpatient hospital or ambulatory surgery center after the deductible

Not covered:

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

All charges

Up to 100 days per calendar year when you need full-time skilled nursing care.

All necessary services are covered, including:

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

$500 per inpatient admission

$750 per inpatient admission after the deductible

Not covered:

• Custodial care and care in an intermediate care facility
• Personal comfort items, such as phone, television, barber services, and guest meals and beds  

All charges

Supportive and palliative care for a terminally ill member:

• You must reside in the service area
• Services are provided:
  • in the home, when a Plan physician determines that it is feasible to maintain effective supervision and control of your care in your home, or
  • in a Plan-approved hospice facility if approved by the hospice interdisciplinary team.

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.

Nothing

Nothing after the deductible

Not covered:

• Independent nursing (private duty nursing)
• Homemaker services  

All charges

• Local licensed ambulance service when medically necessary

No charge when we transfer you from an emergency room or hospital to a Plan facility

$100 per service for all other ambulance services

No charge when we transfer you from an emergency room or hospital to a Plan facility

$100 per service for all other ambulance services after the deductible

• Non-emergent transportation services when medically necessary and ordered by a Plan Provider

 Note: See Section 5(d) for emergency services

Nothing

Not covered: 

• Transportation by car, taxi, bus, and any other type of transportation (other than ambulette or a licensed ambulance), even if it is the only way to travel to a Plan Provider
• Non-emergent transportation services that are not medically appropriate and that have not been ordered by a Plan provider

All charges

• Emergency care at a Plan urgent care center 
• Urgent care at a Plan urgent care center

$40 per visit

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

Note:

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

$150 per visit after the deductible

Not covered:

• Elective care or non-emergency care
• Urgent care at a non-Plan urgent care center

All charges

All charges

• Emergency care at an urgent care center
• Urgent care at an urgent care center

$40 per visit

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

$150 per visit after the deductible

Notes:

• If you receive emergency care and then are transferred to observation care, you pay the emergency services cost-sharing. If you are admitted as an inpatient, we will waive your emergency room copayment and you will pay your cost-sharing related to your inpatient hospital stay.
• See Section 5(h) for travel benefit coverage of continuing or follow-up care.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered:

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

All charges

Licensed ambulance service, including air ambulance, when medically necessary.

Notes:

• Coverage is also provided for medically necessary transportation or services rendered as the result of a 911 call, whether or not transport is required.
• See Section 5(c) for non-emergency service.
• Service means any time an ambulance is summoned on your behalf. 

Nothing

$100 per service

$100 per service after the deductible

Not covered:

• Ambulance services we determine are not medically necessary
• Transportation by car, bus, gurney van, wheelchair van, minivan, and any other type of transportation (other than a licensed ambulance), even if it is the only way to travel to a provider or facility 

All charges

We cover professional services recommended by a Plan mental health and substance use disorder treatment provider that are covered services, drugs, and supplies described in this brochure.

Notes:

• We cover the services only when we determine that the care is clinically appropriate to treat your condition.

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

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

• Medication, evaluation and management (pharmacotherapy)
• Professional charges for intensive outpatient treatment in a provider's office or other professional setting
• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual and group therapy visits)
• Electroconvulsive therapy

$10 per individual therapy visit

$5 per group therapy visit

(nothing from infancy through age 4)

$20 per individual therapy visit

$10 per group therapy visit

(nothing from infancy through age 17)

$30 per individual therapy visit

$15 per group therapy visit

(nothing from infancy through age 4)

Diagnosis and treatment of substance use disorders. Outpatient services include:

• Detoxification (medical management of withdrawal from the substance)
• Treatment and counseling (including individual and group therapy visits)
• Intensive day treatment
• Medication evaluation and management (pharmacotherapy)

$10 per individual therapy visit

$5 per group therapy visit

(nothing from infancy through age 4)

$20 per individual therapy visit

$10 per group therapy visit

(nothing from infancy through age 17)

$30 per individual therapy visit

$15 per group therapy visit

(nothing from infancy through age 4)

•  Methadone treatment

$10 per week

(nothing from infancy through age 4)

$20 per week

(nothing from infancy through age 17)

$30 per week

(nothing from infancy through age 4)

Notes:

• You may see a Plan mental health or substance use disorder treatment provider for outpatient services without a referral from your primary care physician. See Section 3. How You Get Care, for information about services requiring our prior approval.
• Your Plan mental health or substance use disorder treatment 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.
• See Section 5(a), Treatment therapy, for coverage of Applied Behavior Analysis (ABA).

