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muscular, and/or skeletal systems. Musculoskeletal andRelated Disorders are conditions typically categorized asstructural, degenerative, or inflammatory disorders; orbiomechanical dysfunction of the joints of the bodyand/or related components of the muscle or skeletalsystems (muscles, tendons, fascia, nerves,ligaments/capsules, discs and synovial structures) andrelated manifestations or conditions.Non–Participating Provider: A provider other than anASH Participating Provider.Treatment Plan: One of the following, depending onwhether the Treatment Plan is for Chiropractic Servicesor Acupuncture Services: The course of treatment for your Musculoskeletal andRelated Disorder, which may include laboratory tests,X-rays, chiropractic supports and appliances, and aspecific number of visits for chiropracticmanipulations (adjustments) and adjunctive therapiesthat are Medically Necessary Chiropractic Servicesfor you The course of treatment for your Musculoskeletal andRelated Disorder, nausea, or pain, which will includea specific number of visits for acupuncture (includingadjunctive therapies) that are Medically NecessaryAcupuncture Services for youUrgent Acupuncture Services: Acupuncture Servicesthat meet all of the following requirements: They are necessary to prevent serious deterioration ofyour health resulting from an unforeseen illness,injury, or complication of an existing condition,including pregnancy They cannot be delayed until you return to the ServiceAreaUrgent Chiropractic Services: Chiropractic Servicesthat meet all of the following requirements: They are necessary to prevent serious deterioration ofyour health resulting from an unforeseen illness,injury, or complication of an existing condition,including pregnancy They cannot be delayed until you return to the ServiceAreaASH Participating ProvidersPLEASE READ THE FOLLOWINGINFORMATION SO YOU WILL KNOW FROMWHOM OR WHAT GROUP OF PROVIDERSHEALTH CARE MAY BE OBTAINED.ASH Plans contracts with ASH Participating Providersand other licensed providers to provide the Servicescovered under this Amendment (including laboratorytests, X-rays, and chiropractic supports and appliances).You must receive Services covered under thisAmendment from an ASH Participating Provider oranother licensed provider with which ASH contracts toprovide covered care, except for Services covered under“Emergency and Urgent Services Covered Under thisAmendment” in the “Covered Services” section andServices that are not available from contracted providersand that are authorized in advance by ASH Plans.How to Obtain ServicesTo obtain Services covered under this Amendment callan ASH Participating Provider to schedule an initialexamination. If additional Services are required after theinitial examination, verification that the Services areMedically Necessary may be required, as describedunder “Decision time frames” below. Your ASHParticipating Provider will request any required medicalnecessity determinations. An ASH Plans clinician in thesame or similar specialty as the provider of Servicesunder review will determine whether the Services are orwere Medically Necessary Services.Decision time framesThe ASH Plans’ clinician will make the authorizationdecision within the time frame appropriate for yourcondition, but no later than five business days afterreceiving all of the information (including additionalexamination and test results) reasonably necessary tomake the decision, except that decisions about urgentServices will be made no later than 72 hours after receiptof the information reasonably necessary to make thedecision. If ASH Plans needs more time to make thedecision because it doesn’t have information reasonablynecessary to make the decision, or because it hasrequested consultation by a particular specialist, you andyour ASH Participating Provider will be informed inwriting about the additional information, testing, orspecialist that is needed, and the date that ASH Plansexpects to make a decision.Your ASH Participating Provider will be informed of thedecision within 24 hours after the decision is made. If theServices are authorized, your ASH Participating Providerwill be informed of the scope of the authorized Services.If ASH Plans does not authorize all of the Services, ASHPlans will send you a written decision and explanation,including the rationale for the decision and the criteriaused to make the decision, within two business days afterthe decision is made. The letter will also includeinformation about your appeal rights, which areChiropractic, Acupuncture, and Silver&Fit Healthy Aging and Exercise Program for San Francisco Health Service System FundEffective: 1/1/22-12/31/22Date: August 31, 2021Page 9

