Kaiser Permanente: TRADITIONAL PLAN

1 Kaiser permanente : TRADITIONAL PLANC overage Period: 01/01/2017-12/31/2017 Summary of Benefits and Coverage: What this plan covers and what it for: Individual+FamilyPlan type: HMOThis is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling QuestionsAnswersWhy this Matters:What is the overall deductible?$0 See the Common Medical Events chart below for your costs for services this plan there other deductibles for specific services? don t have to meet deductibles for specific services, but see the chart starting on page 2 for other costs for services this plan there an out of pocket limit on my expenses?

2 Yes. $1,500 Individual/$3,000 Family The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care is not included in the out of pocket limit?Premiums, health care this plan doesn't cover, and cost sharing for certain services listed in plan though you pay these expenses, they don't count toward the out-of-pocket there an overall annual limit on what the plan pays? chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office this plan use a network of providers?

3 Yes. For a list of plan providers, see or call you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of I need a referral to see a specialist?Yes, but you may self-refer to certain plan will pay some or all of the costs to see a specialist for covered services but only if you have the plan s permission before you see the there services this plan doesn t cover?

4 Of the services this plan doesn t cover are listed on page 5. See your policy or plan document for additional information about excluded services. Kaiser permanente : TRADITIONAL PLANC overage Period: 01/01/2017-12/31/2017 Summary of Benefits and Coverage: What this plan Covers & What it CostsCoverage for: Individual+Family | plan Type: HMOQ uestions: Call 1-800-278-3296 or 711 (TTY), or visit us at OF KERNIf you aren t clear about any of the underlined terms used in this form, see the Glossary. You can view thePID:229170 CNTR:1 EU:601 plan ID:250 SBC ID:264238 Glossary at or call 1-800-278-3296 or 711 (TTY) to request a of 10 Copayments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service.

5 Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan s allowed amount for an overnight hospital stay is $1,000, your coinsurance payment of 20% would be $200. This may change if you haven t met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference.

6 (This is called balance billing.) This plan may encourage you to use plan providers by charging you lower deductibles, copayments and coinsurance EventServices You May NeedYour cost if you use aPlan ProviderYour cost if you use aNon- plan ProviderLimitations & ExceptionsIf you visit a health care provider s office or clinicPrimary care visit to treat an injury or illness$10 per visitNot Covered none Specialist visit$10 per visitNot CoveredServices related to infertility covered at 50% coinsurance per practitioner office visit$10 per visit for chiropractic services, $10 per visit for acupuncture CoveredUp to 30 visits per year for chiropractic services, Physician referred care/screening/immunizationNo ChargeNot CoveredSome preventive screenings (such as lab and imaging) may be at a different cost you have a testDiagnostic test (x-ray, blood work)X-ray: No Charge.

7 Lab tests: No ChargeNot Covered none Imaging (CT/PET scans, MRI's)No ChargeNot Covered none 2 of 10 CommonMedical EventServices You May NeedYour cost if you use aPlan ProviderYour cost if you use aNon- plan ProviderLimitations & ExceptionsIf you need drugs to treat your illness or conditionMore information about prescription drug coverage is available at .Generic drugs$5 per prescription for 1 to 100 daysNot CoveredIn accordance with formulary guidelines. Certain drugs may be covered at a different cost brand drugs$15 per prescription for 1 to 100 daysNot CoveredIn accordance with formulary guidelines.

8 Certain drugs may be covered at a different cost brand drugsSame as preferred brand CoveredSame as preferred brand drugs when approved through exception drugsSame as preferred brand CoveredSame as preferred brand drugs when approved through exception you have outpatient surgeryFacility fee ( , ambulatory surgery center)$10 per procedureNot Covered none Physician/surgeon feesNo ChargeNot Covered none If you need immediate medical attentionEmergency room services$75 per visit$75 per visit none Emergency medical transportationNo ChargeNo Charge none Urgent care$10 per visit$10 per visitNon- plan providers covered when outside the service you have a hospital stayFacility fee ( , hospital room)

9 $250 per admissionNot Covered none Physician/surgeon feeNo ChargeNot Covered none 3 of 10 CommonMedical EventServices You May NeedYour cost if you use aPlan ProviderYour cost if you use aNon- plan ProviderLimitations & ExceptionsIf you have mental health, behavioral health, or substance abuse needsMental/Behavioral health outpatient services$10 per individual visit; $5 per group visit; No Charge for other outpatient servicesNot Covered none Mental/Behavioral health inpatient services$250 per admissionNot Covered none Substance use disorder outpatient services$10 per individual visit; $5 per group visit; $5 per day for other outpatient servicesNot Covered none Substance use disorder inpatient services$250 per admissionNot Covered none If you are pregnantPrenatal and postnatal carePrenatal care: No Charge; Postnatal care: No ChargePrenatal care: Not covered.

10 Postnatal care: Not coveredPrenatal: Cost sharing is for routine preventive care only; Postnatal: Cost sharing is for the first postnatal visit and all inpatient services$250 per admissionNot Covered none If you need help recovering or have other special health needsHome health careNo ChargeNot CoveredUp to 2 hours maximum per visit, up to 3 visits maximum per day, up to 100 visits maximum per servicesInpatient: $250 per admission; Outpatient: $10 per visitNot Covered none Habilitation services$10 per visitNot Covered none Skilled nursing careNo ChargeNot CoveredUp to 100 days maximum per benefit medical equipmentNo ChargeNot CoveredMust be in accordance with formulary guidelines.