Applies to this benefit

Applies to this benefit

Applies to this benefit

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner
• Outpatient diagnostic tests and billed provided and billed by a laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

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

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

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

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

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services 
• Inpatient psychiatric care
• Inpatient detoxification
• Acute inpatient substance use rehabilitation
• Services in an inpatient residential treatment center

Notes:

• All inpatient admissions and hospital alternative services treatment programs require approval by a Plan mental health or substance use disorder treatment 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.

$500 per inpatient admission

$750 per inpatient admission after the deductible

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

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

$10 per visit; or $100 per inpatient admission if your treatment is more than 24 continuous hours

$20 per visit; or $500 per inpatient admission if your treatment is more than 24 continuous hours

$30 per visit; $750 per inpatient admission after the deductible if your treatment is more than 24 continuous hours

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

All charges

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

• Drugs and medications that, by federal law, require a prescription for their purchase, except those listed as Not covered
• Insulin
• Other implanted time-release drugs
• Self-injectable drugs, other than ovulation stimulants
• 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
• Disposable needles and syringes for the administration of covered medications, except disposable needles and syringes for the administration of insulin (See Section 5(a). Durable medical equipment)
• Drugs to treat gender dysphoria, including hormones and androgen blockers

For up to a 30-day supply:

• At a Plan medical center pharmacy:
$7 preferred generic; $30 preferred brand-name and high-cost generic; $45 non-preferred; $100 specialty

• At an affiliated network pharmacy:
$17 preferred generic; $50 preferred brand-name and high-cost generic; $65 non-preferred; $150 specialty

• Through our mail service:
$5 preferred generic; $28 preferred brand-name and high-cost generic; $43 non-preferred; $100 specialty

Note: You pay the standard prescription drug cost-sharing for insulin up to a maximum of $30 and for drugs for the treatment of diabetes, HIV, or AIDS up to a maximum of $150.

For up to a 30-day supply:

• At a Plan medical center pharmacy:
$10 preferred generic; $40 preferred brand-name and high-cost generic; $60 non-preferred; $150 specialty

• At an affiliated network pharmacy:
$20 preferred generic; $60 preferred brand-name and high-cost generic; $80 non-preferred; $200 specialty

• Through our mail service:
$8 preferred generic; $38 preferred brand-name and high cost generic; $58 non-preferred; $150 specialty

Note: You pay the standard prescription drug cost-sharing for insulin up to a maximum of $30 and for drugs for the treatment of diabetes, HIV, or AIDS up to a maximum of $150.

For up to a 30-day supply:

• At a Plan medical center pharmacy:
$10 preferred generic; $45 preferred brand-name and high-cost generic; $65 non-preferred; $200 specialty

• At an affiliated network pharmacy:
$20 preferred generic; $65 preferred brand-name and high-cost generic; $85 non-preferred; $250 specialty

• Through our mail service:
$8 preferred generic; $43 preferred brand-name and high-cost generic; $63 non-preferred; $200 specialty

Note: You pay the standard prescription drug cost-sharing for insulin up to a maximum of $30 and for drugs for the treatment of diabetes, HIV, or AIDS up to a maximum of $150.

Contraceptive drugs and devices as listed in the ACA/HRSA site. Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below.

• We cover contraceptive drugs and devices, including implanted contraceptive devices, diaphragms, hormonal contraceptive methods, and prescribed FDA approved over-the-counter women's contraceptives and devices

• We cover non-preferred contraceptives if they would otherwise be covered, and a Plan provider receives an approved drug formulary exception

• We cover prescribed FDA approved over-the-counter women’s contraceptives and devices when prescribed by a Plan provider and obtained at a Plan pharmacy

Nothing

• Fertility drugs for covered infertility treatments
• Sexual dysfunction drugs

50% of our allowance

Notes:

• For information about mail order discounts, see “These are the dispensing limitations” in the introduction to Section 5(f)
• The brand-name drug copayment will apply to single source generic products. For compound drugs, you will be charged your applicable generic or brand-name drug copayment depending on the compounded product’s main ingredient, whether the main ingredient is a generic or brand-name drug.
• A compound drug is one in which two or more drugs or pharmaceutical agents are combined together. We limit coverage to products listed in our drug formulary or when one of the ingredients requires a prescription by law.
• Non-maintenance self-injectables are limited to a dispensing limit of 30 days.
• Home IV and growth hormone requires our prior approval. See Section 3, You need prior Plan approval for certain services.

