Kaiser Permanente: Gold 80 HMO

1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning on or after 01/01/2019. : Gold 80 HMO Coverage for: Individual/Family | Plan Type: HMO. Summary Kaiser Coverage Plan type: Permanente: of Period: for: HMOB enefits Individual/Family Beginning Gold and 80. Coverage: on HMOor after What 01/01/2019. this plan covers and What You Pay For Covered Services The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage see or call 1-800-278-3296 (TTY: 711).

2 For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at or call 1-800-278-3296 (TTY: 711) to request a copy. Important Questions Answers Why this Matters: What is the overall $0 See the Common Medical Events chart below for your costs for services this plan deductible? covers. This plan covers some items and services even if you haven't yet met the deductible Are there services amount. But a copayment or coinsurance may apply. For example, this plan covers covered before you meet Not Applicable. certain preventive services without cost sharing and before you meet your your deductible? deductible.

3 See a list of covered preventive services at Are there other deductibles for specific No. You don't have to meet deductibles for specific services. services? What is the out-of-pocket $7,200 Individual / $14,400 Family The out-of-pocket limit is the most you could pay in a year for covered services. If limit for this plan? you have other family members in this plan, they have to meet their own out-of- pocket limits until the overall family out-of-pocket limit has been met. What is not included in Premiums, and health care services this plan Even though you pay these expenses, they don't count toward the out-of-pocket the out-of-pocket limit? doesn't cover, indicated in chart starting on limit. page 2. This plan uses a provider network.

4 You will pay less if you use a provider in the plan's network. You will pay the most if you use an out-of-network provider, and you Will you pay less if you Yes. See or call 1-800-278-3296 might receive a bill from a provider for the difference between the provider's charge use a network provider? (TTY: 711) for a list of network providers. and what your plan pays (balance billing). Be aware, your network providers might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. Do you need a referral to Yes, but you may self-refer to certain This plan will pay some or all of the costs to see a specialist for covered services but see a specialist? specialists. only if you have a referral before you see the specialist.

5 1 of 6. All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. What You Will Pay What You Will Pay Common Services You May Limitations, Exceptions & Other Important Plan Provider Non-Plan Provider Medical Event Need Information (You will pay the least) (You will pay the most). Primary care visit to treat an injury or $30 / visit Not Covered None illness If you visit a health Specialist visit $55 / visit Not Covered None care provider's office or clinic You may have to pay for services that aren't Preventive care/ preventive. Ask your provider if the services you screening/ No Charge Not Covered need are preventive. Then check what your immunization plan will pay for.

6 Diagnostic test (x- X-ray: $55 / encounter; Lab Not Covered None ray, blood work) tests: $35 / encounter If you have a test Imaging (CT/PET $275 / procedure Not Covered None scans, MRI's). Up to 30-day supply retail and 100-day supply Generic drugs (Tier Retail: $15 / prescription; Mail Not Covered mail order. Female contraceptives are no If you need drugs to 1) Order: $30 / prescription charge. Subject to formulary guidelines. treat your illness or condition Up to 30-day supply retail and 100-day supply Preferred brand Retail: $55 / prescription; Mail Not Covered mail order. Female contraceptives are no drugs (Tier 2) Order: $110 / prescription charge. Subject to formulary guidelines. More information about prescription The cost-sharing for non-preferred brand drugs drug coverage is Non-preferred brand Retail: $55 / prescription; Mail under this plan aligns with the cost-sharing for available at Not Covered drugs (Tier 2) Order: $110 / prescription preferred brand drugs (Tier 2), when approved through the formulary exception process.

7 Formulary. Specialty drugs (Tier Up to $250 / prescription. Up to 30-day supply. 20% coinsurance Not Covered 4) Subject to formulary guidelines. 2 of 6. What You Will Pay What You Will Pay Common Services You May Limitations, Exceptions & Other Important Plan Provider Non-Plan Provider Medical Event Need Information (You will pay the least) (You will pay the most). Facility fee ( , ambulatory surgery $340 / procedure Not Covered None If you have center). outpatient surgery Physician/surgeon Physician/Surgeon Fee is included in the Not Applicable Not Covered fees Facility Fee Emergency room Copayment is waived if admitted to hospital as $325 / visit $325 / visit care inpatient If you need Emergency medical immediate medical $250 / trip $250 / trip None transportation attention Non-Plan providers covered when temporarily Urgent care $30 / visit $30 / visit outside the service area.

8 Facility fee ( , $600 / day Not Covered Up to 5 days then no charge. If you have a hospital room). hospital stay Physician/surgeon Physician/Surgeon Fee is included in the Not Applicable Not Covered fee Facility Fee. If you need mental $30 / individual visit; $30 / day Mental / Behavioral health: $15 / group visit health, behavioral Outpatient services for other outpatient services Not Covered Substance Abuse: $5 / group visit health, or substance abuse services Inpatient services $600 / day Not Covered Up to 5 days then no charge. Depending on the type of services, a copayment, coinsurance, or deductible may Office visits No Charge Not Covered apply. Maternity care may include tests and services described elsewhere in the SBC ( ultrasound).

9 If you are pregnant Childbirth/delivery Professional services are included in the professional services Not Applicable Not Covered Facility Fee. Childbirth/delivery $600 / day Not Covered Up to 5 days then no charge. facility services 3 of 6. What You Will Pay What You Will Pay Common Services You May Limitations, Exceptions & Other Important Plan Provider Non-Plan Provider Medical Event Need Information (You will pay the least) (You will pay the most). Up to 2 hours / visit, up to 3 visits / day, up to Home health care $30 / visit Not Covered 100 visits / year. Rehabilitation Inpatient: $600 / day; Outpatient: Not Covered Inpatient: Up to 5 days then no charge. services $30 / visit If you need help Inpatient: $600 /day; Outpatient: Not Covered recovering or have Habilitation services $30 /visit.

10 Inpatient: Up to 5 days then no charge. other special health needs Up to 5 days then no charge. 100 day limit /. Skilled nursing care $300 / day Not Covered benefit period. Durable medical 20% Coinsurance Not Covered Requires prior authorization equipment Hospice service No Charge Not Covered None Children's eye exam No Charge Not Covered None Limited to one pair of glasses/year from select If your child needs Children's glasses No Charge Not Covered frames and lenses. dental or eye care Children's dental No Charge Not Covered Limited to two check-ups / year. check-up Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)