described in the “Coverage Decisions, Appeals, andComplaints” section of your Health Plan EOC for KaiserPermanente Senior Advantage Members, and “DisputeResolution” section of your Health Plan EOC for allother Members. Any written criteria that ASH Plans usesto make the decision to authorize, modify, delay, or denythe request for authorization will be made available toyou upon request. If you have questions or concerns,please contact ASH Plans or Kaiser Permanente asdescribed under “Customer Service” in this Amendment.Covered ServicesWe cover the Services listed in this “Covered Services”section, subject to exclusions described in the“Exclusions” section, only if all of the followingconditions are satisfied: You are a Member on the date that you receive theServices ASH Plans has determined that the Services areMedically Necessary, except for: the initial examination described under “OfficeVisits” in this “Covered Services” section Services covered under “Emergency and UrgentServices Covered Under this Amendment” in this“Covered Services” section You receive the Services from ASH ParticipatingProviders or other licensed providers with whichASH contracts to provide covered care, except for: Services covered under “Emergency and UrgentServices Covered Under this Amendment” in this“Covered Services” section Services that are not available from ASHParticipating Providers or other licensed providerswith which ASH contracts to provide covered careand that are authorized in advance by ASH PlansWhen you receive covered Services, you must pay theCost Share listed in this “Covered Services” section. Ifyou receive Services that are not covered under thisAmendment, you may be liable for the full price of thoseServices.Note: If Charges for Services are less than theCopayment described in this “Covered Services” section,you will pay the lesser amount.The Cost Share you pay for Services covered under thisAmendment does not apply toward any Plan Deductibleor Plan Out-of-Pocket Maximum described in yourHealth Plan EOC.If you have questions about your Cost Share for specificServices that you are scheduled to receive or that yourprovider orders during a visit or procedure, please callthe ASH Plans Customer Service Department toll free at1-800-678-9133 (TTY users call 711) weekdays from 5a.m. to 6 p.m.Coverage of Acupuncture Services under thisAmendment is different from the coverage ofacupuncture Services under your Health Plan EOC. Youdo not need a referral to get covered Services under thisAmendment, but covered Services and your Cost Sharemay differ from those under your Health Plan EOC. Ifyou receive acupuncture Services for which you have areferral (as described under “Getting a Referral” in the“How to Obtain Services” section of the EOC), thenunless you tell us otherwise, we will assume that you areusing your coverage under your Health Plan EOC.If you are a Kaiser Permanente Senior AdvantageMember, refer to your Health Plan EOC for informationabout the chiropractic Services that we cover in accordwith Medicare guidelines, which are separate from theServices covered under this Amendment.Office VisitsWe cover up to a combined total of 30 of the followingtypes of office visits per 12-month period at a 15 Copayment per visit: Initial chiropractic examination: An examinationperformed by an ASH Participating Provider todetermine the nature of your problem (and, ifappropriate, to prepare a Treatment Plan), and toprovide Medically Necessary Chiropractic Services,which may include an adjustment and adjunctivetherapy. We cover an initial examination only if youhave not already received covered ChiropracticServices from an ASH Participating Provider in thesame 12-month period for your Musculoskeletal andRelated Disorder Subsequent chiropractic office visits: SubsequentASH Participating Provider office visits forChiropractic Services that are determined to beMedically Necessary by an ASH Plans clinician.These subsequent office visits may include anadjustment, adjunctive therapy, and a re-examinationto assess the need to continue, extend, or change aTreatment Plan Initial acupuncture examination: An examinationperformed by an ASH Participating Provider todetermine the nature of your problem (and, ifappropriate, to prepare a Treatment Plan), and toprovide Medically Necessary Acupuncture Services.Chiropractic, Acupuncture, and Silver&Fit Healthy Aging and Exercise Program for San Francisco Health Service System FundEffective: 1/1/22-12/31/22Date: August 31, 2021Page 10