Applies to this benefit

Applies to this benefit

Applies to this benefit

Not covered: 

• Drugs or supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Prescriptions filled at a non-Plan pharmacy, except for out-of-area emergencies as described in Section 5(d). Emergency Services/Accidents
• Vitamins, nutritional and herbal supplements that can be purchased without a prescription, unless they are included in our drug formulary or listed as covered above or below
• Over-the-counter (nonprescription) drugs, including prescription drugs for which there is an over-the-counter drug equivalent available
• Prescription drugs not on our drug formulary, unless by exception
• Over-the-counter drugs, unless they are included in our drug formulary or listed as covered above
• Medical supplies such as dressings and antiseptics, except as listed above
• Drugs to shorten the duration of the common cold
• Any requested packaging of drugs other than the dispensing pharmacy’s standard packaging
• Replacement of lost, stolen, or damaged prescription drugs and accessories
• Drugs related to non-covered services
• Drugs for the promotion, prevention, or other treatment of hair loss or growth
• Dental prescriptions other than those prescribed for pain relief or antibiotics

All charges

The following are covered:

• Aspirin to reduce the risk of heart attack
• Oral fluoride for children to reduce the risk of tooth decay
• Folic acid for women to reduce the risk of birth defects
• Medication to reduce the risk of breast cancer

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

Nothing

Not covered:

• Prescriptions filled at a non-Plan pharmacy, except for emergencies as described in Section 5(d). Emergency Services/Accidents
• Vitamins, nutritional and herbal supplements that can be purchased without a prescription, unless they are included in our drug formulary or listed as covered above
• Over-the-counter, unless they are included in our drug formulary or listed as covered above
• Prescription drugs not on our drug formulary, unless approved through an exception process
• Any requested packaging of drugs other than the dispensing pharmacy’s standard packaging
• Replacement of lost, stolen or damaged prescription drugs and accessories
• Drugs related to non-covered services

All charges

All charges

All charges

We cover medically necessary dental services to treat injuries to the jaw, sound natural teeth, mouth or face as a result of an accident. Dental appliances required to diagnose or treat an accidental injury to the teeth, and the repair of dental appliances damaged as a result of accidental injury to the jaw, mouth or face, are also covered.

• Damage is due to an accidental injury from trauma to the mouth from violent contact with an external object,
• The tooth has not been restored previously, and
• The tooth has not been weakened by decay, periodontal disease, or the existing dental pathology.

$30 per primary care office visit

$40 per specialty care office visit

Not covered:

• Services for conditions caused by an accidental injury occurring before your eligibility date
• Injury that results from chewing or biting

All charges

General anesthesia and associated hospital or ambulatory surgery facility charges, in conjunction with dental care, are covered for members:

• 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
• 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
• 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)

Note: Dental care must be provided by a fully accredited specialist in pediatric dentistry, a fully accredited specialist in oral and maxillofacial surgery, or a dentist for whom hospital privileges have been granted.

$20 per primary care office visit

$30 per specialty care office visit

$150 per outpatient surgery

$500 per inpatient admission

$30 per primary care office visit

$40 per specialty care office visit

$300 per outpatient surgery after the deductible

$750 per inpatient admission after the deductible

Not covered:

• The dentist’s or specialist’s professional services
• Dental care for temporal mandibular joint (TMJ) disorders
• Lab fees associated with cysts that are considered dental according to our medical guidelines

All charges

Diagnostic and preventive dental services when provided by a participating Dominion National dentist, such as:

• Routine oral examinations – twice per calendar year
• Cleaning (prophylaxis) – twice per calendar year (excluding periodontal prophylaxis)
• Topical application of fluoride – twice per calendar year
• Bitewing X-rays – twice per calendar year

All charges

Other covered dental services when provided by a Plan dentist.

Note: All dental procedures listed in the schedule of discounted 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 DOMINION are liable for payment of these fees or for any fees incurred as the result of receipt of non-covered dental services.

See Kaiser Permanente Dental Plan Provider Directory for schedule of discounted dental fees

See Kaiser Permanente Dental Plan Provider Directory for schedule of discounted dental fees

All charges

Dental emergencies outside our service area

Notes:

• 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.

