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2016 Summaryof BenefitsKaiser Permanente Medicare (Cost) Plus Group PlanPlan C with Part DJanuary 1, 2016 – December 31, 2016Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.Mid-Atlantic RegionA nonprofit corporation H2150 EG 15 44

1Kaiser Permanente Medicare Plus Plan C with Part D (Cost)(a Cost Plan offered by KAISER FNDN HP OF THE MID-ATLANTIC STS with a Medicare contract).Summary of BenefitsJanuary 1, 2016 – December 31, 2016This booklet gives you a summary of what we cover. To get a complete list of your Kaiser Permanente Medicare Plus (Cost) benefits, pleaserefer to your Evidence of Coverage (EOC). Contact your employer or trust fund or call Kaiser Permanente Medicare Plus (Cost) and ask for the“Evidence of Coverage.” To get a complete list of services we cover, call us and ask for the “Evidence of Coverage.”You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by theFederal government. However, if you enroll in Original Medicare alone, you may endanger the coverage you receive through your employeror trust fund, and your benefits may be reduced. Another choice is to get your Medicare benefits by joining a Medicare Plus (Cost) plan (such as Kaiser Permanente Medicare Plus (Cost)),which is made available through your employer or trust fund. For information about the benefits available through your employer or trustfund, please see your EOC. No matter what you decide, you are still in the Medicare Program. Your employer or trust fund may restrict whenyou may join or leave its plan. Usually this is connected to your employer or trust fund’s annual enrollment period. Please call your employeror trust fund for more information about enrollment periods.Tips for comparing your Medicare choices As a member who receives Kaiser Permanente Medicare Plus (Cost) coverage through an employer or trust fund, you will receive all of thebenefits that the Original Medicare plan offers, plus additional benefits purchased for you by your employer or trust fund, which may changefrom year to year. If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View itonline at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY usersshould call 1-877-486-2048.Sections in this booklet Things to Know About Kaiser Permanente Medicare Plus Plan C with Part D (Cost) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug BenefitsThis document is available in other formats such as Braille and large print.This document may be available in a non-English language. For additional information, call us at 1-888-777-5536.

2Things to Know About Kaiser Permanente Medicare Plus Plan C with Part D (Cost)Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time.Kaiser Permanente Medicare Plus Plan C with Part D (Cost) Phone Numbers and Website If you are a member of this plan, call toll-free 1-888-777-5536 (TTY 711) If you are not a member of this plan, call toll-free 1-877-408-8607 (TTY 711) Our website: kp.org/medicareWho can join?To join Kaiser Permanente Medicare Plus Plan C with Part D (Cost), you must be enrolled in Medicare Part B (or have both Medicare Part Aand Medicare Part B), and live in our service area. Our service area includes the following county in Washington, D.C.: District of Columbia;Maryland: Anne Arundel, Baltimore, Baltimore City, Calvert*, Carroll, Charles*, Frederick*, Harford, Howard, Montgomery, and Prince George’s;and Virginia: Alexandria City, Arlington, Fairfax, Fairfax City, Falls Church City, Loudoun, Manassas City, Manassas Park City, and Prince William.* denotes partial county* Calvert: 20639, 20678, 20689, 20714, 20732, 20736, 20754.* Charles: 20601, 20602, 20603, 20604, 20612, 20616, 20617, 20637, 20640, 20643, 20646, 20658, 20675, 20677, and 20695.* Frederick: 21701, 21702, 21703, 21704, 21705, 21709, 21710, 21714, 21716, 21717, 21718, 21754, 21755, 21758, 21759, 21762, 21769, 21770,21771, 21774, 21775, 21777, 21790, 21792, 21793.Which doctors, hospitals, and pharmacies can I use?Kaiser Permanente Medicare Plus Plan C with Part D (Cost) has a network of doctors, hospitals, pharmacies, and other providers. If you use theproviders in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network.You must generally use network pharmacies to fill your prescriptions for covered Part D drugs.Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these pharmacies.You can see our plan’s provider directory at our website (kp.org/medicare).You can see our plan’s pharmacy directory at our website (kp.org/seniorrx).Or, call us and we will send you a copy of the provider and pharmacy directories.

3What do we cover? Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than youwould in Original Medicare. For others, you may pay less.We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, kp.org/seniorrx. Or, call us and we will send you a copy of the formulary.How will I determine my drug costs?Our plan groups each medication into one of six “tiers.” You will need to use your formulary to locate what tier your drug is on to determinehow much it will cost you. The amount you pay depends on the drug’s tier and what stage of the benefit you have reached. Later in thisdocument we discuss the benefit stages that occur: Initial Coverage and Catastrophic Coverage.