We cover an initial examination only if you have notalready received covered Acupuncture Services froman ASH Participating Provider in the same 12-monthperiod for your Musculoskeletal and RelatedDisorder, nausea, or pain Subsequent acupuncture office visits: SubsequentASH Participating Provider office visits forAcupuncture Services that are determined to beMedically Necessary by an ASH Plans clinician,which may include a re-examination to assess theneed to continue, extend, or change a Treatment PlanEach office visit counts toward any visit limit, ifapplicable.Laboratory Tests and X-raysWe cover Medically Necessary laboratory tests and Xrays when prescribed as part of covered chiropractic caredescribed under “Office Visits” in this “CoveredServices” section at no charge when an ASHParticipating Provider provides the Services or refers youto another licensed provider with which ASH contractsto provide covered Services.Chiropractic Supports and AppliancesWe provide a 50 Allowance per 12-month periodtoward the ASH Plans fee schedule price for chiropracticappliances listed in this paragraph when the item isprescribed and provided to you by an ASH ParticipatingProvider as part of covered chiropractic care describedunder “Office Visits” in this “Covered Services” section.If the price of the items in the ASH Plans fee scheduleexceed 50 (the Allowance), you will pay the amount inexcess of 50 (and that payment does not apply towardthe Plan Out-of-Pocket Maximum described in yourHealth Plan EOC). Covered chiropractic appliances arelimited to: elbow supports, back supports (thoracic),cervical collars, cervical pillows, heel lifts, hot or coldpacks, lumbar braces and supports, lumbar cushions,orthotics, wrist supports, rib belts, home traction units(cervical or lumbar), ankle braces, knee braces, ribsupports, and wrist braces.Second OpinionsYou may request a second opinion in regard to coveredServices by contacting another ASH ParticipatingProvider. Your visit to another ASH ParticipatingProvider for a second opinion generally will counttoward any visit limit, if applicable. An ASHParticipating Provider may also request a second opinionin regard to covered Services by referring you to anotherASH Participating Provider in the same or similarspecialty. When you are referred by an ASHParticipating Provider to another ASH ParticipatingProvider for a second opinion, your visit to the otherASH Participating Provider will not count toward anyvisit limit, if applicable. An authorization or denial ofyour request for a second opinion will be provided in anexpeditious manner, as appropriate for your condition. Ifyour request for a second opinion is denied, you will benotified in writing of the reasons for the denial, and ofyour right to file a grievance as described under“Grievances” in this Amendment.Emergency and Urgent ServicesCovered Under this AmendmentEmergency and urgent chiropractic ServicesWe cover Emergency Chiropractic Services and UrgentChiropractic Services provided by an ASH ParticipatingProvider or a Non–Participating Provider at a 15 Copayment per visit. We do not cover follow-up orcontinuing care from a Non-Participating Provider unlessASH Plans has authorized the Services in advance. Also,we do not cover Services from a Non-ParticipatingProvider that ASH Plans determines are not EmergencyChiropractic Services or Urgent Chiropractic Services.Emergency and urgent acupuncture ServicesWe cover Emergency Acupuncture Services and UrgentAcupuncture Services provided by an ASH ParticipatingProvider or a Non–Participating Provider at a 15 Copayment per visit. We do not cover follow-up orcontinuing care from a Non–Participating Providerunless ASH Plans has authorized the Services inadvance. Also, we do not cover Services from a NonParticipating Provider that ASH Plans determines are notEmergency Acupuncture Services or UrgentAcupuncture Services.How to file a claimAs soon as possible after receiving EmergencyChiropractic Services or Urgent Chiropractic Services orEmergency Acupuncture Services or UrgentAcupuncture Services, you must file an ASH Plans claimform. To request a claim form or for more information,please call ASH Plans toll free at 1-800-678-9133 (TTYusers call 711) or visit the ASH Plans website atashlink.com. You must send the completed claim formto:ASH PlansP.O. Box 509002San Diego, CA 92150-9002Chiropractic, Acupuncture, and Silver&Fit Healthy Aging and Exercise Program for San Francisco Health Service System FundEffective: 1/1/22-12/31/22Date: August 31, 2021Page 11