All charges, not to exceed $100 per incident

All charges, not to exceed $100 per incident

All charges

Notes:

• You may select a Participating Dental Provider, who is a “general dentist”, from whom you and your eligible family members will receive covered dental services. For specialty care, your general dentist must refer you to a specialist who is a Participating Dental Provider.
• For a complete list of covered dental services, a schedule of discounted dental fees, limitations, exclusions and a directory of Participating Dental Providers, refer to your Kaiser Permanente Dental Plan booklet. You can obtain a Dental Plan booklet by calling our Federal Member Services Department at 877-KP4-FEDS (877-574-3337), (TTY: 711).
• For assistance concerning dental coverage questions or for help finding a Participating Dental Provider, contact DOMINION Member Services, Monday through Friday from 7:30 am to 6:00 pm at toll-free at 855-733-7524 (TTY: 800-688-4889).

Applies to this benefit

Applies to this benefit

Applies to this benefit

Under the flexible benefits option, we determine the most effective way to provide services. 

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claims process (see Section 8).

The Centers of Excellence program began in 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 provide TTY/text phone number TTY: 711. Sign language services are also available.

When you visit a different Kaiser Foundation Health Plan service area, you can receive visiting member services from designated providers in that area. Visiting member services are subject to the terms, conditions and cost-sharing described in this FEHB brochure. Certain services are not covered as a visiting member.

For more information about receiving visiting member services, including provider and facility locations in other Kaiser Permanente service areas please call our Away from Home Travel Line at 951-268-3900 or visit www.kp.org/feds.

Kaiser Permanente’s travel benefits for Federal employees provides you with outpatient follow-up and/or continuing medical and mental health and substance use care when you are temporarily (for example, on a temporary work assignment or attending school) outside your home service area by more than 100 miles and outside of any other Kaiser Permanente service area. These benefits are in addition to your emergency services/accident benefit and include:

• Outpatient follow-up care necessary to complete a course of treatment after a covered emergency. Services include removal of stitches, a catheter, or a cast.
• Outpatient continuing care for covered services for conditions diagnosed and treated within the previous 12 months by a Kaiser Permanente healthcare provider or affiliated Plan provider. Services include dialysis and prescription drug monitoring.

You pay $25 for each follow-up or continuing care office visit. This amount will be deducted from the reimbursement we make to you or to the provider. We limit our payment for this travel benefit to no more than $1,200 each calendar year. For more information about this benefit you should contact the Plan’s dedicated Federal Member Services Department at 877-KP4-FEDS (877-574-3337) (TTY: 711). 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
• Durable medical equipment (DME)
• Prescription drugs
• Home health services

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

High and Standard Options

• $200 for completing a confidential, online, Total Health Assessment (available in English or Spanish) and being up to date on the following biometric screenings: blood glucose, blood pressure, Body Mass Index (BMI) and total cholesterol. To view and determine the status of your screenings, go to www.kp.org/feds. If you have not had these screenings recently, you may be required to contact your Kaiser Permanente doctor. You will get a picture of your overall health and a customized action plan with tips and resources to improve your well-being.

Prosper

• $375 for completing a confidential, online, Total Health Assessment (available in English or Spanish) and being up to date on the following biometric screenings: blood glucose, blood pressure, Body Mass Index (BMI) and total cholesterol. To view and determine the status of your screenings, go to kp.org/feds. If you have not had these screenings recently, you may be required to contact your Kaiser Permanente doctor.

Program Guidelines (applies to High Option, Standard Option and Prosper)
You must accept the Wellness Program Agreement to be eligible to earn rewards. Please go to www.kp.org/feds to learn how to earn your reward and how to view and track the status of your reward activities.

You must complete reward activities (Total Health Assessment and a biometric screening) during the plan year. We will issue you a Kaiser Permanente Health Payment Card 4-6 weeks after you complete both activities. We will send each eligible member their own debit card.

You may use your Health Payment Card to pay for certain qualified medical expenses, such as:

• Copayments for office visits, prescription drugs and other services at Kaiser Permanente or other providers
• Prescription eyeglasses or contacts
• Dental services
• Over-the-counter medication for certain diseases
• Other medical expenses, as permitted by the IRS

Please keep your card for use in the future. As you complete activities, we will add rewards to your card. We will not send you a new card until the card expires. Rewards you earn during this calendar year may be used until March 31 of the next calendar year. Funds are forfeited if you leave this plan.

For more information, please go to www.kp.org/feds. If you have questions about completing a Total Health Assessment or biometric screenings, you may call us at 866-300-9867. If you have questions about your account balance or what expenses the Health Payment Card can be used for, you may call the phone number on the back of your Health Payment Card.

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, call us at 877-KP4-FEDS (877-574-3337) (TTY:711).