4Summary of BenefitsJanuary 1, 2016 – December 31, 2016MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICESKaiser Permanente Medicare Plus Plan C with Part D (Cost)How much is the deductible?This plan does not have a deductible.Is there any limit on how muchI will pay for my covered services?Yes. Our plan protects you by having yearly limits on your out-of-pocket costs for medical andhospital care.Your yearly limit (s) in this plan: 3,400 for services you receive from in-network providers.If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medicalservices and we will pay the full cost for the rest of the year. Please note that you will still need topay your monthly premiums and cost-sharing for your Part D prescription drugs.Is there a limit on how much the planwill pay?No. There are no limits on how much our plan will pay.Kaiser Permanente is a Cost plan with a Medicare contract. Enrollment in Kaiser Permanente depends on contract renewal.

5Covered Medical and Hospital BenefitsNOTE: Services with a 1 may require prior authorization.Services with a 2 may require a referral from your doctor.OUTPATIENT CARE AND SERVICESKaiser Permanente Medicare Plus Plan C with Part D (Cost)AcupunctureNot coveredAmbulance 1 0 copayCopay applies pre one-way trip.Chiropractic Care 1, 2Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spinemove out of position): 5 copayServices are provided in accord with Medicare guidelines.Dental Services 1, 2Limited dental services (this does not include services in connection with care, treatment, filling,removal, or replacement of teeth): 5 copayDental Services: 30 copay for a single office visit that includes: Cleaning (for up to 2 every year) Dental x-ray(s) (for up to 2 every year) Fluoride treatment (for up to 2 every year) Oral exam (for up to 2 every year)Diabetes Supplies and Services 1Diabetes monitoring supplies: You pay nothingDiabetes self-management training: You pay nothingTherapeutic shoes or inserts: You pay nothing

6Kaiser Permanente Medicare Plus Plan C with Part D (Cost)Diagnostic Tests, Lab andRadiology Services, and X-Rays(Costs for these services may varybased on place of service)1, 2Diagnostic radiology services (such as MRIs, CT scans): 0 copay, depending on the service.Diagnostic tests and procedures: 0 copay, depending on the serviceLab Services: You pay nothingOutpatient X-Rays: You pay nothingTherapeutic radiology services (such as radiation treatment for cancer): 5 copayDoctor’s Office Visits 1, 2Primary care physician visit: 5 copaySpecialist visit: 5 copayVisits to your primary care physician do not require a referral.Durable Medical Equipment(wheelchairs, oxygen, etc.) 1 0 copayEmergency Care 50 copayIf you are admitted to the hospital within 48 hours, you do not have to pay your share of the costfor emergency care. See the “Inpatient Hospital Care” section of this booklet for other costs.Foot Care(Podiatry Services) 1, 2Foot exams and treatment if you have diabetes-related nerve damage and/or meet certainconditions: 5 copayHearing Services 1, 2Exam to diagnose and treat hearing and balance issues: 5 copayHome Health Care 1, 2You pay nothingServices are provided in accord with Medicare guidelines.

7Kaiser Permanente Medicare Plus Plan C with Part D (Cost)Mental Health Care 1, 2Inpatient visit: Our plan covers unlimited days per benefit period. You pay nothingOutpatient group therapy visit: 5 copayOutpatient individual therapy visit: 5 copayOutpatient Rehabilitation 1, 2Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessionsup to 36 weeks): 5 copayOccupational therapy visit: 5 copayPhysical therapy and speech and language therapy visit: 5 copayOutpatient Substance Abuse 1, 2Group therapy visit: 5 copayIndividual therapy visit: 5 copayOutpatient Surgery 1, 2Ambulatory surgical center: 0 copayOutpatient hospital: 0 copayOver the Counter ItemsNot covered.Prosthetic Devices(braces, artificial limbs, etc.) 1Prosthetic devices: 0 copayRenal Dialysis 1, 2You pay nothingTransportationNot covered.Urgently Needed Services 5 copayRelated medical supplies: 0 copayThis copay applies to urgent care office visits. See the “Emergency Care” section for EmergencyDepartment copays.

8Kaiser Permanente Medicare Plus Plan C with Part D (Cost)Vision Services 1, 2Exam to diagnose and treat diseases and conditions of the eye(including yearly glaucoma screening): 0-5 copay, depending on the serviceRoutine eye exam: 5 copay, depending on the serviceContact lenses: 85% of the costEyeglasses (frames and lenses): 75% of the costEyeglasses or contact lenses after cataract surgery: 20% of the costPreventive Care 1, 2You pay nothing.Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots “Welcome to Medicare” preventive visit (one-time) Yearly “Wellness” visitAny additional preventive services approved by Medicare during the contract year will be covered.