Exclusions Services for pre-employment physicals or vocationalrehabilitationThe items and services listed in this “Exclusions” sectionare excluded from coverage under this Amendment.(Note: Some items and services listed in this“Exclusions” section may be covered Services underyour Health Plan EOC. Please refer to your Health PlanEOC for details.) These exclusions apply to all Servicesthat would otherwise be covered under this Amendmentregardless of whether the services are within the scope ofa provider’s license or certificate: Drugs and medicines, including non-legend orproprietary drugs and medicines Hospital services, anesthesia, manipulation underanesthesia, and related services Acupuncture services for conditions other thanMusculoskeletal and Related Disorders, nausea, andpain Dietary and nutritional supplements, such as vitamins,minerals, herbs, herbal products, injectablesupplements, and similar products Acupuncture performed with reusable needles Massage therapy Services provided by an acupuncturist that are notwithin the scope of licensure for an acupuncturistlicensed in California Maintenance care (services provided to Memberswhose treatment records indicate that they havereached maximum therapeutic benefit) For Acupuncture Services, adjunctive therapies unlessprovided during the same course of treatment and inconjunction with acupunctureCustomer Service Services provided by a chiropractor that are notwithin the scope of licensure for a chiropractorlicensed in California For Chiropractic Services, adjunctive therapy notassociated with spinal, muscle, or joint manipulations Air conditioners, air purifiers, therapeutic mattresses,chiropractic appliances, durable medical equipment,supplies, devices, appliances, and any other itemexcept those listed as covered under “ChiropracticSupports and Appliances” in the “Covered Services”section of this Amendment Services for asthma or addiction, such as nicotineaddiction Services you receive outside the state of California,except for Services covered under “Emergency andUrgent Services Covered Under this Amendment” inthe “Covered Services” sectionIf you have a question or concern regarding the Servicesyou received from an ASH Participating Provider or anyother licensed provider with which ASH contracts toprovide covered Services, you may call the ASH PlansCustomer Service Department toll free at 1-800-6789133 (TTY users call 711) weekdays from 5 a.m. to 6p.m., or write ASH Plans at:ASH PlansCustomer Service DepartmentP.O. Box 509002San Diego, CA 92150-9002 Hypnotherapy, behavior training, sleep therapy, andweight programsGrievances ThermographyYou can file a grievance with Kaiser Permanenteregarding any issue. Your grievance must explain yourissue, such as the reasons why you believe a decisionwas in error or why you are dissatisfied about Servicesyou received. If you are a Kaiser Permanente SeniorAdvantage Member, you may submit your grievanceorally or in writing to Kaiser Permanente as described inthe “Coverage Decisions, Appeals, and Complaints”section of your Health Plan EOC. Otherwise, you maysubmit your grievance orally or in writing to KaiserPermanente as described in the “Dispute Resolution”section of your Health Plan EOC. Experimental or investigational Services. If coveragefor a Service is denied because it is experimental orinvestigational and you want to appeal the denial,refer to your Health Plan EOC for information aboutthe appeal process CT scans, MRIs, PET scans, bone scans, nuclearmedicine, and any other type of diagnostic imaging orradiology other than X-rays covered under the“Covered Services” section of this Amendment Ambulance and other transportation Education programs, non-medical self-care or selfhelp, any self-help physical exercise training, and anyrelated diagnostic testingChiropractic, Acupuncture, and Silver&Fit Healthy Aging and Exercise Program for San Francisco Health Service System FundEffective: 1/1/22-12/31/22Date: August 31, 2021Page 12

Silver&Fit Healthy Aging andExercise ProgramThe Silver&Fit program is provided by AmericanSpecialty Health Fitness, Inc., a subsidiary of AmericanSpecialty Health Incorporated (ASH). Silver&Fit is afederally registered trademark of ASH and used withpermission herein. Participating fitness centers andfitness chains may vary by location and are subject tochange.educational materials, newsletters, online classes, andother helpful featuresFor more information about the Silver&Fit program andthe list of participating fitness centers and fitness kits,visit kp.org/silverandfit or call Silver&Fit customerservice at 1 877 750 2746 (TTY 711), Monday throughFriday, 5 a.m. to 6 p.m. (PST).Covered ServicesThe Silver&Fit program includes the following at nocharge: You can join a participating Silver&Fit fitness centerand take advantage of the services that are included inthe fitness center’s basic membership (for example,use of fitness center equipment or instructor-ledclasses that do not require an additional fee). If yousign-up for a Silver&Fit fitness center membership,the following applies: the fitness center provides facility and equipmentorientation services offered by fitness centers vary bylocation. Any nonst

Kaiser Foundation Health Plan, Inc. Northern and Southern California Regions . Combined Chiropractic and Acupuncture Services and Silver&Fit Healthy Aging and Exercise Program Amendment of the Kaiser Foundation Health Plan, Inc. Evidence of Coverage for SAN FRANCISCO HEALTH SERVICE SYSTEM . January 1, 2022, through December 31, 2022