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

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

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

Submit your claims to:

Mid-Atlantic Claims Administration
Kaiser Permanente
P.O. Box 371860
Denver, CO 80237-9998

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

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

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

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

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

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

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

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

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

b) Send your request to us at: Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc., Nine Piedmont Center, 3495 Piedmont Road NE, Atlanta, GA 30305, 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.

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

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

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information.

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

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street NW, Washington, DC 20415-3630.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim;
• Your daytime phone number and the best time to call; and
• Your email address, if you would like to receive OPM's decision via email. Please note that by providing your email address, you may receive OPM's decision more quickly.

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

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

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

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

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

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

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

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays healthcare expenses without regard to fault. This is called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary payor and the other plan pays a reduced benefit as the secondary payor. We, like other insurers, determine which coverage is primary according to the National Association of Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit the NAIC website at www.kp.org/feds.

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

When we are the secondary payor, we will determine our allowance. After the primary plan processes the benefit, we will pay what is left of our allowance, up to our regular benefit, except Medicare-eligible members with Original Medicare as primary payor must pay cost-sharing described in this FEHB brochure (see Sections 4 and 5, members with Medicare should also see the Original Medicare Plan portion of this Section 9). We will not pay more than our allowance. If we are the secondary payor, and you received your services from Plan providers, we may bill the primary carrier.

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

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

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

We do not cover services that:

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

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

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

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

When you receive money to compensate you for medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our subrogation procedures.

If you obtain a judgment or settlement from or on behalf of a third party who allegedly caused or is responsible for an injury or illness for which you received covered healthcare services or benefits (“Services”), you must pay us Charges for those Services. “Charges” are: 1) for Services that we pay the provider on a fee-for-service basis, the payments that we made for the Services; and 2) for all other Services, the charges in the provider’s schedule of charges for Services provided to Members less any cost share payments that you made to the provider. Our payments for Services in these circumstances are expressly conditioned on your agreement to comply with these provisions. You are still required to pay cost-sharing to the provider, even if a third party has allegedly caused or is responsible for the injury or illness for which you received Services.

You must also pay us Charges for such Services if you receive or are entitled to receive a recovery from any insurance for an injury or illness alleged to be based on a third party’s or your own fault, such as from uninsured or underinsured motorist coverage, automobile or premises medical payments coverage, or any other first party coverage. You must also pay us Charges for such Services if you receive or are entitled to receive recovery from any Workers' Compensation benefits.

To secure our rights, we will have a lien on and reimbursement right to the proceeds of any judgment or settlement you or we obtain. The proceeds of any judgment or settlement that you or we obtain shall first be applied to satisfy our lien, regardless of whether the total amount of the proceeds is less than the actual losses and damages you incurred. Our right  to receive payment is not subject to reduction based on attorney fees or costs under the “common fund” doctrine and is fully enforceable regardless of whether you are “made whole” or fully compensated for the full amount of
damages claimed.

We are entitled to full recovery regardless of whether any liability for payment is admitted by any person, entity or insurer. We are entitled to full recovery regardless of whether the settlement or judgment received by you identifies the medical benefits provided or purports to allocate any portion of such settlement or judgment to payment of expenses other than medical expenses. We are entitled to recover from any and all settlements, even those designated as for pain and suffering, non-economic damages and/or general damages only.

In order for us to determine the existence of any rights we may have and to satisfy those rights, you must complete and send us all consents, releases, authorizations, assignments, and other documents, including lien forms directing your attorney and any, insurer to pay us directly. You may not agree to waive, release, or reduce our rights under this provision without our prior, written consent. You must cooperate in doing what is reasonably necessary to assist us with our right of recovery. You must notify us within 30 days of the date you or someone acting on your behalf notifies anyone, including an insurer or attorney, of your intention to pursue or investigate a claim to recover damages or obtain compensation due to your injury or illness. You must not take any action that may prejudice our right of recovery.

If your estate, parent, guardian, or conservator asserts a claim based on your injury or illness, that person or entity and any settlement or judgment recovered by that person or entity shall be subject to our liens and other rights to the same extent as if you had asserted the claim against the party. We may assign our rights to enforce our liens and other rights.

We have the option of becoming subrogated to all claims, causes of action, and other rights you may have against a third party or an insurer, government program, or other source of coverage for monetary damages, compensation, or indemnification on account of the injury or illness allegedly caused by the third party. We will be so subrogated as of the time we mail or deliver a written notice of our exercise of this option to you or your attorney, but we will be subrogated only to the extent of the total of Charges for the relevant Services. Contact us if you need more information about recovery or subrogation.

If you enter into a Surrogacy Agreement, you must reimburse us for covered services you receive related to conception, pregnancy, delivery, or postpartum care in connection with the Surrogacy Agreement, except that the amount you must pay will not exceed the payments or other compensation you and any other payee are entitled to receive under the Surrogacy Agreement. A "Surrogacy Agreement" is one in which a person agrees to become pregnant and to surrender the baby (or babies) to another person or persons who intend to raise the child (or children), in exchange for payment or compensation for being a surrogate. The "Surrogacy Agreement" does not affect your obligation to pay your cost-sharing for services received, but we will credit any such payments toward the amount you must pay us under this paragraph. We will only cover charges incurred for any services when you have legal custody of the baby and when the baby is covered as a family member under your Self Plus One or Self and Family enrollment (the legal parents are financially responsible for any services that the baby receives).

By accepting services, you automatically assign to us your right to receive payments that are payable to you or any other payee under the Surrogacy Agreement, regardless of whether those payments are characterized as being for medical expenses. To secure our rights, we will also have a lien on those payments and on any escrow account, trust, or any other account that holds those payments. Those payments (and amounts in any escrow account, trust, or other account that holds those payments) shall first be applied to satisfy our lien. The assignment and our lien will not exceed the total amount of your obligation to us under the preceding paragraph.

Within 30 days after entering into a Surrogacy Agreement, you must send written notice of the Agreement, a copy of the Agreement, including the names, addresses, and phone numbers of all parties involved in the Agreement. You must send this information to:

Kaiser Permanente
Attention: Patient Financial Services
2101 E. Jefferson Street, 4 East
Rockville, MD 20852
Attn: Surrogacy Coordinator

You must complete and send us consents, releases, authorizations, lien forms, and other documents that are reasonably necessary for us to determine the existence of any rights we may have under this "Surrogacy Agreements" section and to satisfy those rights.

If your estate, parent, guardian, or conservator asserts a claim against a third party based on the Surrogacy Agreement, your estate, parent, guardian, or conservator and any settlement or judgment recovered by the estate, parent, guardian, or conservator shall be subject to our liens and other rights to the same extent as if you had asserted the claim against the third party. We may assign our rights to enforce our liens and other rights.

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

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

We will cover routine care costs and may cover some extra care costs not provided by the clinical trial in accordance with Section 5 when Plan physicians provide or arrange for your care. We encourage you to contact us to discuss specific services if you participate in a clinical trial.

• Routine care costs are costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition whether the patient is in a clinical trial or is receiving standard therapy. We cover routine care costs not provided by the clinical trial.
• Extra care costs are costs related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not as part of the patient’s routine care. We cover some extra care costs not provided by the clinical trial. We encourage you to contact us to discuss coverage for specific services if you participate in a clinical trial.
• Research costs are costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. The Plan does not cover research costs.

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

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us toll free, at 877-KP4-FEDS (877-574-3337) (TTY: 711), 7:30 a.m. to 9:00 p.m., Monday through Friday, or visit our website at www.kp.org/feds.

We do not waive any costs if the Original Medicare Plan is your primary payor.

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

We offer a program designed to help members with their Medicare Part B premium. This program is called "Medicare Advantage 2". For each month you are enrolled in Medicare Advantage 2, have Medicare Parts A and B or Part B only and are enrolled in Medicare Advantage for Federal Members, you will be reimbursed up to $200 (up to $2,400 per year) of your Medicare Part B monthly premium. In addition to reimbursing for the Part B monthly premium, we will cover additional benefits, including lower copayments for office visits, outpatient surgery, inpatient hospital care, emergency care, plus additional coverage for the Silver&Fit^® fitness program.

You may enroll in this program if:

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

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

To learn more about Medicare Advantage 2 and how to enroll, call us at 877-547-4909 (TTY:711), 8 a.m. to 8 p.m., 7 days a week, or visit our website at www.kp.org/feds. We will send you additional information and an additional application for enrollment in Medicare Advantage 2. 

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227) (TTY: 877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage Plan: We offer a Medicare Advantage plan known as Kaiser Permanente Medicare Advantage for Federal Members. Kaiser Permanente Medicare Advantage for Federal Members enhances your FEHB coverage by lowering cost-sharing for some services and/or adding benefits. High and Standard Option Members can chose between 2 Medicare Advantage plans: "Medicare Advantage 1" (richest benefits) and "Medicare Advantage 2" (some rich benefits) and Part B premium reimbursement. If you live in our Medicare Advantage service area and you have Medicare Parts A and B, or Medicare Part B only, you can enroll in Medicare Advantage for Federal Members. Enrolling in Medicare Advantage for Federal Members does not change your FEHB premium. Your enrollment is in addition to your FEHB High Option, Standard Option or Prosper enrollment; however, your benefits will be provided under the Kaiser Permanente Medicare Advantage for Federal Members plan and are subject to Medicare rules. If you are already enrolled and would like to understand your additional benefits in more detail, please refer to your Medicare Advantage for Federal Members plan’s Evidence of Coverage. If you are considering enrolling in our Medicare Advantage for Federal Members, please call us at 301-816-6143 (TTY:866-513-0008), 8:30 a.m. to 5 p.m., Monday through Friday, or visit our website at www.kp.org/feds.

With a Kaiser Permanente Medicare Advantage for FEHB Members plan, you will get more coverage, such as lower cost sharing and additional benefits. This 2023 benefit summary allows you to make a comparison of your choices:

This is a summary of the features of the Kaiser Permanente Medicare Advantage for Federal Members. As a Medicare Advantage member, you are still entitled to coverage under the FEHB Program. All benefits are subject to the definitions, limitations, and exclusions set forth in this FEHB brochure and the Kaiser Permanente Medicare Advantage for Federal Members Evidence of Coverage.

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

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

When we are the primary payor, we process the claim first. If you enroll in another plan's Medicare Part D plan and we are the secondary payor, when you fill your prescription at a Plan pharmacy that is not owned and operated by Kaiser Permanente we will review claims for your prescription drug costs that are not covered by Medicare Part D and consider them for payment under the FEHB plan. Our Kaiser Permanente owned and operated pharmacies will not consider another plan's Medicare Part D benefits. These Kaiser Permanente pharmacies will only provide your FEHB Kaiser Permanente benefits.

You will still need to follow the rules in this brochure for us to cover your care. We will only cover your prescription if it is written by a Plan provider and obtained at a Plan pharmacy or through our Plan mail service delivery program, except in an emergency or urgent care situation.

If you enroll in a Kaiser Permanente Medicare plan, you will get all of the benefits of Medicare Part D plus additional drug benefits covered under your FEHB plan.

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

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

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

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

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

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

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

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

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

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

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

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

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

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

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

We do not cover a service, supply, item or drug that we consider experimental, except for the limited coverage specified in Section 9, Clinical trials. We consider a service, supply, item or drug to be experimental when the services, supply, item or drug:

1. has not been approved by the FDA; or
2. is the subject of a new drug or new device application on file with the FDA; or
3. is available as the result of a written protocol that evaluates the service’s safety, toxicity, or efficacy; or
4. is subject to the approval or review of an Institutional Review Board; or
5. requires an informed consent that describes the service as experimental or investigational.

We carefully evaluate whether a particular therapy is safe and effective or offers a degree of promise with respect to improving health outcomes. The primary source of evidence about health outcomes of any intervention is peer-reviewed medical literature.

Healthcare benefits that are available as a result of your employment, or the employment of your spouse, and that are offered by an employer or through membership in an employee organization. Healthcare coverage may be insured or indemnity coverage, self-insured or self-funded coverage, or coverage through health maintenance organizations or other managed care plans. Healthcare coverage purchased through membership in an organization is also “group health coverage.”

A physician or other healthcare professional licensed, accredited, or certified to perform specified health services consistent with state law.

Hospice is a program for caring for the terminally ill patient that emphasizes supportive services, such as home care and pain and symptom control, rather than curative care. If you make a hospice election, you are not entitled to receive other healthcare services that are related to the terminal illness. If you have made a hospice election, you may revoke that election at any time, and your standard health benefits will be covered.

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

Our allowance is the amount we use to determine our payment and your coinsurance for covered services. We determine our allowance as follows:

• For services and items provided by Kaiser Permanente, the applicable charges in the Plan's schedule of Kaiser Permanente charges for services and items provided to Plan members.
• For services and items for which a provider (other than Kaiser Permanente) is compensated on a capitation basis, the charges in the schedule of charges that Kaiser Permanente negotiates with the capitated provider.
• For items obtained at a pharmacy owned and operated by Kaiser Permanente, the amount the pharmacy would charge a Plan member for the item if a Plan member's benefit plan did not cover the item. This amount is an estimate of: the cost of acquiring, storing, and dispensing drugs, the direct and indirect costs of providing Kaiser Permanente pharmacy services and items to Plan members, and the pharmacy program's contribution to the net revenue requirements of the Plan.
• For all other services and items, the payments that Kaiser Permanente makes for the services and items or, if Kaiser Permanente subtracts cost-sharing from its payment, the amount Kaiser Permanente would have paid if it did not subtract cost-sharing.
• For non-Plan Providers practicing in the state of Maryland, our allowance shall not be less than the amount the Health Plan must pay pursuant to §19-710.1 of the Health General Article of the Annotated Code of Maryland.

You should also see Important Notice About Surprise Billing – Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

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

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

Urgent care claims involve Pre-service claims and not Post-service claims. We will determine whether or not a claim is an urgent care claim by applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine.

If you believe your claim qualifies as an urgent care claim, please contact our Member Services Department at 877-KP4-FEDS (877-574-3337). You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

$10 per primary care office visit (nothing from infancy through age 4)
$20 per specialty care office visit

(Applies to printed brochure only)

$100 per admission, except nothing for maternity care

(Applies to printed brochure only)

$75 per visit

(Applies to printed brochure only)

$100 per visit

(Applies to printed brochure only)

Regular cost-sharing

(Applies to printed brochure only)

$7 preferred generic;
$30 preferred brand-name;
$45 non-preferred;
$100 specialty.

(Applies to printed brochure only)

$17 preferred generic;
$50 preferred brand-name;
$65 non-preferred;
$150 specialty.

(Applies to printed brochure only)

$5 preferred generic; 
$28 preferred brand-name;
$43 non-preferred;
$100 specialty. 
Up to a 90-day supply of maintenance drugs for 2 copays through our mail order program.

(Applies to printed brochure only)

Various copayments based on procedure rendered

(Applies to printed brochure only)

$10 per office visit

(Applies to printed brochure only)

See Section 5(h) for more information.

(Applies to printed brochure only)

Nothing after $2,250/Self Only or $4,500/ Family enrollment per year. Some costs do not count toward this protection.

(Applies to printed brochure only)

$20 per primary care office visit (nothing from infancy through age 17)
$30 per specialty care office visit

(Applies to printed brochure only)

$500 per admission, except nothing for maternity care

(Applies to printed brochure only)

$150 per visit

(Applies to printed brochure only)

$150 per visit

(Applies to printed brochure only)

Regular cost-sharing

(Applies to printed brochure only)

$10 preferred generic;
$40 preferred brand-name;
$60 non-preferred;
$150 specialty.

(Applies to printed brochure only)

$20 preferred generic;
$60 preferred brand-name;
$80 non-preferred; 
$200 specialty.

(Applies to printed brochure only)

$8 preferred generic;
$38 preferred brand-name;
$58 non-preferred;
$150 specialty. 
Up to a 90-day supply of maintenance drugs for 2 copays through our mail order program.

(Applies to printed brochure only)

Various copayments based on procedure rendered

(Applies to printed brochure only)

$20 per office visit

(Applies to printed brochure only)

See Section 5(h) for more information.

(Applies to printed brochure only)

Nothing after $3,500/Self Only or $7,000/Family enrollment per year. Some costs do not count toward this protection.

(Applies to printed brochure only)

$100 per person
$200 per family

(Applies to printed brochure only)

$30 per primary care office visit (nothing from infancy through age 4)
$40 per specialty care office visit

(Applies to printed brochure only)

$750 per admission*

(Applies to printed brochure only)

$300 per visit*

(Applies to printed brochure only)

$150 per visit*

(Applies to printed brochure only)

Regular cost-sharing

(Applies to printed brochure only)

$10 preferred generic;
$45 preferred brand-name;
$65 non-preferred;
$200 specialty.

(Applies to printed brochure only)

$20 preferred generic;
$65 preferred brand-name;
$85 non-preferred;
$250 specialty.

(Applies to printed brochure only)

$8 preferred generic;
$43 preferred brand-name;
$63 non-preferred;
$200 specialty. 
Up to a 90-day supply of maintenance drugs for 2 copays through our mail order program.

(Applies to printed brochure only)

Various copayments based on procedure rendered

(Applies to printed brochure only)

$30 per office visit

(Applies to printed brochure only)

See Section 5(h) for more information.

(Applies to printed brochure only)

Nothing after $4,000/Self Only or $8,000/ Family enrollment per year. Some costs do not count toward this protection.

(Applies to printed brochure only)